Impact of valvular surgery according to frailty risk in patients with infective endocarditis.

BACKGROUND: Observational studies suggest that valvular surgery can reduce mortality in selected patients with infective endocarditis (IE). However, the benefit of this intervention according to frailty levels remains unclear. Our study aims to assess the effect of valvular surgery according to frailty status in this population. METHODS: We performed a retrospective study using the 2016-2019 National Inpatient Sample database. Adult patients with a primary diagnosis of IE were included. Frailty was assessed using the Hospital Frailty Risk Score. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences between groups. RESULTS: A total of 53,275 patients with IE were included, with 18.3% underwent valvular surgery. The median age was 52 (34-68) years, with 41% females. Overall, 42.7% had low risk of frailty, 53.1% intermediate risk, and 4.2% high risk. After IPTW adjustment, in-hospital mortality was similar both for the entire cohort between valvular and non-valvular surgery groups (3.7% vs. 4.1%, p = .483), and low (1% vs. 0.9%, p = .952) or moderate (5.4% vs. 6%, p = .548) risk of frailty. However, patients at high risk of frailty had significantly lower in-hospital mortality in the valvular surgery group (4.6% vs. 13.9%, p = .016). Renal replacement therapy was similar between groups across frailty status. In contrast, surgery was associated with increased use of mechanical circulatory support and pacemaker implantation. CONCLUSIONS: Our findings suggest that there was no difference in survival between valve surgery and medical management in patients at low/intermediate frailty risk, but not for high-risk individuals.

Clinical characteristics and risk factors for right-sided infective endocarditis in Korea: a 12-year retrospective cohort study.

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (LSIE) and exhibits distinct epidemiological, clinical, and microbiological characteristics. Previous studies have focused primarily on RSIE in patients with intravenous drug use. We investigated the characteristics and risk factors for RSIE in an area where intravenous drug use is uncommon. A retrospective cohort study was conducted at a tertiary hospital in South Korea. Patients diagnosed with infective endocarditis between November 2005 and August 2017 were categorized into LSIE and RSIE groups. Of the 406 patients, 365 (89.9%) had LSIE and 41 (10.1%) had RSIE. The mortality rates were 31.7% in the RSIE group and 31.5% in the LSIE group (P = 0.860). Patients with RSIE had a higher prevalence of infection with Staphylococcus aureus (29.3% vs. 13.7%, P = 0.016), coagulase-negative staphylococci (17.1% vs. 6.0%, P = 0.022), and gram-negative bacilli other than HACEK (12.2% vs. 2.2%, P = 0.003). Younger age (adjusted odds ratio [aOR] 0.97, 95% confidence interval [CI] 0.95-0.99, P = 0.006), implanted cardiac devices (aOR 37.75, 95% CI 11.63-141.64, P ≤ 0.001), and central venous catheterization  (aOR 4.25, 95%  CI 1.14-15.55, P = 0.029) were independent risk factors for RSIE. Treatment strategies that consider the epidemiologic and microbiologic characteristics of RSIE are warranted.

Predictors of infective endocarditis associated in-hospital mortality in Ayder Comprehensive Specialized Hospital, Tigray, North Ethiopia: Microbiological,clinical features, and management profiles.

BACKGROUND: Infective endocarditis (IE) is a continuously evolving disease with a high mortality rate despite different advances in treatment. In Ethiopia, there is a paucity of data regarding IE. Therefore, this study is aimed at assessing IE-related in-hospital mortality and characterization of IE patients based on their microbiological, clinical features, and management profiles in the Ayder Comprehensive Specified Hospital (ACSH). METHODS: We conducted a hospital-based prospective follow-up study with all consecutive sampling techniques for suspected infective endocarditis patients admitted to ACSH from January 2020 to February 2022. Echocardiography was performed, and three sets of blood samples for blood culture were taken as per the standard protocol. We also performed isolation of microbial etiologies and antimicrobial susceptibility tests. The data was analyzed using STATA version 16. Stepwise logistic regression was run to identify predictors of in-hospital mortality. Effects were measured through the odds ratio at the 5% level of significance. RESULTS: Seventy-four cases of suspected infective endocarditis were investigated; of these, 54 episodes fulfilled modified Duke's criteria. Rheumatic heart disease (RHD) (85.2%) was the most common underlying heart disease. Murmur (94.4%), fever (68.5%), and pallor (57.4%) were the most common clinical findings. Vegetation was present in 96.3% of episodes. Blood culture was positive only in 7 (13%) episodes. Complications occurred in 41 (75.9%) cases, with congestive heart failure being the most common. All patients were managed medically, with no surgical intervention. The in-hospital mortality was 14 (25.9%). IE-related in-hospital mortality was significantly associated with surgery recommendation and myalgia clinical symptoms. CONCLUSION: IE occurred relatively in a younger population, with RHD as the most common underlying heart disease. There was a high rate of culture-negative endocarditis, and the majority of patients were treated empirically. Mortality was high. The establishment of cardiac surgery and strengthening microbiology services should be given top priority.

Sex differences and outcomes in surgical infective endocarditis.

BACKGROUND: Cardiac surgery for infective endocarditis (IE) is associated with significant hospital mortality, and female sex may be associated with worse outcomes. However, the impact of sex on the presenting characteristics, management, and outcomes of patients operated on for acute infective endocarditis (IE) has not been adequately studied. OBJECTIVES: The goal of our study was to analyse differences in management and outcome of IE between women and men who undergo surgery. METHODS: Clinical data of 717 patients undergoing cardiac surgery for IE between December 2005 and December 2019 were prospectively collected. Sex-related postoperative outcomes including in-hospital mortality were recorded. Univariable and multivariable analyses were performed to identify potential sex-related determinant of in-hospital mortality. RESULTS: In all, 532 male patients (74.2%) and 185 female patients (25.8%) underwent surgery for IE. At baseline, women had more frequent mitral regurgitation with 63 patients (34.1%) than men with 135 patients (25.4%) (P = 0.002). Female sex was associated with higher in-hospital mortality (23.2% versus 17.3%, P = 0.049). However, multivariable analysis revealed age (P < 0.01), antibiotics < 7 days before surgery (P = 0.01) and staphylococcal IE (P < 0.01) but not female sex (P = 0.99) as independent determinants of hospital mortality. CONCLUSIONS: In this study of patients operated-on for IE, female sex was associated with more severe manifestations of IE and significantly higher in-hospital mortality. However, after multivariable analysis, initial presentation, but not sex, seemed to determine clinical outcomes.

Minimally invasive procedures for right side infective endocarditis: A targeted literature review.

INTRODUCTION: Right-side infective endocarditis (RSIE) is caused by microorganisms and develops into intracardiac and extracardiac complications with high in-hospital and 1-year mortality. Treatments involve antibiotic and surgical intervention. However, those presenting with extremes e.g. heart failure, or septic shock who are not ideal candidates for conventional medical therapy might benefit from minimally invasive procedures. OBJECTIVE: This review summarizes existing observational studies that reported minimally invasive procedures to debulk vegetation due to infective endocarditis either on valve or cardiac implantable electronic devices. METHODS: A targeted literature review was conducted to identify studies published in PubMed/MEDLINE, EMBASE, and Cochrane Central Database from January 1, 2015 to June 5, 2023. The efficacy and/or effectiveness of minimally invasive procedural interventions to debulk vegetation due to RSIE were summarized following PRISMA guidelines. RESULTS: A total of 11 studies with 208 RSIE patients were included. There were 9 studies that assessed the effectiveness of the AngioVac system and 2 assessed the Penumbra system. Overall procedure success rate was 87.9%. Among 8 studies that reported index hospitalization, 4 studies reported no death, while the other 4 studies reported 10 deaths. CONCLUSIONS: This study demonstrates that multiple systems can provide minimally invasive procedure options for patients with RSIE with high procedural success. However, there are mixed results regarding complications and mortality rates. Further large cohort studies or randomized clinical trials are warranted to assess and/or compare the efficacy and safety of these systems.

Mortality patterns in older adults with infective endocarditis in the US: A retrospective analysis.

BACKGROUND: Infective Endocarditis (IE) has become a significant cause of morbidity and mortality over the last two decades. Despite management advancements, mortality trends in the USA's geriatric population are unexplored. The aim of this study was to assess the trends and regional differences in IE related mortality among geriatric patients in the USA. METHODS: We analyzed death certificates sourced from the CDC WONDER database spanning 1999 to 2020. The research targeted individuals aged 65 and older. Age-adjusted mortality rates (AAMRs) per 100,000 and annual percent change (APC), along with 95% CI, were calculated through joinpoint regression analysis. RESULTS: From 1999 to 2020, infective endocarditis caused 222,573 deaths, showing a declining trend (APC: -0.8361). Males had higher AAMR (26.8) than females (22.2). NH White had the highest AAMR (25.8), followed by NH American Indians or Alaska Natives (19.6). Geographically, the Midwest had the highest AAMR (27.4), followed by the Northeast (25.8). Rural areas consistently had higher AAMRs (26.6) than urban areas (23.6), while 80.16% of deaths occurring in urban settings. North Dakota, Nebraska, and Montana had the highest state AAMRs, approximately double than the states with the lowest mortality rates: Mississippi, Hawaii, California, and Massachusetts. Those aged 85 and above accounted for 42.9% of deaths. CONCLUSION: IE mortality exhibited a clear pattern: rising till 2004, declining from 2004 to 2018, and increasing again till 2020. Key risk factors were male gender, Midwest residence, NH White ethnicity, and age ≥85.Targeted interventions are essential to reduce IE mortality, especially among vulnerable older populations.

Enterococcus spp. and Streptococcus spp. bloodstream infections: epidemiology and therapeutic approach

Streptococcus spp. and Enterococcus spp. are frequent etiologies of bloodstream infection and endocarditis. In recent years, the incidence of Enterococcus spp. has been increasing, especially with nosocomial involvement, and with a high mortality rate. In this entity, the risk of endocarditis and its relationship with colorectal neoplastic pathology remains to be clarified, in order to establish indications for echocardiography and colonoscopy. In the case of Streptococcus spp., the risk of endocarditis depends on the species and the mortality rates are usually lower. Finally, in recent years, the treatment of endocarditis has been directed towards oral consolidation regimens and new long-term antibiotic treatments. (AU)

Incidence, Cause, and Outcome of Reinterventions After Aortic Root Replacement.

BACKGROUND: This study aims to comprehensively characterize details of aortic and aortic valve reinterventions after aortic root replacement (ARR). METHODS: Between 2005 and 2019, 882 patients underwent ARR. Indications were aneurysm in 666, aortic valve related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 patients, whereas a Bio-Bentall procedure was done in 528. Among them, 52 patients (5.9%) required reintervention. The incidence, cause, and time to reintervention and the outcomes after reintervention were investigated. A cause-specific Cox hazard model was performed to identify predictors for reintervention after ARR. RESULTS: The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% (95% confidence interval, 7.3%-14.0%). Age per year decrease was the only independent predictor for reintervention (subdistribution hazard ratio, 0.97; 95% confidence interval, 0.95-0.99). The causes for 52 reinterventions were aortic valve causes in 29 patients (55.8%), including aortic stenosis/insufficiency, and prosthetic valve dysfunction; IE in 15 (28.9%); aortic-related causes in 7 (13.5%), including pseudoaneurysm, development of aneurysm, and residual dissection; and coronary button pseudoaneurysm in 1 (1.9%). Median time to reintervention was 11.0 months (interquartile range, 2.0-20.5) for IE, 24.0 months (interquartile range, 3.7-46.1) for aortic-related causes, and 77.0 months (interquartile range, 28.4-97.6) for aortic valve-related causes (P = .005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% for IE (3/15). CONCLUSIONS: Reintervention for IE occurred relatively early after ARR, whereas aortic valve- and aortic-related reinterventions gradually increased over time. In-hospital mortality after the reintervention was low, with the exception of IE.

Surgical treatment of valve endocarditis in high-risk patients and predictors of long-term outcomes.

Infective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97-100%), 96% (95% CI 92-100%), 85.9% (95% CI 76-97%), and 74% (95% CI 60-91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

U-Shaped Association Between Serum Uric Acid and Short-Term Mortality in Patients With Infective Endocarditis.

Background: Increased uric acid (UA) levels have been reported to be associated with poor clinical outcomes in several conditions. However, the prognostic value of UA in patients with infective endocarditis (IE) is yet unknown. Methods: A total of 1,117 patients with IE were included and divided into two groups according to the current definition of hyperuricemia (UA>420 µmol/L in men and >360 µmol/L in women): hyperuricemia group (n=336) and normouricemia group (n=781). The association between the UA level and short-term outcomes were examined. Results: The in-hospital mortality was 6.2% (69/1117). Patients with hyperuricemia carried a higher risk of in-hospital death (9.8% vs. 4.6%, p=0.001). Hyperuricemia was not an independent risk factor for in-hospital death (adjusted odds ratio [aOR]=1.92, 95% confidence interval [CI]: 0.92-4.02, p=0.084). A U-shaped relationship was found between the UA level and in-hospital death (p<0.001). The in-hospital mortality was lower in patients with UA in the range 250-400 µmol/L. The aOR of in-hospital death in patients with UA>400 and <250 µmol/L was 3.48 (95% CI: 1.38-8.80, p=0.008) and 3.28 (95%CI: 1.27-8.51, p=0.015), respectively. Furthermore, UA>400 µmol/L (adjusted hazard ratio [aHR]=3.54, 95%CI: 1.77-7.07, p<0.001) and <250 µmol/L (aHR=2.23, 95%CI: 1.03-4.80, p=0.041) were independent risk factors for the 6-month mortality. Conclusion: The previous definition of hyperuricemia was not suitable for risk assessment in patients with IE because of the U-shaped relationship between UA levels and in-hospital death. Low and high levels of UA were predictive of increased short-term mortality in IE patients.

Bibliometric analysis on infective endocarditis

Introduction: Although infective endocarditis (IE) is rare disease, this disease has importance due to its high morbidity and mortality rates. The exact incidence is not known as it is not a reportable disease. Unlike developed countries, the disease affects the young more than the elderly in developing countries. Most of the time, the diagnosis cannot be made at the first examination and the disease is often overlooked. In order to reduce the mortality and morbidity of this disease, it is important to quickly recognize the disease by following current diagnosis and treatment methods, to identify the causative agent and to treat accordingly. Both the epidemiology and the management of IE are changing due to medical advances. This situation may also be reflected in scientific publications. We aimed to analyze the global researches on IE. Material and methods: The Scopus database was searched for bibliometric analysis without selecting document type. Data were retrieved for the time period January 1, 1940 and Semptember 26, 2021, containing the keywords " Infective’’ and’’endocarditis " in their title. Results: 7911 publications were included in the study. The first publication was made in the year 1891. Most of the publications were research articles [n=5784 (73.11%)] and were from the United States of America (USA) [n =1622 (20.50%)]. Japan, France, United Kingdom and Spain were also in the top 5 publishing countries on IE. Conclusions: Infective endocarditis is still an important reason of mortality, and there are many unanswered questions about the managament and preventation of this disease. This situation reflected the scientific publications. Since this is a global problem, not just some developed countries involved in the IE research, also more countries should be encouraged to participate the studies on IE. (AU)

Introducción: Si bien la endocarditis infecciosa (EI) es una enfermedad rara, esta enfermedadtiene importancia por sus altas tasas de morbilidad y mortalidad. No se conoce la incidencia exacta ya que no es una enfermedad de notificación obligatoria. A diferencia de los países desarrollados, la enfermedad afecta más a los jóvenes que a los ancianos en los países en desarrollo. La mayoría de las veces, el diagnóstico no se puede hacer en el primer examen y la enfermedad a menudo se pasa por alto. Para reducir la mortalidad y morbilidad de esta enfermedad, es importante reconocer rápidamente la enfermedad siguiendo los métodos de diagnóstico y tratamiento actuales, para identificar el agente causal y tratar en consecuencia. Tanto la epidemiología como el manejo de la EI están cambiando debido a los avances médicos. Esta situación también puede verse reflejada en publicaciones científicas. Nuestro objetivo era analizar las investigaciones globales sobre la EI. Material y métodos: Se buscó en la base de datos Scopus para el análisis bibliométrico sin seleccionar el tipo de documento. Se recuperaron datos para el período de tiempo del 1 de enero de 1940 y el 26 de septiembre de 2021, que contenían las palabras clave "Infeccioso" y "Endocarditis" en su título. Resultados: Se incluyeron 7911 publicaciones en el estudio. La primera publicación se realizó en el año 1891. La mayoría de las publicaciones fueron artículos de investigación [n = 5784 (73,11%)] y fueron de los Estados Unidos de América (EE.UU.) [n = 1622 (20,50%)]. Japón, Francia, Reino Unido y España también se encontraban entre los 5 principales países editores en la EI. Conclusiones: La endocarditis infecciosa sigue siendo una causa importante de mortalidad y hay muchas preguntas sin respuesta sobre el manejo y prevención de esta enfermedad. Esta situación reflejó las publicaciones científicas... (AU)

Nomogram based on neutrophil-to-platelet ratio to predict in-hospital mortality in infective endocarditis.

Aim: To develop a nomogram based on neutrophil-to-platelet ratio (NPR) to predict in-hospital mortality in infective endocarditis (IE) patients. Methods: We retrospectively analyzed 294 consecutive patients classified as survivors or nonsurvivors according to hospitalization outcome. Logistic regression analyses were performed to identify independent predictors for in-hospital mortality. A nomogram based on them was established and assessed by receiver operating characteristic (ROC) curve analysis. Results: Admission NPR (odds ratio [OR] = 1.095, 95% CI: 1.037-1.156), positive blood culture (OR = 9.220; 95% CI: 1.478-57.521) and left-sided endocarditis (OR = 5.099; 95% CI: 1.104-23.553) independently predicted in-hospital mortality in IE. The area under the ROC curve for the nomogram based on these predictors was 0.832. Conclusion: The nomogram based on NPR could be used for early risk stratification of IE patients.

Pulmonary complications observed in patients with infective endocarditis with and without injection drug use: An analysis of the National Inpatient Sample.

BACKGROUND: The impact of cardiovascular and neurologic complications on infective endocarditis (IE) are well studied, yet the prevalence and significance of pulmonary complications in IE is not defined. To better characterize the multifaceted nature of IE management, we aimed to describe the occurrence and significance of pulmonary complications in IE, including among persons with IE related to drug use. METHODS: Hospitalizations of adult (≥18 years old) patients diagnosed with IE were identified in the 2016 National Inpatient Sample using ICD-10 codes. Multivariable logistic and linear regression were used to compare IE patient outcomes between those with and without pulmonary complications and to identify predictors of pulmonary complications. Interaction terms were used to assess the impact of drug-use IE (DU-IE) and pulmonary complications on inpatient outcomes. RESULTS: In 2016, there were an estimated 88,995 hospitalizations of patients diagnosed with IE. Of these hospitalizations,15,490 (17%) were drug-use related. Drug-use IE (DU-IE) had the highest odds of pulmonary complications (OR 2.97, 95% CI 2.50, 3.45). At least one pulmonary complication was identified in 6,580 (7%) of IE patients. DU-IE hospitalizations were more likely to have a diagnosis of pyothorax (3% vs. 1%, p<0.001), lung abscess (3% vs. <1%, p<0.001), and septic pulmonary embolism (27% vs. 2%, p<0.001). Pulmonary complications were associated with longer average lengths of stay (CIE 7.22 days 95% CI 6.11, 8.32), higher hospital charges (CIE 78.51 thousand dollars 95% CI 57.44, 99.57), more frequent post-discharge transfers (acute care: OR 1.37, 95% CI 1.09, 1.71; long-term care: OR 2.19, 95% CI 1.83, 2.61), and increased odds of inpatient mortality (OR 1.81 95% CI 1.39, 2.35). CONCLUSION AND RELEVANCE: IE with pulmonary complications is associated with worse outcomes. Patients with DU-IE have a particularly high prevalence of pulmonary complications that may require timely thoracic surgical intervention, likely owing to right-sided valve involvement. More research is needed to determine optimal management strategies for complications to improve patient outcomes.

Multicenter Study of Endocarditis After Transcatheter Pulmonary Valve Replacement.

BACKGROUND: Endocarditis has emerged as one of the most impactful adverse events after transcatheter pulmonary valve replacement (TPVR), but there is limited information about risk factors for and outcomes of this complication. OBJECTIVES: The purpose of this study was to evaluate risk factors for and outcomes of endocarditis in a large multicenter cohort. METHODS: The authors established an international registry focused on characterizing endocarditis after TPVR, including the incidence, risk factors, characteristics, and outcomes. RESULTS: Investigators submitted data for 2,476 patients who underwent TPVR between July 2005 and March 2020 and were followed for 8,475 patient-years. In total, 182 patients were diagnosed with endocarditis a median of 2.7 years after TPVR, for a cumulative incidence of 9.5% (95% CI: 7.9%-11.1%) at 5 years and 16.9% (95% CI: 14.2%-19.8%) at 8 years (accounting for competing risks: death, heart transplant, and explant) and an annualized incidence of 2.2 per 100 patient-years. Staphylococcus aureus and Viridans group Streptococcus species together accounted for 56% of cases. Multivariable analysis confirmed that younger age, a previous history of endocarditis, and a higher residual gradient were risk factors for endocarditis, but transcatheter pulmonary valve type was not. Overall, right ventricular outflow tract (RVOT) reintervention was less often to treat endocarditis than for other reasons, but valve explant was more often caused by endocarditis. Endocarditis was severe in 44% of patients, and 12 patients (6.6%) died, nearly all of whom were infected with Staphylococcus aureus. CONCLUSIONS: The incidence of endocarditis in this multicenter registry was constant over time and consistent with prior smaller studies. The findings of this study, along with ongoing efforts to understand and mitigate risk, will be critical to improve the lifetime management of patients with heart disease involving the RVOT. Although endocarditis can be a serious adverse outcome, TPVR remains an important tool in the management of RVOT dysfunction.

Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist.

BACKGROUND: Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery. METHODS: We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection. RESULTS: Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points. INTERPRETATION: We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.

Prognostic value of D-dimer for adverse outcomes in patients with infective endocarditis: an observational study.

BACKGROUND: Increased D-dimer levels have been shown to correlate with adverse outcomes in various clinical conditions. However, few studies with a large sample size have been performed thus far to evaluate the prognostic value of D-dimer in patients with infective endocarditis (IE). METHODS: 613 patients with IE were included in the study and categorized into two groups according to the cut-off of D-dimer determined by receiver operating characteristic (ROC) curve analysis for in-hospital death: > 3.5 mg/L (n = 89) and ≤ 3.5 mg/L (n = 524). Multivariable regression analysis was used to determine the association of D-dimer with in-hospital adverse events and six-month death. RESULTS: In-hospital death (22.5% vs. 7.3%), embolism (33.7% vs 18.2%), and stroke (29.2% vs 15.8%) were significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L. Multivariable analysis showed that D-dimer was an independent risk factor for in-hospital adverse events (odds ratio = 1.11, 95% CI 1.03-1.19, P = 0.005). In addition, the Kaplan-Meier curve showed that the cumulative 6-month mortality was significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L (log-rank test = 39.19, P < 0.0001). Multivariable Cox regression analysis showed that D-dimer remained a significant predictor for six-month death (HR 1.11, 95% CI 1.05-1.18, P < 0.001). CONCLUSIONS: D-dimer is a reliable prognostic biomarker that independently associated with in-hospital adverse events and six-month mortality in patients with IE.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan.

OBJECTIVE: The current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear. METHODS: We extracted data on patients in Japan with community-acquired IE who were admitted and discharged between April 2010 and February 2018 using a nationwide inpatient, the Diagnosis Procedure Combination database. We divided patients into three groups: non-elderly (<65 years), elderly (65-79 years) and very elderly (≥80 years). A 1:1 propensity score matching was performed to compare proportions of surgical treatment and in-hospital mortality among the groups. RESULTS: We identified 20 667 eligible patients (median age 70 years, 61.0% men). The proportion of very elderly patients significantly increased (19.1% in 2010 to 29.7% in 2018). The proportion of surgical treatment was significantly lower, and in-hospital mortality was significantly higher in very elderly patients. This tendency was more pronounced among patients with in-hospital complications such as heart failure, stroke or embolism. Surgical treatment was significantly associated with lower in-hospital mortality even in very elderly patients, both in an unmatched (OR 0.61; 95% CI 0.47 to 0.78) and a propensity score matched cohort (OR 0.61; 95% CI 0.43 to 0.85). CONCLUSIONS: The proportion of very elderly patients with IE was increasing, and very elderly patients had higher in-hospital mortality. The proportion of surgical treatment for IE among very elderly patients was low, but it was associated with lower in-hospital mortality. Further studies are needed to establish the optimal strategy for IE among very elderly patients.

Burden of Infective Endocarditis in Homeless Patients in the United States: A National Perspective.

BACKGROUND: Earlier studies have shown disparate cardiovascular care in homeless patients. Limited data exist on burden of infective endocarditis (IE) in homeless patients and in this study, we aimed to analyze it using a nationally representative United States population sample. METHODS: Data were extracted from National Inpatient Sample database from January 2000 to December 2017. Patients with endocarditis were sampled using International Classification of Diseases, 9th Revision, Clinical Modification codes of 421.0, 421.1 or 421.9 and International Classification of Diseases, 10th Revision, Clinical Modification codes of I33.0 or I33.9. Homeless patients were identified using codes of V60 and Z59. Linear regression was used for trend analysis and logistic regression was utilized to identify predictors of mortality. 1:1 propensity score (PS) matching was also done to balance confounders and outcomes were assessed in both unmatched and matched cohorts. RESULTS: We found an increase in proportion of homeless patients admitted with endocarditis from 0.2% in year 2000 to 2.4% in year 2017. Mortality was not statistically significant in PS matched homeless and non-homeless cohorts (4.7% vs 6.6%, p = 0.072). There was a trend towards increased mortality in homeless endocarditis patients over our study years with lower utilization of valvular surgeries. Advanced age, alcohol abuse and admission to large hospitals were independently associated with mortality in homeless endocarditis patients. CONCLUSION: Homeless patients have rising trend of IE and IE related mortality and also found to have low utilization of life saving valvular surgeries when compared to general population.