Outcomes following heart valve surgery in patients with infective endocarditis and preoperative septic cerebral embolism: insights from the CAMPAIGN study group.

OBJECTIVES: This study aimed to analyse the impact of preoperative septic cerebral embolism on early and late postoperative outcomes in patients with infective endocarditis undergoing valve surgery. METHODS: Retrospective multicentric study based on the Clinical Multicentric Project for Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry comprising patients with infective endocarditis who underwent valve surgery between 1994 and 2018 at 6 German centres. Patients were divided into 2 groups for statistical comparison according to the presence or absence of preoperative septic cerebral embolism. Propensity score matching was performed for adjusted comparisons of postoperative outcomes. Primary outcomes were 30-day mortality and estimated 5-year survival. RESULTS: A total of 4917 patients were included in the analysis, 3909 (79.5%) patients without and 1008 (20.5%) patients with preoperative septic cerebral embolism. Patients with preoperative septic cerebral embolism had more baseline comorbidities. Mitral valve endocarditis (44.1% vs 33.0% P < 0.001), large vegetations >10 mm (43.1% vs 30.0%, P < 0.001), and Staphylococcus species infection (42.3% vs 21.3%, P < 0.001) were more frequent in the cerebral embolism group. Among patients with preoperative cerebral embolism, 286 (28.4%) patients had no stroke signs (silent stroke). After matching (1008 matched pairs), there was no statistically significant difference in 30-day mortality (20.1% vs 22.8%; P = 0.14) and 5-year survival (47.8% vs 49.1%; stratified log-rank P = 0.77) in patients with and without preoperative cerebral embolism, respectively. CONCLUSIONS: Preoperative septic cerebral embolism in patients with infective endocarditis requiring valve surgery does not negatively affect early or late mortality; therefore, it should not play a major role in deciding if surgery is to be performed.

Valvular Endocarditis and Biventricular Heart Failure in the Setting of Tropheryma whipplei Disease.

Whipple disease is a rare systemic illness associated with weight loss, diarrhea, and arthralgia. Asymptomatic carriage is common, but the disease can be complicated by cardiac involvement and may result in culture-negative endocarditis. Cardiac manifestations of the disease can lead to death. This report presents the case of a 66-year-old man with Whipple disease and biventricular heart failure with cardiogenic shock. Medical therapy followed by successful replacement of the aortic and mitral valves resulted in substantial improvement.

A Multidisciplinary Approach to Staphylococcus aureus Triple-Valve Infective Endocarditis With Multi-Organ Involvement.

Multivalvular endocarditis is a rare and potentially fatal complication that can occur in people who inject drugs. Currently, there are few cases that have been studied or reported in literature. A complication of this manifestation that worsens prognosis and treatment is the distribution of septic emboli throughout the body which highlights the dissemination of the infection. There are no specific guidelines on the treatment of multivalvular endocarditis, but its complexity can present challenges in administering medical and surgical treatment. In this case of a 37-year-old man with infective endocarditis of 3 valves, a comprehensive work-up found septic emboli in the lungs, kidneys, ribs, spine, and brain with ophthalmologic involvement that resulted in visual impairment. This case highlights important complications that can occur with septic emboli and management of these issues using a multidisciplinary approach including the treatment of substance use disorder.

Infective endocarditis secondary to a hemodialysis catheter revealed by subarachnoid hemorrhage: Case report.

INTRODUCTION: Endocarditis associated with medical care is a rare and serious entity. The risk of occurrence is increased in hemodialysis patients due to the immunosuppression and the multiplicity of vascular accesses of different kinds. The mode of revelation can be variable given the diversity of symptoms it causes. Herein, we describe the case of endocarditis associated with medical care in a patient with renal failure who presents with neurological symptoms. OBSERVATION: A 38-year-old patient with a history of kidney disease in the hemodialysis stage presented to the emergency room with altered neurological status in the context of fever. The patient's condition requires airway control, sedation, and vasopressor medication. Brain imaging revealed Fisher 4 subarachnoid hemorrhage with brain turgor. Transthoracic and transesophageal cardiac ultrasound exploration revealed infective mitro-aortic endocarditis with trigonal abscess fistulized in the left ventricle and destruction of the aortic valve with massive regurgitation. The additional imaging in a second step did not highlight any images of mycotic aneurysm. The indication for early surgery was not approved given the hemodynamic instability and the poor intracerebral hemodynamics demonstrated by transcranial doppler ultrasound. The initial outcome under antibiotic treatment and renal replacement was favorable. But the subsequent course was fatal due to septic shock with multiple organ failure. CONCLUSION: The diagnosis of infective endocarditis should always be considered in hemodialysis patients presenting in a septic state with signs of systemic involvement. It is a source of mortality in these debilitated patients.

Double trouble: an unusual case of Klebsiella pneumoniae invasive syndrome with liver abscess, gallbladder empyema and infective endocarditis.

BACKGROUND: Klebsiella pneumoniae invasive syndrome (KPIS) is characterized by primary pyogenic liver abscess associated with metastatic infections. Although rare, Klebsiella endocarditis carries a high mortality risk. CASE PRESENTATION: A 60-year-old lady with type II diabetes mellitus presented with fever, malaise, right hypochondriac pain and vomiting for two weeks. Ultrasound abdomen revealed a collection within liver, and distended gallbladder with echogenic debris within. 3 days after ultrasound guided pigtail drainage of gallbladder empyema, newly presence murmur detected. Pus, urine, and blood cultures obtained were positive for Klebsiella pneumonia. Echocardiogram exhibited oscillating mass attached to anterior mitral valve leaflet. After 6 weeks of intravenous ceftriaxone, follow-up echocardiogram and ultrasound showed complete resolution of mitral valve vegetation, hepatic and gallbladder collection. CONCLUSION: Concomitant extrahepatic infective endocarditis (IE) should raise concerns in daily practice for patients with Klebsiella pneumoniae liver abscesses, despite the rarity of Klebsiella endocarditis. In the absence of diagnostic suspicion, antibiotic treatment regimens may be shortened, and adverse effects from IE infection may ensue.

Case Report: Non-ischemic Papillary Muscle Rupture due to MRSA Myocarditis with Concurrent Thromboembolic Myocardial Infarction Secondary to Infective Endocarditis.

Non-ischemic papillary muscle rupture (PMR) is rare. PMR caused by myocarditis in the presence of concurrent infective endocarditis (IE) and myocardial infarction (MI) has not been described. We report a 46-year-old male with recurrent MRSA bacteremia who presented in septic shock and suffered cardiac arrest. Echocardiography revealed acute mitral valve regurgitation resulting from posteromedial PMR. An intra-aortic balloon pump was implanted. Angiography revealed thrombotic occlusion of a small distal left circumflex artery. Emergent mitral valve replacement surgery was performed. MRSA myocarditis and IE were diagnosed by tissue cultures. Coexistence of myocarditis, IE, and MI poses a challenge in determining etiology.

Bivalvular Endocarditis Due to Polymicrobial Coinfection with Enterococcus faecalis and Coxiella burnetii: A Case Report and Review of the Literature.

Polymicrobial endocarditis is uncommon, and polymicrobial endocarditis in combination with Coxiella burnetii is very rare. We herein describe an extremely rare case of polymicrobial bivalvular endocarditis due to coinfection with Enterococcus faecalis and Coxiella burnetii in a 62-year-old male patient, and extensively review the relevant medical literature. To the best of our knowledge, only three similar cases have been previously reported. Q fever is a worldwide endemic bacterial zoonosis, but it and its most common chronic complication, endocarditis, are still underestimated and underdiagnosed worldwide. This situation reflects the paucity of reported cases of polymicrobial endocarditis in combination with Coxiella burnetii. Clinical presentation of Q fever endocarditis is highly nonspecific, and diagnosis may be delayed or missed, leading to severe and potentially fatal disease. Our case and the previously reported similar cases emphasize the need for further evaluation of infective endocarditis due to Coxiella burnetii, in all cases of culture-negative endocarditis, and in prolonged oligo-symptomatic inflammatory syndrome, particularly in the presence of valvular heart disease. This approach should be applied even when typical pathogens are isolated, especially in endemic areas of Q fever, and with atypical presentation.

Cryoglobulinemic vasculitis triggered by Staphylococcus aureus endocarditis with chronic hepatitis C virus co-infection: a case report and literature review.

Infective endocarditis is a rare but life-threatening condition, occasionally linked to diverse immunologic manifestations, including mixed cryoglobulinemia. This can lead to cryoglobulinemic vasculitis, which has the potential for widespread organ damage. Although some cases have highlighted the relationship between infective endocarditis and cryoglobulinemic vasculitis, no comprehensive epidemiological evaluation or optimal treatment strategies have been advanced for such a combination. We present a case of methicillin-sensitive Staphylococcus aureus infective endocarditis associated with cryoglobulinemic vasculitis and conduct a literature review to compare management and outcomes in similar cases. Our patient presented with classical Meltzer's triad and mild renal involvement. Cryoimmunofixation confirmed type III cryoglobulinemia, and serum cytokines showed elevated IL-6 levels. The differential diagnosis included infective endocarditis and chronic active hepatitis C virus infection. Rapid symptom resolution after antibiotic treatment identified infective endocarditis as the likely cause of cryoglobulinemic vasculitis. Our case and review of the literature highlight that early identification of the cause of cryoglobulinemic vasculitis is crucial for selecting appropriate treatment and preventing recurrence or morbidity.

An Autopsy Case of Streptococcus dysgalactiae subsp. equisimilis Infectious Endocarditis Accompanied by Streptococcal Toxic Shock Syndrome.

A 66-year-old woman with liver cirrhosis and hemodialysis was referred with a 1-week history of pain and rash on the left lower leg. On an examination, the patient was in shock. She was administered catecholamine support for septic shock and ampicillin/sulbactam for severe cellulitis. Streptococcus dysgalactiae subsp. equisimilis (SDSE) was isolated from the blood culture, and she was diagnosed with streptococcal toxic shock syndrome. Despite therapy, the patient died on day 7 of admission. Infective endocarditis (IE) was diagnosed during an autopsy. Clinicians should be aware that overwhelming SDSE-IE can occur even in the absence of necrotizing fasciitis, especially in immunocompromised patients.

Back pain as the initial presentation of subacute bacterial endocarditis in a patient with a complex medical history.

Infective endocarditis (IE) poses a diagnostic challenge due to its diverse clinical presentations, especially among high-risk groups. Diagnosis relies on integrating clinical presentation, blood cultures and imaging findings. Advanced imaging techniques enhance diagnostic accuracy, particularly in complex cases. Treatment involves antimicrobial therapy and surgery in complicated cases, with early intervention crucial for optimal outcomes. Coordinated care by an Endocarditis Team ensures tailored treatment plans, prompt complication management and long-term monitoring after discharge. The authors present a case of subacute IE presenting initially with back pain in a patient with a complex medical history, highlighting diagnostic and management approaches.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review.

BACKGROUND: A fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention. CASE PRESENTATION: A 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4. CONCLUSIONS: The clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient's condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

Risk of infective endocarditis and complicated infection in Staphylococcus aureus bacteremia - a retrospective cohort study on the role of bacteriuria.

PURPOSE: S. aureus bacteremia (SAB) is a common and severe infection with high mortality and morbidity. The clinical relevance of the finding of concurrent S. aureus bacteriuria (SABU) is debated. The goal of this study was to analyze whether a concurrent SABU is associated with complicated SAB, infective endocarditis (IE) and mortality. METHODS: We conducted a retrospective cohort study, reviewing medical charts of all episodes of SAB in patients > 18 years in the region of Skåne, Sweden, between 1st of January and 31st of June 2020. Episodes where a concurrent urine culture was performed were included for analysis. An episode was considered as complicated SAB if there was either attributable mortality, recurrent infection, embolic stroke, or occurrence of a complicated focus of infection. RESULTS: During the study period, there were 279 episodes of SAB. 154 episodes met the eligibility criteria, of whom 37 (24%) had concurrent SABU. In 78 episodes (51%), the patients had a complicated SAB. There was a significantly lower proportion of complicated SAB for episodes with concurrent SABU (32%), compared to episodes without concurrent SABU (56%), p-value 0.014. Moreover, in the cohort there were 11 episodes (7.1%) of IE and a 30 days mortality rate of 16%, with no difference between the groups with or without SABU. CONCLUSIONS: There is an association between concurrent SABU and a decreased risk for complicated SAB among patients with SAB. This study found no significant association between SABU and neither IE nor mortality for patients with SAB.

Infective Endocarditis Involving Implanted Cardiac Electronic Devices: JACC Focus Seminar 1/4.

Cardiac implantable electronic device-related infective endocarditis (CIED-IE) encompasses a range of clinical syndromes, including valvular, device lead, and bloodstream infections. However, accurately diagnosing CIED-IE remains challenging owing in part to diverse clinical presentations, lack of standardized definition, and variations in guideline recommendations. Furthermore, current diagnostic modalities, such as transesophageal echocardiography and [18F]-fluorodeoxyglucose positron emission tomography-computed tomography have limited sensitivity and specificity, further contributing to diagnostic uncertainty. This can potentially result in complications and unnecessary costs associated with inappropriate device extraction. Six hypothetical clinical cases that exemplify the diverse manifestations of CIED-IE are addressed herein. Through these cases, we highlight the importance of optimizing diagnostic accuracy and stewardship, understanding different pathogen-specific risks for bloodstream infections, guiding appropriate device extraction, and preventing CIED-IE, all while addressing key knowledge gaps. This review both informs clinicians and underscores crucial areas for future investigation, thereby shedding light on this complex and challenging syndrome.

Strategies to Improve Patient-Centered Care for Drug Use-Associated Infective Endocarditis: JACC Focus Seminar 2/4.

Drug use-associated infective endocarditis (DUA-IE) is a major cause of illness and death for people with substance use disorder (SUD). Investigations to date have largely focused on advancing the care of patients with DUA-IE and included drug use disorder treatment, decisions about surgery, and choice of antibiotics during the period of hospitalization. Transitions from hospital to outpatient care are relatively unstudied and frequently a key factor of uncontrolled infection, continued substance use, and death. In this paper, we review the evidence supporting cross-disciplinary care for people with DUA-IE and highlight domains that need further clinician, institutional, and research investment in clinicians and institutions. We highlight best practices for treating people with DUA-IE, with a focus on addressing health disparities, meeting health-related social needs, and policy changes that can support care for people with DUA-IE in the hospital and when transitioning to the community.

Surgical management of multiple coronary artery to coronary sinus fistulas with giant left circumflex artery and multivalvular infective endocarditis.

Coronary artery fistula (CAF) is characterized as a congenital or acquired abnormal communication between a coronary artery and any of the four chambers of the heart (coronary-cameral fistula) or great vessels (coronary arteriovenous fistula) bypassing the capillaries within myocardium. CAF is a rare disease, challenging to diagnose and treat depending on the anatomical location and type of the fistula and accompanying diseases. This study aims to report a case with multiple coronary artery to coronary sinus (CS) fistulas with giant left circumflex artery and multivalvular infective endocarditis.

Management of embolic splenic abscess secondary to aortic valve endocarditis - case report and review of literature.

BACKGROUND: Splenic abscess is a serious complication associated with infective endocarditis. There is still contradicting evidence regarding the optimal treatment pathway including timing of valve intervention and the approach for managing splenic foci. CASE PRESENTATION: We present a case of a hybrid staged approach in which we successfully performed a laparoscopic splenectomy following percutaneous abscess drainage and a delayed aortic valve replacement. CONCLUSIONS: A multidisciplinary teamwork is fundamental in providing optimal care for patients with distant complications associated with infective endocarditis. Our hybrid approach seems safe and feasible.

Repair of a fistula between the aorta and right ventricular outflow tract secondary to infective endocarditis of a unicuspid aortic valve and previously repaired ventricular septal defect.

BACKGROUND: Infective endocarditis of the aortic valve can result in a wide range of destructive pathology beyond the valve leaflets and annulus which require careful surgical planning to provide appropriate debridement and reconstruction. Failure to do so can result in a failure of surgical treatment, recurrent infection and cardiac failure with concomitant high morbidity and mortality. CASE REPORT: We describe the case of a 45-year-old male with previous patch repair of a ventricular septal defect, who was diagnosed with sub-acute bacterial endocarditis of the native aortic valve and developed a new fistula from the aorta to the right ventricular outflow tract which. This was managed surgically. CONCLUSION: This unique case highlights another spectrum of infective endocarditis with a unique approach to repair and management.

The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4.

During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.