Surgical repair and replacement for native mitral valve infective endocarditis.

AIMS: The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established. METHODS: Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups. RESULTS: Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ±â€Š15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94). CONCLUSIONS: Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Right-sided infective endocarditis or thrombus? Report of two cases diagnosed by transthoracic echocardiography.

BACKGROUND: Right-sided infective endocarditis (RSIE) is a relatively uncommon condition which is difficult to distinguish from thrombus, particularly when the site of infection or the patient's symptoms are atypical. There have been few reports exploring the differential diagnostic and analytical features between RSIE and thrombus. CASE PRESENTATION: Here, we presented two cases of RSIE-one involving the tricuspid valve and the other affecting the pulmonary artery. Notably, the second case was initially misdiagnosed as thrombus based on the findings of by computed tomography angiography(CTA). CONCLUSIONS: Vegetation and thrombus can be distinguished according to the nature of the mass, its attachment location, and the clinical manifestation. Echocardiography can observe both the location and size of the mass, and the dynamic changes in cardiac hemodynamics and cardiac morphology, thereby facilitating an effective distinction between vegetation and thrombus.

Multimodality Imaging of Infective Endocarditis.

Infective endocarditis (IE) is a complex multisystemic disease resulting from infection of the endocardium, the prosthetic valves, or an implantable cardiac electronic device. The clinical presentation of patients with IE varies, ranging from acute and rapidly progressive symptoms to a more chronic disease onset. Because of its severe morbidity and mortality rates, it is necessary for radiologists to maintain a high degree of suspicion in evaluation of patients for IE. Modified Duke criteria are used to classify cases as "definite IE," "possible IE," or "rejected IE." However, these criteria are limited in characterizing definite IE in clinical practice. The use of advanced imaging techniques such as cardiac CT and nuclear imaging has increased the accuracy of these criteria and has allowed possible IE to be reclassified as definite IE in up to 90% of cases. Cardiac CT may be the best choice when there is high clinical suspicion for IE that has not been confirmed with other imaging techniques, in cases of IE and perivalvular involvement, and for preoperative treatment planning or excluding concomitant coronary artery disease. Nuclear imaging may have a complementary role in prosthetic IE. The main imaging findings in IE are classified according to the site of involvement as valvular (eg, abnormal growths [ie, "vegetations"], leaflet perforations, or pseudoaneurysms), perivalvular (eg, pseudoaneurysms, abscesses, fistulas, or prosthetic dehiscence), or extracardiac embolic phenomena. The differential diagnosis of IE includes evaluation for thrombus, pannus, nonbacterial thrombotic endocarditis, Lambl excrescences, papillary fibroelastoma, and caseous necrosis of the mitral valve. The location of the lesion relative to the surface of the valve, the presence of a stalk, and calcification or enhancement at contrast-enhanced imaging may offer useful clues for their differentiation. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Rare complications of infective endocarditis in marfan-like morphotype: diagnosis of multiple mitral valve aneurysms and aortic root abscess using three-dimensional transesophageal echocardiography.

Mitral valve aneurysm (MVA) is characterized by a saccular outpouching of the mitral leaflet, and it represents a rare condition typically associated with aortic valve endocarditis. Three-Dimensional Transesophageal Echocardiography (3D-TEE) serves as an effective tool for detecting the presence of MVA and its potential complications. In this report, we present a case involving a young man with striking images of bicuspid aortic valve endocarditis complicated by an aortic root abscess and multiple perforated mitral valve aneurysms, diagnosed using 3D TEE. This case suggests the uncommon coexistence of Marfan like morphotype, bicuspid aortic valve, and infective endocarditis as a triple mechanism in the occurrence of MVA. It underscores the significance of early and accurate imaging diagnosis for facilitating prompt surgical intervention.

Splenic Artery Infectious Aneurysms in Infective Endocarditis - An Observational Study and Comprehensive Literature Review.

BACKGROUND: To determine the prevalence, the clinical and radiological features, associated factors, treatment, and outcome of splenic artery aneurysms (SAAs) in infective endocarditis (IE). METHODS: We retrospectively reviewed 474 consecutive patients admitted to our institution with definite IE (2005-2020). RESULTS: Six patients had SAAs (1.3%; 3 women; mean age: 50 years). In all cases, the diagnosis was obtained by abdominal computed tomography angiography (CTA). SAAs-IE were solitary and saccular with a mean diameter of 30 mm (range: 10-90 mm). SAAs-IE were intrasplenic (n = 4) or hilar (n = 2). Streptococcus spp. were the predominant organisms (n = 4). In all cases, a left-sided native valve was involved (aortic, n = 3; mitral, n = 2; mitral-aortic, n = 1). SAAs were silent in half patients and were revealed by abdominal pain (n = 2) and by the resurgence of fever after cardiac surgery (n = 1). All patients underwent emergent valve replacement. One patient died within 24 hr from multiorgan failure. For the others, uneventful coil embolization was performed in 4 patients after valve replacement (3 diagnosed early and 1 at 8 weeks). In the remaining patient, SAA-IE diagnosed at abdominal CTA at day 16, with complete resolution under appropriate antibiotherapy alone. CONCLUSIONS: SAAs-IE are a rare occurrence that may be clinically silent. SAAs-IE can be intrasplenic or hilar in location. Endovascular treatment in this context was safe. According to current guidelines, radiologic screening by abdominal CTA allowed the detection of silent SAAs which could be managed by endovascular treatment to prevent rupture. The delayed formation of these SAAs could justify a CTA control at the end of antibiotherapy.

[SARS-CoV-2-induced non-bacterial endomyocarditis with the development of acquired heart defects]. / SARS-CoV-2-indutsirovannyi nebakterial'nyi endomiokardit s razvitiem priobretennykh porokov serdtsa.

Patients with damage of the mitral, aortic and tricuspid valves and systolic myocardial dysfunction associated with previous SARS-CoV-2 infection are described. The diagnosis of acquired defect was established in 4 patients based on medical history, electrocardiography, echocardiography, magnetic resonance imaging of the heart, endomyocardial or intraoperative myocardial biopsy, and in one case, autopsy. The study of the myocardium included H&E, Van Gieson staining, immunohistochemical (IHC) study with antibodies to CD3, CD20, CD45, CD68, to the nucleocapsid and Spike proteins of SARS-CoV-2. Previous valve diseases (prolapse, bicuspid aortic valve) served as a background for the development of the defect in 2 patients. In all cases, IHC studies revealed coronavirus proteins, lymphocytic endocarditis and myocarditis, moderate fibrosis, and signs of connective tissue disorganization. High titers of anticardiac antibodies indicated an autoimmune mechanism for carditis. No signs of infective endocarditis or thromboembolic complications were identified in any case. In patients with an unclear nature of valvular heart defects, a previous new coronavirus infection should be identified and taken into account as a possible etiological factor. The simultaneous development of lymphocytic myocarditis significantly increases the risk of surgical intervention on the valves and requires an integrated approach to treatment.

Triple Threat: Triple-Valve Endocarditis Case Report and Literature Review.

Triple valve endocarditis (TVE) is a rare presentation of endocarditis often requiring multivalvular surgery. Here we report a case of S. aureus triple valve endocarditis in a patient with a history of intravenous drug use and provide a literature review of TVE identification, treatment, and prognosis.

[Commando Procedure for Rapidly Progressing Infective Endocarditis in Immunosuppressive State: Report of a Case].

A 68-year-old woman with immunosuppressive state following chemotherapy for cancer of unknown primary origin developed infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA). Echocardiography showed shunt blood flow from the aortic annular abscess into the left atrium, which indicated infection of the intervalvular fibrosa (IVF). She underwent Commando procedure owing to progression of heart failure. The aortic valve, IVF, and anterior leaflet of the mitral valve were resected. The mitral valve was replaced with a bioprosthesis, and a bovine pericardial patch was used to reconstruct the IVF and left atrial roof. Bentall procedure was performed because the infection extended to the sinus of Valsalva, and the ascending aorta was 49 mm in diameter. She had no serious postoperative complications and is currently being followed up at the outpatient clinic. Because infection in these patients are potentially fatal, we believe Commando procedure is effective in spite of high early mortality rate.

Fungal Endocarditis: A Rare Cause of Left Ventricular Outflow Obstruction.

A 53-year-old male presented with worsening fever, chest pain, and dyspnea during the past 2 weeks. He was hypoxic, tachycardic, and hypotensive on admission. Labs were notable for high-sensitivity troponin of 657 pg/mL and B-type natriuretic peptide of 1,648 pg/mL. Chest imaging was consistent with acute respiratory distress syndrome. Transthoracic echocardiography revealed an ejection fraction of 30% to 35% and a mobile 1.5 cm x 1.6 cm hyperechoic mass on the ventricular surface of the aortic valve (AV) with left ventricular outflow obstruction and mean pressure gradient of 38.7 mm Hg and maximum velocity of 3.64 m/s. The patient was initiated on empiric antibiotic and antifungal therapy. Cardiothoracic surgery was consulted for urgent AV repair. Blood cultures were positive for Candida metapsilosis, and intravenous fluconazole and micafungin were initiated. Despite aggressive and prompt medical management, the patient sustained cerebral embolic events in the middle cerebral artery territory and passed away.

Marantic Endocarditis in Metastatic Lung Adenocarcinoma.

Marantic endocarditis is a rare condition associated with autoimmune disease, malignancy, and hypercoagulable states. It is characterized by sterile friable vegetations composed of fibrin and platelets that confer a high risk of systemic embolism. Here we showcase imaging that led to the diagnosis of an interesting case of marantic endocarditis secondary to metastatic malignancy.

Real world experience of therapeutic monitoring of medically treated prosthetic valve infective endocarditis by 18F-FDG-PET/CT.

INTRODUCTION: 18F-FDG-PET/CT is recommended to improve the diagnosis of prosthetic valve infective endocarditis (PVIE) and is a major criterion in the ESC-2015 classification. However, there is little evidence for its usefulness in the follow-up of medically treated PVIE patients. METHODS: A monocentric retrospective analysis of patients hospitalized for PVIE between January 2013 and December 2019 who were not treated with surgery and who had at least two 18F-FDG-PET/CT examinations during their medical management. RESULTS: Among 170 patients with PVIE, 117 were treated with antibiotic therapy but no surgery. Of these, 36 (31%) had at least two 18F-FDG-PET/CT examinations. At initial imaging, 28 patients had heterogeneous FDG uptake on their prosthetic valve and eight on their associated aortic graft. Hypermetabolism of spleen and bone marrow (HSBM) was observed in 18 and 19 patients, respectively. At the first follow-up 18F-FDG-PET/CT, 21 (58%) patients still had heterogeneous uptake, indicating persistent active endocarditis. HSBM was still present at the last follow-up imaging in four of the six patients with recurrent PVIE. CONCLUSION: 18F-FDG-PET/CT monitoring of medically treated patients with PVIE provides valuable additional information and prospective multicentric study should be conducted to assess its usefulness.

Prognosis and follow-up of patients with prosthetic valve endocarditis treated conservatively in relation to WBC-SPECT imaging.

BACKGROUND: Our objective was to evaluate in patients with prosthetic valve endocarditis (PVE) treated conservatively, the prognostic value of white blood cell (WBC) signal intensity on SPECT and to describe the evolution of the WBC signal under antibiotics. METHODS: Patients with PVE treated conservatively and positive WBC-SPECT imaging were identified retrospectively. Signal intensity was classified as intense if equal to or higher, or mild if lower, than the liver signal. Clinical, biological, imaging and follow-up information were collected from medical files. RESULTS: Among 47 patients, WBC signal was classified as intense in 10 patients and as mild, in 37. The incidence of the primary composite endpoint (death, late cardiac surgery, or relapse) was significantly higher in patients with intense vs. mild signal (90% vs. 11%). Twenty-five patients underwent a second WBC-SPECT imaging during follow-up. The prevalence of WBC signal decreased progressively from 89% between 3 and 6 weeks to 42% between 6 and 9 weeks and 8% more than 9 weeks after initiation of antibiotics. CONCLUSIONS: In patients with PVE treated conservatively, intense WBC signal was associated with poor outcome. WBC-SPECT imaging appears as an interesting tool for risk stratification and to monitor locally the efficacy of antibiotic treatment.

Outcomes With Percutaneous Debulking of Tricuspid Valve Endocarditis.

BACKGROUND: In patients with tricuspid valve infective endocarditis, percutaneous debulking is a treatment option. However, the outcomes of this approach are less well known. METHODS: We performed a retrospective analysis of all patients who underwent percutaneous vegetation debulking for tricuspid valve infective endocarditis from August 2020 to November 2022 at a large academic tertiary care public hospital. The primary efficacy outcome was procedural success defined by clearance of blood cultures. The primary safety outcome was any procedural complication. For the composite outcome of in-hospital mortality or heart block, outcomes were compared (sequential noninferiority and superiority) with published surgical outcomes data. RESULTS: Of the 29 patients with tricuspid valve infective endocarditis who underwent percutaneous debulking, the average age was 41.3±10.1 years, all patients had septic pulmonary emboli with 27 (93.1%) patients having cavitary lung lesions before the procedure. For the efficacy outcomes, 28 patients (96.6%) had clearance of cultures after their procedure, mean white blood cell count significantly decreased from 16.8±1.4×103 to 12.6±1.0×103 per µL (P<0.01), and mean body temperature significantly decreased from 99.8F ±0.30 to 98.3F ±0.20 (P<0.001) post-procedure. For safety outcomes, there were no procedural complications (0%). Two patients (6.9%) died during the follow-up period, both during the index hospitalization due to severe necrotizing pneumonia. When compared with published data on surgical outcomes, percutaneous debulking was noninferior and superior for the composite of in-hospital death or heart block (noninferiority, P<0.001; superiority, P=0.016). CONCLUSIONS: Percutaneous debulking is feasible, effective, and safe in treating patients with tricuspid valve infective endocarditis refractory to medical therapy.

18F-FDG PET/CT-derived total lesion glycolysis predicts abscess formation in patients with surgically confirmed infective endocarditis: Results of a retrospective study at a tertiary center.

BACKGROUND: Abnormal activity of 18F-FDG PET/CT is a major Duke criterion in the diagnostic work-up of infective prosthetic valve endocarditis (IE). We hypothesized that quantitative lesion assessment by 18F-FDG PET/CT-derived standard maximum uptake ratio (SURmax), metabolic volume (MV), and total lesion glycolysis (TLG) might be useful in distinct subgroups of IE patients (e.g. IE-related abscess formation). METHODS: All patients (n = 27) hospitalized in our tertiary IE referral medical center from January 2014 to October 2018 with preoperatively performed 18F-FDG PET/CT and surgically confirmed IE were included into this retrospective analysis. RESULTS: Patients with surgically confirmed abscess formation (n = 10) had significantly increased MV (by ~ fivefold) and TLG (by ~ sevenfold) as compared to patients without abscess (n = 17). Receiver operation characteristics (ROC) analyses demonstrated that TLG (calculated as MV × SURmean, i.e. TLG (SUR)) had the most favorable area under the ROC curve (0.841 [CI 0.659 to 1.000]) in predicting IE-related abscess formation. This resulted in a sensitivity of 80% and a specificity of 88% at a cut-off value of 14.14 mL for TLG (SUR). CONCLUSION: We suggest that 18F-FDG PET/CT-derived quantitative assessment of TLG (SUR) may provide a novel diagnostic tool in predicting endocarditis-associated abscess formation.

Multimodality imaging in marantic endocarditis associated with cancer: a multicentric cohort study.

AIMS: We aimed to assess the role of multimodality imaging (MMI) in the diagnosis of marantic endocarditis (ME) associated with cancers and to describe the clinical characteristics, management, and outcome of these patients. METHODS AND RESULTS: In a retrospective multicentric study including four tertiary centres for the treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, MMI [echocardiography, computed tomography (CT), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)], and management data were collected. Long-term mortality was analysed. Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65 ± 11 years. ME occurred in 43 cases (91%) on native valves. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by CT. No patient had an increased cardiac 18F-FDG valve uptake. The most common cardiac valve involved was aortic (34 cases, 73%). Twenty-two patients (46%) had a known cancer before ME, and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18FDG PET/CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). Systemic embolism was frequent (40 patients, 85% of cases). Forty-one patients (87%) were treated medically with anticoagulation therapy. One-year mortality was 55% (26 patients). CONCLUSION: ME remains associated with a high risk of complications and death.