[Complications of infective endocarditis]. / Complications de l'endocardite infectieuse.

COMPLICATIONS OF INFECTIVE ENDOCARDITIS. The high in-hospital mortality of patients with infective endocarditis (about 20%) is mainly due to its complications. These complications are essentially of cardiac, neurological, and infectious origin. Rapid diagnosis and early antibiotic treatment are of paramount importance and allow drastic reduction of the frequency and severity of such complications. Discussion with all physicians caring for the patients with infective endocarditis in an "endocarditis team" setting is a mandatory step in management optimization and outcome improvement. This "endocarditis team" approach allows faster identification of patients at high risk of acute heart failure and/or cerebral embolism, and selection of those who might benefit from urgent valvular surgery. Factors associated with high embolic risk are the size and mobility of vegetation, mitral valve endocarditis, and infection with Staphylococcus aureus. When neurological complications occur, there is a risk that these may be worsened by the valvular surgery if there is a hemorrhagic component. This risk needs to be careful weighed in a team approach before sending patients to surgery. Persistent sepsis after effective antibiotic treatments prompts to local extension of the disease or to embolic extra cardiac secondary infectious localization.

COMPLICATIONS DE L'ENDOCARDITE INFECTIEUSE. Les complications de l'endocardite infectieuse (EI) sont à l'origine d'une mortalité hospitalière élevée d'environ 20 %. Elles sont essentiellement cardiaques, neurologiques et septiques. Un diagnostic rapide et une antibiothérapie précoce sont essentiels, car ils permettent de réduire la fréquence et la sévérité de ces complications. Une discussion collégiale au sein de l'équipe pluridisciplinaire (endocarditis team) est indispensable pour optimiser la prise en charge et améliorer le pronostic. Elle permet notamment d'identifier rapidement les patients à haut risque d'insuffisance cardiaque aiguë et/ou d'embolie cérébrale et de sélectionner les patients nécessitant une chirurgie valvulaire urgente. Les facteurs prédictifs d'un haut risque embolique sont la taille et la mobilité de la végétation, sa localisation sur la valve mitrale et l'EI à Staphylococcus aureus. La survenue d'une complication neurologique nécessite une évaluation rigoureuse compte tenu des risques d'aggravation de la lésion par la chirurgie valvulaire en présence d'une composante hémorragique. Un sepsis persistant sous traitement antibiotique doit faire rechercher une extension locale de l'endocardite ou des foyers emboliques extracardiaques.

Infective Endocarditis: Etiology, Epidemiology and Current Recommendations for the Dental Practitioner.

Infective endocarditis (IE) remains one of the most serious diseases with a high morbidity and mortality rate. Although the condition is more common in the medical field in a hospital setting, dentists must have a thorough understanding of the overall pathogenesis, epidemiology, risk factors and signs and symptoms that may be present in their patient population. In 2021, the American Heart Association (AHA) updated its guidelines on IE, emphasizing the specific criteria that put a patient at risk of acquiring IE, specific dental procedures that can increase the risk of IE by inducing bacteremia and an antibiotic prophylaxis regimen to act as a preventive measure if needed. This literature review gives the dental practitioner a general overview of the AHA guidelines as well as information on prevention in their at-risk patients and the need to emphasize a well-structured, consistent daily oral hygiene routine.

Infectious mass debulking in lead-associated endocarditis with a percutaneous aspiration system.

AIMS: Debulking of infective mass to reduce the burden if infective material is a fundamental principle in the surgical management of infection. The aim of this study was to investigate the validity of this principle in patients undergoing transvenous lead extraction in the context of bloodstream infection (BSI). METHODS AND RESULTS: We performed an observational single-centre study on patients that underwent transvenous lead extraction due to a BSI, with or without lead-associated vegetations, in combination with a percutaneous aspiration system during the study period 2015-22. One hundred thirty-seven patients were included in the final analysis. In patients with an active BSI at the time of intervention, the use of a percutaneous aspiration system had a significant impact on survival (log-rank: P = 0.0082), while for patients with a suppressed BSI at the time of intervention, the use of a percutaneous aspiration system had no significant impact on survival (log-rank: P = 0.25). CONCLUSION: A reduction of the infective burden by percutaneous debulking of lead vegetations might improve survival in patients with an active BSI.

Infection of Transcatheter Valvular Devices.

PURPOSE OF REVIEW: This review explores the epidemiology, clinical traits, and diagnosis of Transcatheter Aortic Valve Replacement-Associated Infective Endocarditis (TAVR-IE) and mitral transcatheter edge-to-edge repair infective endocarditis (TEER-IE), focusing on a multimodal imaging approach. It addresses the rising prevalence of TAVR and TEER, emphasizing the need to understand long-term complications and clinical consequences, which poses significant challenges despite advancements in valve technology. RECENT FINDINGS: Studies report a variable incidence of TAVR-IE and TEER-IE influenced by diverse patient risk profiles and procedural factors. Younger age, male gender, and certain comorbidities emerge as patient-related risk factors. Procedure-related factors include intervention location, valve type, and technical aspects. Microbiologically, Staphylococcus aureus, Viridans Group Streptococcus, and Enterococcus are frequently encountered pathogens. TAVR-IE and TEER-IE diagnosis involves a multimodal imaging approach due to limitations in echocardiography. Blood cultures and imaging aid identification, with Fluorescence in situ hybridization is showing promise. Treatment encompasses medical management with antibiotics and, when necessary, surgical intervention. The management approach requires a multidisciplinary "Endocarditis Team." This review underscores the need for continued research to refine risk prediction, enhance diagnostic accuracy, and optimize management strategies for TAVR-IE, considering the evolving landscape of transcatheter interventions.

Percutaneous treatment of an early complication after endocarditis surgery with Cabrol type repair.

We present a 70-year-old man with rheumatic mitral valve disease who had undergone 3 previous open-heart surgeries, the last of which was a new mitral valve replacement for a mechanical prosthesis due to early bioprosthetic endocarditis.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs.

BACKGROUND: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review.

BACKGROUND: Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations. OBJECTIVE: To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis. MATERIALS AND METHODS: A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors. RESULTS: The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures. CONCLUSION: These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

Infective endocarditis after isolated aortic valve replacement: comparison between catheter-interventional and surgical valve replacement.

BACKGROUND AND AIMS: Prosthetic valve endocarditis (PVE) is the prognostically most unfavourable complication after aortic valve replacement. This study aims to contribute to a better understanding of the different pathological and therapeutical aspects between PVE following surgical (SAVR) and transcatheter aortic valve replacement (TAVI). METHODS: All patients who had undergone primary isolated SAVR (n = 3447) or TAVI (n = 2269) at our Centre between 01/2012 and 12/2018 were analysed. Diagnosis of PVE was based on Duke criteria modified in 2015. Incidence, risk factors, pathogens, impact of complications or therapy on mortality were analysed and compared between SAVR- and TAVI-PVE. RESULTS: PVE incidence did not differ significantly after SAVR with 4.9/100 patient-years and TAVI with 2.4/100 patient-years (p = 0.49), although TAVI patients were older (mean 80 vs. 67 years) and had more comorbidities (STS score mean 5.9 vs. 1.6) (p < 0.001). TAVI prostheses with polymer showed a 4.3-fold higher risk to develop PVE than without polymer (HR 4.3; p = 0.004). Most common pathogens were staphylococci and enterococci (p > 0.05). Propensity-score matching analysis showed that the type of aortic valve replacement had no effect on the development of post-procedural PVE (p = 0.997). One-year survival was higher in TAVI-PVE patients treated with antibiotics only compared to additional surgical therapy (90.9% vs. 33.3%; p = 0.005). In SAVR-PVE patients, both therapies were comparable in terms of survival (p = 0.861). However, SAVR-PVE patients who were not operated, despite ESC-guideline recommendation, had significantly poorer one-year survival (p = 0.004). CONCLUSION: TAVI patients did not have a significantly higher risk to develop PVE. Our data suggest that TAVI-PVE patients in contrast to SAVR-PVE patients can more often be treated with antibiotics only, presumably due to the lack of a polymeric suture ring.

Infective Endocarditis After Transcatheter Versus Surgical Aortic Valve Replacement.

BACKGROUND: Scarce data are available comparing infective endocarditis (IE) following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study aimed to compare the clinical presentation, microbiological profile, management, and outcomes of IE after SAVR versus TAVR. METHODS: Data were collected from the "Infectious Endocarditis after TAVR International" (enrollment from 2005 to 2020) and the "International Collaboration on Endocarditis" (enrollment from 2000 to 2012) registries. Only patients with an IE affecting the aortic valve prosthesis were included. A 1:1 paired matching approach was used to compare patients with TAVR and SAVR. RESULTS: A total of 1688 patients were included. Of them, 602 (35.7%) had a surgical bioprosthesis (SB), 666 (39.5%) a mechanical prosthesis, 70 (4.2%) a homograft, and 350 (20.7%) a transcatheter heart valve. In the SAVR versus TAVR matched population, the rate of new moderate or severe aortic regurgitation was higher in the SB group (43.4% vs 13.5%; P < .001), and fewer vegetations were diagnosed in the SB group (62.5% vs 82%; P < .001). Patients with an SB had a higher rate of perivalvular extension (47.9% vs 27%; P < .001) and Staphylococcus aureus was less common in this group (13.4% vs 22%; P = .033). Despite a higher rate of surgery in patients with SB (44.4% vs 27.3%; P < .001), 1-year mortality was similar (SB: 46.5%; TAVR: 44.8%; log-rank P = .697). CONCLUSIONS: Clinical presentation, type of causative microorganism, and treatment differed between patients with an IE located on SB compared with TAVR. Despite these differences, both groups exhibited high and similar mortality at 1-year follow-up.

Assessment of the current knowledge about infective endocarditis prevention among dental hygienists in Italy: A national survey.

OBJECTIVES: To date, there is a lack of data regarding the acceptance of the guidelines for infective endocarditis (IE) prevention among dentists in Italy, and similarly, there are no data on the understanding and compliance of those among dental hygienists (DH). Thus, we tried to assess the ability of DH to recognize and manage categories of patients at high risk of EI, to identify which dental procedures are at increased risk and to assess the level of knowledge of doses and how antibiotic prophylaxis should be administered in specific cases. METHODS: An anonymous questionnaire was prepared and made accessible online by sharing a Google Forms® link; general personal data and educational background information were collected to obtain a profile of the participants. RESULTS: A total of 362 DH answered to our web-based survey, showing a prevalent female percentage (86.7%) and the most represented age group of 30-39 years old (43.1%). Regarding the gender differences, there were not overall statistically significant differences; similarly, we did not find any differences regarding the overall number of wrong questions if considering the different ages of the participant and the year of graduation. Graduates in Northern Italy have mistaken fewer questions than graduates in other geographical areas. CONCLUSION: To the best of our knowledge, this is the largest survey about the knowledge of IE for DH ever performed. Because the overprescription of antibiotics contributes to the development of drug resistance, antibiotic stewardship should be at the forefront of patient care. Our data reflect the need for placing a greater emphasis on IE prophylaxis education in training and during continuing professional development events for DH.

Features of infective endocarditis in a contemporary cohort of persons who inject drugs: a matched comparison analysis of long-term prognostic factors.

The objective of the study was to assess the short- and long-term mortality of infective endocarditis (IE) among people who inject drugs (PWID). Using prospectively collected data on hospitalized patients (years 2000 through 2021) with IE, PWID were identified and included in this study. Survival analysis was performed to analyze short- and long-term mortality and study their risk factors among PWID and a matched group of non-intravenous drug users (N-IDU). In a study of 485 patients admitted for IE, 55 (11%) of them were PWID. These PWID patients were 1:1 age- and sex- matched to an N-IDU group (N = 55 per group). Both groups had similar baseline comorbid conditions, including congestive heart failure, type 2 diabetes, and neoplastic diseases. However, PWID were more likely to have HCV co-infection (62% vs 16%, respectively, p < 0.001) and advanced liver disease/cirrhosis (52% vs 7.9%, respectively, p < 0.001). IE in PWID more often affected the tricuspid valve (42% vs 22%, respectively, p = 0.024) and presented with more embolic events (66% vs 35%, respectively, p < 0.01). S. aureus was the primary cause of IE in PWID (44% vs 21%, respectively, p = 0.01). After adjusting for other variables, PWID (HR = 2.99, 95% CI [1.06, 8.43], p = 0.038) and valve bioprosthetic replacement (HR = 5.37, 95% CI [1.3, 22.1], p = 0.02) were independently associated with increased mortality risk, whereas IE caused by tricuspid valve infection was associated with reduced mortality risk (HR = 0.25, 95% CI [0.06, 0.97], p = 0.046). In this cohort, PWID had increased risk of long-term mortality after hospital discharge for IE, when compared to matched N-IDU with similar baseline characteristics. The reasons behind the significant increase in mortality warrant further investigation.

Root-commando operation with a modified self-assembled aortic root conduit for endocarditis after sutureless aortic valve replacement.

We present a case of a Staphylococcus epidermidis early prosthetic valve endocarditis after minimally invasive sutureless aortic valve replacement. The patient developed a root abscess with a fistula, severe mitral and periprosthetic regurgitations, with a large mitral vegetation and a residual patent foramen ovale. The surgical approach consisted of a redo median sternotomy, explantation of a sutureless aortic prosthesis, resection of an intervalvular fibrosa and anterior mitral leaflet and debridement of an aortic root-left ventricle outflow tract abscess. These procedures were followed by a root-commando procedure with mitral and aortic root placement using a self-assembled mechanical aortic root conduit. The technique used is an alternative to a root-commando procedure performed with an allograft or a Medtronic Freestyle bioprosthesis. The same technique can be utilized with a commercially available stented bioprosthesis.

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis.

BACKGROUND: Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown. OBJECTIVES: To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE. METHODS: Two independent reviewers screened abstracts and full text for inclusion and independently extracted data. DATA SOURCES: MEDLINE, Embase, and Web of Science. STUDY ELIGIBILITY CRITERIA: Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included. ASSESSMENT OF RISK OF BIAS: As this was a scoping review, risk of bias assessment was not performed. METHODS OF DATA SYNTHESIS: Descriptive data was reported. RESULTS: We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294). CONCLUSIONS: While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Recurrent Bioprosthetic Valve Serratia marcescens Endocarditis in Intravenous Drug Users.

BACKGROUND We report 2 cases of recurrent right-sided endocarditis in 2 young patients known to be intravenous (i.v.) drug users. We highlight the importance of early diagnosis and management, especially in recurrent infection, which has a higher mortality rate and poor prognostic outcome despite antibiotic treatment. CASE REPORT A 30-year-old woman with a medical history of active i.v. drug use and tricuspid valve replacement owing to Serratia marcescens endocarditis 2 months prior to presentation was admitted to the Intensive Care Unit for septic shock. The patient did not respond to i.v. fluids and required vasopressors. Blood cultures returned positive for S. marcescens again. The antibiotic regimen consisted of meropenem and vancomycin. The patient underwent redo sternotomy, explant of old tricuspid valve bioprosthesis, debridement of tricuspid valve annulus, and bioprosthetic valve replacement. She continued antibiotic treatment during hospital admission for 6 weeks. In another similar case, a 30-year-old woman, also an i.v. drug user, was admitted to the hospital for tricuspid bioprosthetic valve S. marcescens endocarditis after tricuspid valve replacement 5 months prior to her presentation with S. marcescens endocarditis. Her antibiotic regimen consisted of meropenem and vancomycin. She was eventually transferred to a tertiary cardiovascular surgery center for further case management. CONCLUSIONS In the setting of recurrent bioprosthetic valve S. marcescens endocarditis, it is suggested that treatment should be more focused on source control, including cessation of i.v. drug abuse and providing appropriate antibiotic treatment to prevent recurrence because, in the case of recurrence, morbidity and mortality risk can increase significantly.

Infective endocarditis after transcatheter edge-to-edge repair for severe mitral regurgitation; a case report and a systematic review.

Transcatheter edge-to-edge repair (TEER) is used extensively in patients with symptomatic severe mitral regurgitation and high surgical risk. While prosthetic valve endocarditis is well documented, infective endocarditis (IE) after TEER is a rare occurrence. To date, no study has been conducted on this complication. We report the case of an 85-year-old man who developed IE 3 months after undergoing TEER, and we systematically review 26 previously published cases of this complication. Our review findings indicate that discussion within the heart team is essential for the decision-making process and treatment strategy determination.

Risk factors for infective endocarditis in patients receiving hemodialysis: A propensity score matched cohort study.

In patients receiving hemodialysis, infective endocarditis (IE) may present in a similar way to other causes of bacteremia, which may delay early diagnosis and can lead to worse outcomes. In this study, we aimed to identify the risk factors for IE in hemodialysis patients with bacteremia. This study was conducted on all patients diagnosed with IE and receiving hemodialysis between 2005 and 2018 in Salford Royal Hospital. Patients with IE were propensity score matched with similar hemodialysis patients with episodes of bacteremia between 2011 and 2015 (non-IE bacteremic (NIEB)). Logistic regression analysis was used to predict the risk factors associated with infective endocarditis. There were 35 cases of IE, and these were propensity matched with 70 NIEB cases. The median age of the patients was 65 years with a predominance of males (60%). The IE group had higher peak C-reactive protein compared to the NIEB group (median, 253 mg/L vs. 152, p = 0.001). Patients with IE had a longer duration of prior dialysis catheter use than NIEB patients (150 vs. 28.5 days: p = 0.004). IE patients had a much higher 30-day mortality rate (37.1% vs. 17.1%, p = 0.023). Logistic regression analysis showed previous valvular heart disease (OR: 29.7; p < 0.001), and a higher baseline C-reactive protein (OR: 1.01; p = 0.001) as significant predictors for infective endocarditis. Bacteremia in patients receiving hemodialysis through a catheter access should be actively investigated with a high index of suspicion for infective endocarditis, particularly in those with known valvular heart disease and a higher baseline C-reactive protein.