Correlating cardiac F-18 FDG PET/CT results with intra-operative findings in infectious endocarditis.

BACKGROUND: Multiple studies have demonstrated that when incorporated with conventional imaging modalities, cardiac F-18 PET/CT can aid in diagnosis of endocarditis and improve the sensitivity of the Duke Criteria. These studies used as their gold standard the opinion of an endocarditis team and were characterized by low percentages of patients who underwent surgery. We reviewed 4 years of surgically managed IE cases where F-18 cardiac PET/CT was used to aid diagnosis. METHODS: Between July 2014 and December 2018, we retrospectively reviewed 68 surgically managed endocarditis cases to identify patients who underwent pre-operative PET scans. RESULTS: Fourteen patients were identified who underwent F-18 cardiac PET/CT prior to surgical intervention. Nine cases were classified as possible endocarditis by Duke Criteria and 8 involved prosthetic valves. Twelve out of fourteen scans were interpreted as suggestive of or consistent with endocarditis based on FDG uptake. Twelve positive PETs were associated with either operative findings of infection and/or positive PCR testing on the excised valve. Two patients with negative scans were found to have non-infectious mobile masses intra-operatively, negative valve cultures and negative pathology. CONCLUSION: In a small cohort, F-18 FDG cardiac PET/CT correlated closely with intra-operative findings in patients with endocarditis and helped guide surgical decision-making. It could be considered for addition to the Duke Criteria in the American Heart Association endocarditis guidelines similar to European protocols.

Physician perceptions of a multidisciplinary endocarditis team.

Infectious endocarditis is a highly morbid infection that requires coordination of care across medical and surgical specialties, often through the use of a multidisciplinary team model. Multiple studies have demonstrated that such conferences can improve clinical outcomes. However, little is known about physicians' impressions of these groups. We surveyed 126 (response rate of 30%) internal medicine, infectious diseases, cardiology, and cardiac surgery providers 1 year after the implementation of an endocarditis team at the University of Michigan. Ninety-eight percent of physicians felt that the endocarditis team improved communication between specialties. Additionally, over 85% of respondents agreed that the group influenced diagnostic evaluation, reduced management errors, increased access to surgery, and decreased in-hospital mortality for endocarditis patients. These results suggest that multidisciplinary endocarditis teams are valued by physicians as a tool to improve patient care and serve an important role in increasing communication between providers.

Cerebral oxygenation and processed EEG response to clamping and shunting during carotid endarterectomy under general anesthesia.

Clamping and shunting during carotid endarterectomy (CEA) surgery causes changes in cerebral blood flow. The purpose of this study was to assess and compare, side by side, the cerebral oxygenation (rSO2) and processed electroencephalogram (EEG) response bilaterally to carotid artery clamping and shunting in patients undergoing CEA under general anesthesia. With institutional approval and written informed consent, patients undergoing CEA under general anesthesia and routine carotid artery shunting were recorded bilaterally, simultaneously and continuously with an rSO2 and processed EEG monitor. The response of the monitors during carotid artery clamping and shunting were assessed and compared between monitors and bilaterally within each monitor. Sixty-nine patients were included in the study. At clamping the surgical-side and contralateral-side rSO2 dropped significantly below the baseline incision value (-17.6 and -9.4% respectively). After shunting, the contralateral-side rSO2 returned to baseline while the surgical-side rSO2 remained significantly below baseline (-9.0%) until the shunt was removed following surgery. At clamping the surgical-side and contralateral-side processed EEG also dropped below baseline (-19.9 and -20.6% respectively). However, following shunt activation, the processed EEG returned bilaterally to baseline. During the course of this research, we found the rSO2 monitor to be clinically more robust (4.4% failure rate) than the processed EEG monitor (20.0% failure rate). There was no correlation between the rSO2 or processed EEG changes that occurred immediately after clamping and the degree of surgical side stenosis measured pre-operatively. Both rSO2 and processed EEG respond to clamping and shunting during CEA. Cerebral oximetry discriminates between the surgical and contralateral side during surgery. The rSO2 monitor is more reliable in the real-world clinical setting. Future studies should focus on developing algorithms based on these monitors that can predict clamping-induced cerebral ischemia during CEA in order to decide whether carotid artery shunting is worth the associated risks. From the practical point of view, the rSO2 monitor may be the better monitor for this purpose.

Invasive Candida Infection in Patients With Bacterial Infective Endocarditis.

Over 21 months, 12 patients with invasive Candida infections detected during the course of treatment of bacterial endocarditis, including 11 with candidemia, were identified. Invasive Candida infections can occur as a complication of bacterial endocarditis and may occur more frequently in patients with injection drug use and broad-spectrum antibiotic exposure.

Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis.

BACKGROUND: The opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data. This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery. METHODS: The authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. RESULTS: Between January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008). CONCLUSION: The study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Shared Decision-Making for Partial Oral Antibiotic Treatment of Infective Endocarditis: A Case Series.

Although literature has demonstrated the noninferiority of oral antibiotics in the treatment of infectious endocarditis, widespread adoption of this practice has yet to occur in the United States. We report on 32 patients with infectious endocarditis treated by a multidisciplinary endocarditis team and a standardized approach to partial oral antibiotic therapy with a high rate of clinical success.

Beyond a team: The comprehensive interdisciplinary endocarditis program in the United States.

Although multidisciplinary teams have been shown to decrease in-hospital mortality for patient with infectious endocarditis, most studies have focused on the inpatient role of these teams, and are primarily based at European tertiary care centers. There is limited literature available on the optimal longitudinal care of this patient population. Here we outline our experience developing an interdisciplinary endocarditis program at the University of Kentucky, which cares for patients from their index hospitalization into the outpatient setting, while also coordinating transfers from regional hospitals and offering education to regional providers.

Intracranial Hemorrhage as a Marker for Mycotic Aneurysm in Patients With Infective Endocarditis.

Background and Objective: Mycotic aneurysms are a significant complication of IE that can lead to intracranial hemorrhage (ICH) and occasionally require intervention before valve surgery. Digital subtraction angiography (DSA) remains the gold standard for the detection of mycotic aneurysms but is an invasive procedure with contrasted dye exposure. Our objective was to determine predictive factors for the presence of mycotic aneurysms in patients with known infective endocarditis (IE). Methods: IRB exemption was obtained from the University of Pittsburgh Medical Center. Patients with left-sided or right-sided endocarditis with patent foramen ovale (PFO) were identified. Records were retrospectively reviewed by an independent investigator. Patients were stratified by demographic information, diagnostic imaging, and clinical outcomes. Standard descriptive statistics were used for characterization. The χ2 analysis and Fisher exact test were used for categorical comparisons. The Student t test was used for group comparisons. Results: 36 cases of left-sided or right-sided endocarditis with PFO undergoing evaluation for valve surgery were identified. Twenty-seven patients underwent CNS imaging, and 24 underwent DSA. Six patients were found to have ICH on CNS imaging. Mycotic aneurysms were identified by DSA in 5 patients (13.9%), and of these patients, 4 (80%) presented with ICH and 1 with ischemic stroke. Notably, the patient who presented with ischemic stroke then developed ICH on follow-up CT imaging. The negative predictive value of the absence of ICH on initial CNS imaging for the presence of mycotic aneurysm was 97.4%. Discussion: Patients with left-sided and right-sided endocarditis with PFO and ICH on CNS imaging were more likely to have mycotic aneurysms detected through DSA than similar patients without ICH. Routine DSA screening for mycotic aneurysms may not be required in patients with endocarditis undergoing evaluation for valve surgery who present without ICH on CNS imaging.

Outcomes of Endocarditis in Pregnancy: A Single-Center Experience.

Background: The incidence of infective endocarditis (IE) in pregnancy is rare (0.006%), with increasing prevalence during the opioid epidemic. IE in pregnancy is associated with high rates of mortality and morbidity, and existing data on outcomes in pregnancy are limited. Our study compares the outcomes of pregnant patients with IE with those of nonpregnant patients. Methods: Patients diagnosed with IE during pregnancy and 30 days postpartum between 2014 and 2021 were identified by International Classification of Diseases, Clinical Modification, Ninth and Tenth Edition codes. Pregnant cases were matched to nonpregnant reproductive-age endocarditis patients in a 1:4 ratio. Data were collected and validated through chart review. Results: One hundred eighty patients with IE were identified; 34 were pregnant or within 30 days postpartum at diagnosis. There were higher rates of hepatitis C and opioid maintenance therapy in the pregnant patients. The etiology of IE in pregnant patients was predominantly S. aureus (methicillin-resistant/sensitive S. aureus), whereas nonpregnant woman had greater microbiological variation. We observed comparable rates of valve replacement (32.4% vs 29%; P = .84) and 2-year mortality (20.6% vs 17.8%; P > .99) in pregnant patients. There were nonsignificantly higher rates of pulmonary emboli (17.6% vs 7.5%; P = .098) and arrhythmia (17.6% vs 9.6%; P = .222) among pregnant patients. There were high rates of intravenous drug use relapse in both groups (>40%). Conclusions: We observed similar rates of mortality in the pregnant IE patients. We observed a microbial predilection for S. aureus in pregnancy, suggesting that the pregnancy physiology may select for this microbiologic etiology. This study, which represents the largest single-center retrospective review of IE in pregnancy, suggests that surgical intervention may be performed safely in the postpartum period.

Paradoxical embolisation to the brain in right-sided infective endocarditis and patent foramen ovale in a pregnant woman.

The incidence of infective endocarditis in pregnancy has increased as a result of the opioid epidemic. Right-sided infective endocarditis (RSIE), specifically tricuspid valve endocarditis, is more commonly linked to injection drug use. In pregnant patients, a prompt diagnosis and treatment of infective endocarditis are crucial to prevent fetal and maternal morbidity and mortality. Complications associated with infective endocarditis in pregnancy include death, preterm labour and embolic disease. RSIE is classically linked to septic pulmonary emboli; however, we report a unique case of a pregnant patient with known tricuspid valve infective endocarditis. Our patient unfortunately developed an ischaemic stroke from paradoxical brain embolisation in the setting of a previously undiagnosed patient foramen ovale. Furthermore, we demonstrate the importance of considering how normal cardiac physiological changes associated with pregnancy can impact the clinical course in patients with RSIE.

Embolic myocardial infarction with cardiac arrest as an initial manifestation of non-bacterial thrombotic endocarditis.

Non-bacterial thrombotic endocarditis, characterised by sterile vegetations, is commonly caused by systemic lupus erythematosus and is known to be complicated with embolic cerebrovascular disease. Embolic myocardial infarction with non-bacterial thrombotic endocarditis is extremely rare. We report a case of ventricular fibrillation arrest from presumed coronary embolisation in non-bacterial thrombotic endocarditis. While there are no standardised guidelines on the management of embolic myocardial infarction in endocarditis, it requires a multidisciplinary approach unique for every encountered clinical scenario.

The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter.

The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.

Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale.

Intravenous drug use (IVDU) is a growing public health crisis worldwide. A known complication of IVDU is right-sided infective endocarditis (RSIE) involving the tricuspid valve. As the tricuspid valve is burdened with infectious vegetations, it becomes a potential source of pulmonary and, very rarely, paradoxical systemic emboli. We report two patients with RSIE involving the tricuspid valve presenting with acute change in mental status. Subsequent imaging demonstrated embolisation to the brain in the setting of elevated right atrial pressures and the presence of a patent foramen ovale (PFO) with right-to-left shunting. We employed a strategy of percutaneous closure of PFO, to prevent further embolisation, as a successful bridge to definitive surgical management of RSIE. We emphasise that clinicians should evaluate for intracardiac shunting and pursue transesophageal echocardiography when encountering systemic emboli of unknown origin, particularly in patients with RSIE.

Cryoglobulinemic vasculitis in two patients with infective endocarditis: a case series.

Cryoglobulins are circulating immune complexes that precipitate at cool temperatures and can induce a small-vessel vasculitis. While patients with endocarditis are well known to have circulating cryoglobulins, cryoglobulinemic vasculitis is a rare complication of infective endocarditis with infrequent publication of reported cases. We present two cases of methicillin-resistant Staphylococcus aureus tricuspid valve infective endocarditis in patients with substance use disorder complicated by cryoglobulinemic cutaneous vasculitis confirmed by skin biopsy, including one patient who developed renal and colonic manifestations of vasculitis. Both patients had symptomatic improvement in their vasculitis with appropriate antimicrobial therapy, including one patient who received a short course of prednisone and another with chronic active hepatitis C that remained untreated. Providers should have a high-index of suspicion for infective endocarditis in patients presenting with new onset cryoglobulinemic vasculitis, particularly if the patients have underlying risk factors for endocarditis.

Management of infective endocarditis in pregnancy by a multidisciplinary team: a case series.

INTRODUCTION: The incidence of infective endocarditis (IE) in pregnancy is rare and has been increasing during the opioid epidemic. IE in pregnancy is associated with high rates of maternal and fetal morbidity and mortality. Multidisciplinary endocarditis teams for management of IE have been shown to reduce in-hospital and 1-year mortality. We present a single-center experience managing IE in pregnancy utilizing a multidisciplinary endocarditis team. METHODS: Patients diagnosed with IE while pregnant or within 30 days post-partum were identified. All patients discussed at the institution's weekly multidisciplinary endocarditis meeting were included. Demographic and clinical data and outcome-related variables were retrospectively reviewed and recorded. RESULTS: Between 1 October 2020 and 1 June 2021 6 pregnant or 30-day post-partum patients with IE were identified. All patients had co-morbid injection drug use; Staphylococcus aureus was the etiologic pathogen in all patients. All patients had embolic complications and 5 required ICU admission and mechanical ventilatory support. Four patients underwent valve replacement. There were no patient-directed discharges. All patients survived to hospital discharge and 90-days after diagnosis. Four pregnancies resulted in delivery at an average gestational age of 32.4 weeks with 3 requiring NICU admissions and prolonged lengths of stay. All patients were seen by addiction medicine and 5 were started on medication-assisted treatment for opioid use disorder. DISCUSSION: In a small retrospective cases series, coordination of care by a multidisciplinary endocarditis team led to a high-rate of surgical intervention with no patient-directed discharges and no in-hospital or 90-day mortality. CONCLUSION: Multidisciplinary endocarditis teams are a low-risk intervention that may improve outcomes in pregnant patients with IE.

Partial oral antibiotic treatment of endocarditis in patients who inject drugs: a case series.

BACKGROUND: Recent literature has demonstrated that partial oral antibiotic treatment of infectious endocarditis is non-inferior to IV therapy in select patients. Despite the rising incidence of injection drug use-related endocarditis, partial oral therapy has not been well studied in persons who inject drugs. OBJECTIVES: To evaluate the rate of relapsed infection and 90 day mortality in patients with infectious endocarditis treated with partial oral antibiotic therapy. METHODS: Consecutive patients with infectious endocarditis treated with partial oral antibiotic therapy were identified by study investigators and reviewed by independent clinicians. The decision to use partial oral antibiotic therapy was made by the institution's multidisciplinary endocarditis team. RESULTS: In 11 cases of infective endocarditis treated with partial oral antibiotic therapy, 9 of which were complicated by injection drug use, there were no relapsed infections with the primary organism. Five patients underwent surgical valve replacement, and the median duration of oral antibiotic therapy was 23 days. All patients survived to in-hospital discharge and 90 days post-discharge. Ten patients followed up with an infectious diseases provider after discharge. CONCLUSIONS: These data add to existing literature demonstrating non-inferior outcomes with partial oral antibiotic treatment when compared with IV antibiotic treatment alone in patients with endocarditis, including persons who inject drugs.

The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team.

BACKGROUND: Infectious endocarditis is associated with substantial in-hospital mortality of 15%-20%. Effective management requires coordination between multiple medical and surgical subspecialties, which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality. METHODS: The multidisciplinary endocarditis team was formed in May 2018. The group developed an evidence-based algorithm for management of endocarditis that was used to provide recommendations for hospitalized patients over a 1-year period. Mortality outcomes were then retroactively assessed and compared to a historical control utilizing propensity matching. RESULTS: Between June 2018 and June 2019 the team provided guideline-based recommendations on 56 patients with Duke Criteria-definite endocarditis and at least 1 American Heart Association indication for surgery. The historical control included 68 patients with definite endocarditis and surgical indications admitted between July 1, 2014, and June 30, 2015. In-hospital mortality decreased significantly from 29.4% in 2014-2015 to 7.1% in 2018-2019 (P < .0001). There was a non-significant increase in the rate of surgical intervention after implementation of the team (41.2% vs 55.4%; P = 0.12). Propensity score matching demonstrated similar results. CONCLUSIONS: Implementation of a multidisciplinary endocarditis team was associated with a significant 1-year decrease in all-cause in-hospital mortality for patients with definite endocarditis and surgical indications, in the presence of notable differences between the 2 studied cohorts. In conjunction with previous studies demonstrating their effectiveness, these data support the idea that widespread adoption of endocarditis teams in North America could improve outcomes for this patient population.