[Bacillus cereus endocarditis and a probable cutaneous gateway]. / Endocardite à Bacillus cereus avec probable porte d'entrée cutanée.

BACKGROUND: Bacillus cereus is a ubiquitous telluric organism. B. cereus endocarditis is a rare condition seen mostly in prosthetic heart valves and among intravenous drug users. We report a new case of a patient without risk factors and with a good clinical outcome not requiring valve replacement. CASE REPORT: In October 2014, a 50-year-old woman was referred to the dermatology department of Lille University Hospital for lower-limb wounds developing 6 months earlier. She presented fever without clinical signs of infection, except for the lower-limbs wounds. Blood cultures revealed the presence of B. cereus. Transesophageal echocardiography was performed and revealed two foci of aortic valve vegetation with a diameter of 5mm. After bacterial sensitivity testing, rifampicin and levofloxacin treatment was given for six weeks, with complete remission. A skin graft was performed and good improvement was seen. DISCUSSION: Nineteen cases of B. cereus endocarditis have been described previously, only one of which was without risk factors. We described a case of complete remission after a 6-week course of antibiotics. Our case demonstrates that BC should not be considered as a blood culture contamination, and that treatment may be complex due to antibiotic resistance.

[Infective endocarditis : In-hospital mortality predictive factors]. / Endocardite infectieuse : facteurs prédictifs de mortalité intrahospitalière.

INTRODUCTION: Infective endocarditis (IE) remains a serious disease with significant morbidity and mortality despite therapeutic advancements. The aim of our study was to determine the predictive factors of in-hospital mortality. PATIENTS AND METHODS: A prospective comparative study over a period of 54 months was conducted, including all patients admitted for definite infective endocarditis, diagnosed according to the modified Duke criteria published in 2015 by the European Society of Cardiology. RESULTS: Thirty-four patients were included. Drug addiction was the main risk factor for infective endocarditis (56%). Tricuspid valve involvement was predominant (50%). Staphylococcus aureus was the most commonly isolated pathogen (65%). In-hospital mortality rate was 47%. In multivariate analysis, predictive factors for mortality were acute heart failure (OR=7.4; p=0.026; 95% CI [1.2-44]) and cerebral embolic localization (OR=11.1; p=0.024; 95% CI [13-90]). CONCLUSIONS: Cardiac and cerebral complications influence the prognosis of IE. Thus, close collaboration among multidisciplinary teams is necessary for improved diagnostic and therapeutic management.

[A rare case of arterial thrombosis secondary to Aerococcus viridans aortic endocarditis]. / Un cas rare de thrombose artérielle secondaire à une endocardite aortique à Aerococcus viridans.

Infective endocarditis is an uncommon, yet serious disease responsible for high morbidity and mortality, its incidence is estimated at 3-10 cases per 100,000 person-years. Most infective endocarditis cases emanate from streptococcus and staphylococcus. The incrimination of Aeroccocus viridans is rarely described in the literature and it has a high rate of embolic complication. We report the case of a 31-year-old male patient, with no prior medical history, who was admitted to the cardiology department of Ibn Rochd university center due to a prolonged fever for over 6 months. At admission, his general condition was preserved, he was febrile at 38.7 °C, claudication in the right lower limb with a decrease in the peroneal artery pulse, a graded 4/6 diastolic aortic murmur on auscultation, and no signs of heart failure. The transthoracic echocardiography revealed a type I bicuspid aortic valve disease, severe aortic regurgitation, moderate aortic stenosis, and vegetation implanted on the ventricular side of the right coronary cusp. CT angiography of the lower limbs revealed a bilateral total occlusion of the tibioperoneal trunks extended to the proximal portions of the posterior tibial arteries and peroneal arteries with collateral circulation, endovascular collection, and occlusive calcified plaque of the proximal part of the right anterior tibial artery and the collateral circle. Blood tests showed an inflammatory syndrome. Blood cultures detected Aerococcus viridans. The patient was first put on ceftriaxone, gentamycin, unfractionated heparin, and analgesic-antipyretic when necessary, he was then transferred to the cardiovascular surgery department for replacement of the aortic valve and permeabilization of the lower limbs by the FOGARTY technique. Post-surgical results were satisfying. In conclusion, infective endocarditis secondary to Aerococcus viridans is rare but appears to be virulent because most often discovered at the stage of complications. Therefore, good antibiotic therapy adapted to the antibiogram results in a good prognosis.

[Delayed renal infectious aneurysm 3 months after cardiac surgery for a Streptococcus pyogenes infective endocarditis ; case report and literature review]. / Anévrysme rénal infectieux retardé, 3 mois après chirurgie cardiaque pour une endocardite infectieuse à Streptococcus pyogenes ; cas et revue de la littérature.

Infective endocarditis (IE) due to Streptococcus pyogenes (SP) (Group A Streptococcus) is uncommon and infectious renal artery aneurysm (IRAA) is an exceptional complication of IE, with few cases reported in the literature. We describe a case of SP native mitral valve IE in a 58-year-old man, presenting with large valve vegetations, abscess and severe regurgitation. Initial CT-angiography showed bilateral kidney and splenic infarcts. He underwent successful emergent bioprosthetic valve replacement. Antibiotic regimen consisted in linezolid and rifampicin for 8 weeks. Three months later, CT-angiography for feet gangrene revealed a 16mm aneurysm of the left intraparenchymal renal artery, which was occluded by coil-embolization. This case shows that an infectious aneurysm may develop several months after antibiotic treatment and emergent valve replacement for IE.

[Tetralogy of Fallot with absent pulmonary valve syndrome diagnosed in adulthood by infective endocarditis : Case of report]. / Agénésie de la valve pulmonaire avec communication interventriculaire découverte à l'âge adulte suite à une endocardite infectieuse : à propos d'un cas.

Absent pulmonary valve syndrome is a rare congenital heart disease. Associated with ventricular septal defect, it is considered a rare variant of Tetralogy of Fallot "Tetralogy of Fallot with absent pulmonary valve syndrome". It is characterized by its association with aneurysmal pulmonary arteries responsible for airways compression. Survival to adulthood of this unrepaired congenital heart disease is very rare, and the case of the patient we report in this article is added to the rare cases reported in the literature. Clinical tolerance depends on the degree of severity of the malformation and in particular on the importance of the aneurysmal dilation of the pulmonary arteries, thus determining the age of the diagnosis, the severity of symptoms, and the mode of evolution. Diagnosis of Tetralogy of Fallot with absent pulmonary valve syndrome must be established by transthoracic echography. Other investigations can be of capital contribution, such as thoracic computed tomography angiography and cardiac catheterization. The treatment is surgical and includes closure of the ventricular septal defect, relieve right ventricular outflow tract obstruction, and surgical reduction of the aneurysmal pulmonary arteries.

Infective endocarditis of a native aortic valve due to Pseudomonas aeruginosa complicated by progressive multi-drug resistance.

BACKGROUND: Treatment of infective endocarditis secondary to Pseudomonas aeruginosa can be challenging because of this organism's ability to acquire antimicrobial resistance over time. METHODS: We describe a patient with native aortic valve infective endocarditis due to P. aeruginosa who developed progressive multi-drug resistance while on therapy. The resistance mechanisms were characterized using whole-genome sequencing. RESULTS: We identified two mutations in subsequent isolates (dacB and OprD) that conferred resistance to anti-pseudomonal penicillins, cephalosporins, and carbapenems. The patient was treated with combination high-dose continuous infusion meropenem and ciprofloxacin therapy, in addition to bioprosthetic aortic valve replacement and repair of ventricular septal wall defect. Antibiotics were continued for 6 weeks post-cardiac surgery and the patient remains infection free 18 months post-completion of antibiotic therapy. CONCLUSION: Clinicians should be aware of the ability of P. aeruginosa to acquire resistance mechanisms in response to selective antibiotic pressures in high-inoculum infections such as infective endocarditis. The mutations identified in this case report correlated well with the evolving antimicrobial resistance profile observed.

HISTORIQUE: Il peut être difficile de traiter une endocardite infectieuse causée par un Pseudomonas aeruginosa en raison de la capacité de cet organisme à acquérir une résistance aux antimicrobiens. MÉTHODOLOGIE: Les chercheurs décrivent un patient atteint d'une endocardite infectieuse de la valve aortique d'origine, attribuable à un P. aeruginosa, qui a acquis une multirésistance progressive pendant son traitement. Le mécanisme de résistance était caractérisé par le séquençage du génome entier. RÉSULTATS: Les auteurs ont dépisté deux mutations dans les isolats subséquents (dacB et OprD ), responsables d'une résistance aux pénicillines, aux céphalosporines et aux carbapénèmes antipseudomonaux. Le patient a reçu une polythérapie de perfusion continue de méropénem à forte dose et de ciprofloxacine, en plus du remplacement d'une valve aortique bioprothétique et de la réparation d'une communication interventriculaire. L'antibiothérapie s'est poursuivie six semaines après l'opération, et le patient n'avait pas d'infection 18 mois après la fin de l'antibiothérapie. CONCLUSION: Les cliniciens devraient savoir que le P. aeruginosa peut acquérir des mécanismes de résistance en réponse aux pressions antibiotiques sélectives en cas d'infections comportant un titre élevé d'inoculum comme une endocardite infectieuse. Les mutations constatées dans le présent rapport de cas étaient bien corrélées avec l'évolution du profil de résistance antimicrobienne observé.

Infective endocarditis: Epidemiology and prognosis.

INTRODUCTION: Infective endocarditis (IE) is associated with high morbidity and mortality, despite advances in diagnosis and treatment. OBJECTIVE: To assess changes in the epidemiological profile of IE, to perform a time-trend analysis and to define short-term and long-term prognostic predictors of IE. METHODS: Retrospective analysis of 173 patients admitted with a diagnosis of IE to a Portuguese level II Hospital between January 1998 and December 2013. The patients were divided into two groups according to the period of occurrence of the IE episode (1998-2007 vs. 2008-2013). The clinical event studied was the occurrence of death or the need for urgent surgery during hospitalization, and death in the follow-up period. Independent predictors of short-term and long-term prognosis were identified. RESULTS: In the first portion of the study, IE occurred in younger individuals, often drug addicts, users of intravenous drugs and with gastrointestinal disease, human immunodeficiency virus and hepatitis B infection. In the second portion of the study, IE occurred more frequently in individuals of an older age with concomitant cardiovascular disease; enterococcus was isolated more frequently. The independent predictors of in-hospital death or need for urgent valve surgery were septic shock and the occurrence of peri-annular complications. The independent predictors of long-term mortality were age, chronic kidney disease and IE due to multidrug-resistant microorganisms. CONCLUSION: Differences were found in the epidemiological profile of IE during the study period. Referral for valve surgery increased slightly, but mortality remained high.

Hemangioma of the mitral valve: Following the murmur.

Cardiac hemangiomas are an exceedingly rare condition, with about 100 cases described in the literature, of which only 13 were valvular. We report the case of a 66-year-old woman, with no prior cardiovascular disease, who presented with an abdominal infection caused by Enterococcus faecalis, complicated by recrudescent fever and new-onset systolic mitral murmur. The transesophageal echocardiogram revealed a large vegetation on the posterior leaflet of the mitral valve, with a high embolic risk, leading to a diagnosis of acute endocarditis. The patient began antibiotics, with no clinical improvement, developing severe heart failure and coronary and cerebrovascular embolic phenomena, and underwent excision of the mass and placement of a biological mitral prosthesis. The histopathologic analysis revealed a cavernous hemangioma. Eight months later, the patient presented with recurrence of acute bacterial endocarditis and septic shock, and underwent replacement of the prosthetic valve. The histologic exam showed no signs of hemangioma. The rarity of this case and its complications make its presentation relevant.

Mitral valve repair is better than mitral valve replacement in native mitral valve endocarditis: Results from a prospective matched cohort.

BACKGROUND: In native mitral valve infective endocarditis (NMIE), the respective values of mitral valve repair (MVRep) and replacement (MVR) are still debated. AIM: To compare MVRep and MVR in a large prospective matched cohort. METHODS: Between 2010 and 2017, all consecutive patients operated on for NMIE in our centre were included prospectively. Clinical and outcome features were compared between the two groups. Primary endpoint was event-free survival, including death, reoperation and relapse. Univariate and multivariable survival analyses and a propensity score analysis were performed. RESULTS: Among 152 patients, 115 (75.7%) underwent MVRep, and 37 (24.3%) MVR. Median follow-up was 28±22months. Surgery was performed during the active phase in 75.0% of patients (25.7% on an urgent basis). Compared with the MVRep group, patients in the MVR group were more frequently intravenous drug abusers (10.8% vs. 0.9%; P=0.016), had a more frequent history of rheumatic fever (13.5% vs. 0%; P=0.001), more aortic abscesses (16.7% vs. 3.5%; P=0.018), larger vegetations (16.6±8.1mm vs. 12.6±9.9mm; P=0.042) and poorer New York Heart Association status (P=0.006). Overall mortality was lower in the MVRep group than in MVR group (11.3% vs. 29.3%; P=0.018). Event-free survival was better in the MVRep group than in the MVR group in univariate analysis (hazard ratio: 2.72, 95% confidence interval: 1.34-5.52; P=0.004). Survival analysis in the propensity-matched cohort showed that MVRep was safer than MVR (log rank test: P=0.018). Multivariable analysis using the Cox proportional hazard model confirmed this finding (hazard ratio: 3.48, 95% confidence interval: 1.15-10.61; P=0.03). CONCLUSIONS: MVRep is feasible in most cases of NMIE and, when technically possible, should be preferred, even in urgent surgery.

Premier cas d'endocardite infectieuse sur valve aortique prosthétique dû à Prevotella Intermedia.

INTRODUCTION: Prevotella species (i. e. P. intermedia, P. nigrescens, P. pallens, P. oris) are usually responsible for abscesses of head and neck spaces after dental procedures. P. intermedia - related infective endocarditis has never been reported. CASE REPORT: A 22-year-old man, with a history of aortic valve replacement 6 years ago, presented with fever and persistent retrosternal chest pain. An empirical antibiotic therapy was started on (cefotaxime, 2gx3 - gentamicin, 5mg/kilo). Five blood cultures were positive at Prevotella Intermedia. Metronidazole was introduced (500mg X 3 by day).The oro-pharyngeal spaces were normal. The evolution was marked by a hypotension, a third degree atrio-ventricular block, and a rapidly growing aortic root abscess complicated this case of Prevotella Intermedia infective endocarditis (IE). Aortic valve redux surgery was performed at day 5 of admission. Post-operative course was unremarkable. CONCLUSION: This first reported case of Prevotella Intermedia IE presented suggestive features of anaerobic IE as the patient developed both aortic-ring abscess, third degree atrio-ventricular block and hypotension.

Endocarditis due to Trichosporon beigelii 11 years after mitral valve replacement. / Endocardite por Trichosporon beigelii 11 anos após cirurgia de troca valvar mitral.

Trichosporon beigelii is a non-pathogenic fungus that can however become an opportunist agent of disseminating and potentially fatal infections, especially in immunocompromised patients. In the literature, there are only 11 published cases of infective endocarditis due to T. beigelii. Most of these cases involved immunocompetent individuals and the main risk factor was the presence of a prosthetic valve. The longest interval between surgery and endocarditis was eight years. In the present study, a case of prosthetic valve endocarditis due to T. beigelii is reported in an immunocompetent patient 11 years after mitral valve replacement. As with similar cases, low clinical suspicion and negative blood cultures delayed the beginning of antifungal therapy and cardiac surgery. Considering the high mortality and severity of T. beigelii endocarditis, it should be considered when there is a prosthetic valve infection with negative blood cultures, irrespective of the time elapsed since the previous surgery.

18F-fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of native valve infective endocarditis: A prospective study.

BACKGROUND: 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE). AIMS: Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake). METHODS: Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected. RESULTS: Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P<0.001), without a change in specificity. Diffuse splenic uptake was observed in 39 (52.0%) patients, including 37 (58.7%) with a final diagnosis of NVE (specificity 83.3%). CONCLUSIONS: 18F-FDG PET/CT has poor sensitivity but high specificity in the diagnosis of NVE. The usefulness of 18F-FDG PET/CT is high for embolic detection. Diffuse splenic uptake represents a possible new diagnostic criterion for NVE.

The burden of infective endocarditis in Portugal in the last 30 years - a systematic review of observational studies.

INTRODUCTION: Infective endocarditis affects cardiac valves or devices and has a potentially uncertain prognosis. Little information is available on the epidemiology of this disease in Portugal. OBJECTIVE: A systematic review of all evidence published in the last 30 years to assess epidemiological data in patients hospitalized with infective endocarditis in Portuguese hospital centers. METHODS: Extensive search of all published evidence using Medline, Scopus, general search databases and in addition Portuguese medical journals was performed. All relevant studies in Portuguese or English that reported short- or long-term mortality were included. RESULTS: Eighteen retrospective cohort studies (15 medical and three surgical series) were included with a total of 1872 patients assessed. The medical series included 1279 patients. Older males with predominant native left heart valve involvement were identified. Staphylococcus and streptococcus were the most frequent reported pathogens. Surgical intervention was performed on average in 29.8% of cases. The short-term mortality rate ranged from three to 37.2% (average 21.9%). Surgical cases involved older males with affected native left heart valves, emergent/urgent indication was dominant and short-term mortality ranged from 13.6 to 16%. CONCLUSIONS: The current study provides a descriptive analysis of the published series of infective endocarditis in Portugal over the last 30 years. Therefore, it may serve as a starting point for the development and implementation of a multicentric prospective registry on infective endocarditis patients in Portugal that will allow a better and more accurate characterization of this special patient population.

Infective endocarditis with neurological complications: Delaying cardiac surgery is associated with worse outcome.

BACKGROUND: Infective endocarditis (IE) is associated with a high mortality rate, related in part to neurological complications. Studies suggest that valvular surgery should be performed early when indicated, but is often delayed by the presence of neurological complications. AIM: To assess the effect of delaying surgery in patients with IE and neurological complications and to identify factors predictive of death. METHODS: In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death. RESULTS: Between April 2014 and January 2018, 351 patients with a definite diagnosis of left-sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P=0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61-33.67; P=0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22-121.17; P=0.006). CONCLUSIONS: Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration.

[Libman-Sacks endocarditis under apixaban in a patient with a high-risk profile venous antiphospholipid syndrome]. / Une endocardite de Libman-Sacks survenant sous apixaban chez une patiente atteinte de SAPL veineux de profil à haut risque.

INTRODUCTION: Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile. CASE REPORT: We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement. CONCLUSION: To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome.

Adherence to diagnostic and therapeutic practice guidelines for suspected cardiac implantable electronic device infections.

BACKGROUND: Despite guidelines describing the optimal diagnostic and therapeutic procedures for patients with suspected cardiac implantable electronic device (CIED) infections, their management is often challenging. AIMS: To describe our diagnostic and therapeutic practices for suspected CIED infection, and to compare them with European Heart Rhythm Association (EHRA) guidelines. METHODS: Patients hospitalized in the tertiary care Nancy University Hospital for suspected CIED infection from 2014 to 2019 were included retrospectively. We applied the EHRA classification of CIED infection, and compared diagnostic and therapeutic management with the EHRA guidelines. RESULTS: Among 184 patients (mean age 72.3±12.4 years), 137 had a proven infection of the lead (by transthoracic echocardiography/transoesophageal echocardiography, 18F-fluorodesoxyglucose positron emission tomography/computed tomography or positive culture of the lead) or an isolated pocket infection without proof of lead infection, and 47 had no proof of CIED infection. According to the EHRA classification, CIED infection was considered as definite in 145 patients and possible in 31 and was excluded in eight patients. Regarding recommended diagnostic procedures, blood cultures were performed in 90.8%, transthoracic echocardiography in 97.8%, transoesophageal echocardiography in 85.9%, 18F-fluorodesoxyglucose positron emission tomography/computed tomography in 50.5% and imaging for embolisms in 78.3% of the patients. Compared with therapeutic recommendations for the 145 cases of definite CIED infection, device removal was performed in 96 patients (66.2%) and antibiotic therapy was prescribed in 130 (89.7%), with a duration equal to or longer than that recommended in 105 (72.4%) of the patients. CONCLUSION: This study underlines the difficulties in following theoretical guidelines in daily practice, where both technical and human considerations interfere with their strict appliance.

Invasive aspergillosis and endocarditis.

INTRODUCTION: Aspergillusfumigatus can cause a systemic infection called invasive aspergillosis causing pulmonary and extra-pulmonary damage. Aspergillus endocarditis (AE) is a relatively rare disease but can be life-threatening. CASE REPORTS: We report here on five cases of endocarditis due to invasive aspergillosis: a 58-year-old man receiving immunosuppressive medication following a kidney graft, a 58-year-old man undergoing chemotherapy for chronic lymphocytic leukaemia, a 55-year-old man receiving corticosteroids for IgA vasculitis, a 52-year-old HIV-infected woman under no specific treatment and a 17-year-old boy under immunosuppressive therapy for auto-immune chronic neutropenia. DISCUSSION: Aspergillus accounts for 25-30% of fungal endocarditis and 0.25% to 8.5% of all cases of infectious endocarditis. Aspergillus endocarditis results from invasion of the lung arterioles by hyphae and blood dissemination. It is associated with a very high mortality rate (42-68%). Diagnosing Aspergillus endocarditis is mainly problematic because blood cultures are almost always negative, and fever may be absent. Immunosuppression, haematological malignancies, recent cardiothoracic surgery, negative blood cultures with endocarditis and/or systemic or pulmonary emboli are predictors of AE. In the setting of endocarditis, some clinical characteristics may raise early suspicions of aspergillosis rather than a non-fungal agent: no fever, vegetations affecting the mitral valve, non-valve or aortotomy sites, aortic abscess or pseudo-aneurysm. The identification of invasive aspergillosis is based on a chest CT scan, microscopy/culture or other serological and molecular tests. The treatment of Aspergillus endocarditis requires triazole antifungal drugs, and frequently additional surgical debridement. CONCLUSION: Aspergillus endocarditis is rare but is associated with a very high mortality rate. Knowledge of its predictive factors and key clinical features can help to differentiate aspergillosis from non-fungal endocarditis and may enable improved survival rates.

Bartonella quintana infective endocarditis in northern Alberta: A case report.

We present a case of Bartonella quintana infective endocarditis requiring valvular surgery in an Indigenous patient from northern Alberta that was identified months after initial presentation to hospital with undifferentiated laboratory abnormalities. Syndromes caused by B. quintana are often challenging to diagnose due to their non-specific presentation and the difficulty in detecting this organism using traditional culture methods. Additionally, risk factors for B. quintana include marginal housing and alcohol use disorder, which often impede access to health care. Indigenous patients in northern Canada often face worse health outcomes compared with other regions owing to poor economic conditions, substandard housing, and limited access to health care resources. Given that risk factors for B. quintana are prevalent throughout northern Canada and that this infection is difficult to diagnose, we surmise that the prevalence of B. quintana infection is underestimated in northern Canada.

Les auteurs présentent un cas d'endocardite infectieuse à Bartonella quintana exigeant une chirurgie valvulaire chez un patient autochtone du nord de l'Alberta, dépisté des mois après la première consultation à l'hôpital, alors que les anomalies de laboratoires étaient indifférenciées. Les syndromes causés par le Bartonella quintana sont souvent difficiles à diagnostiquer à cause de leur présentation non spécifique et de la difficulté à déceler cet organisme au moyen des méthodes de culture classiques. De plus, les facteurs de risque de Bartonella quintana incluent des logements inférieurs aux normes et des troubles de l'usage de l'alcool, qui nuisent souvent à l'accès aux soins. Les patients autochtones du nord du Canada présentent souvent des résultats cliniques pires que ceux d'autres régions à cause des mauvaises conditions économiques, des logements inférieurs aux normes et de l'accès limité aux ressources de santé. Puisque les facteurs de risque de Bartonella quintana prévalent dans tout le nord du Canada et que cette infection est difficile à diagnostiquer, les auteurs postulent que la prévalence d'infection à Bartonella quintana est sous-estimée dans cette région.

Coronary angiography in the setting of acute infective endocarditis requiring surgical treatment.

BACKGROUND: International guidelines recommend that preoperative coronary angiography is performed on patients at risk of coronary disease who have infective endocarditis requiring surgical treatment. However, the risks of contrast-induced nephropathy or vegetation embolization in case of aortic endocarditis should be considered. AIMS: To assess the safety, therapeutic implications and prognostic impact of coronary angiography in patients requiring surgical treatment for active infective endocarditis. METHODS: This retrospective monocentric study was conducted in patients referred to a tertiary care centre for active endocarditis management with a theoretical indication for surgery between January 2013 and February 2017. RESULTS: One hundred and ninety-three patients were included; 73.1% were men, the mean age was 61.9±16.3 years and the median EuroSCORE II was 5.8%. One hundred and nineteen patients (61.7%) had aortic endocarditis, which was associated with aortic vegetation in 74 cases (38.3%). Invasive coronary angiography was performed in 142 patients (73.6%) - 130 (91.6%) by radial approach - and 14 patients were evaluated by coronary multislice computed tomography (one patient had exploration with both techniques). Acute renal failure after coronary angiography was observed in 15 patients (10.6%), two patients (1.4%) presented a stroke within 24h after coronary angiography, but none had aortic endocarditis. Among the 178 patients (92.2%) who underwent surgery, 35 (19.7%) had significant coronary lesion(s) and 25 (14.0%) underwent an associated coronary artery bypass graft. CONCLUSIONS: Preoperative coronary angiography in patients affected by infective endocarditis provides relevant information in a significant proportion of patients and can be performed safely.

[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]. / Endocardites infectieuses opérées : indications chirurgicales, complications, mortalité intrahospitalière et à long terme.

BACKGROUND: In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors. METHODS: A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls. RESULTS: Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively. CONCLUSION: The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.