Ultra-High-Resolution and K-Edge Imaging of Prosthetic Heart Valves With Spectral Photon-Counting CT: A Phantom Study.

BACKGROUND AND PURPOSE: The contribution of cardiac computed tomography (CT) for the detection and characterization of prosthetic heart valve (PHV) complications is still limited due mainly to artifacts. Computed tomography systems equipped with photon-counting detectors (PCDs) have the potential to overcome these limitations. Therefore, the aim of the study was to compare image quality of PHV with PCD-CT and dual-energy dual-layer CT (DEDL-CT). MATERIALS AND METHODS: Two metallic and 3 biological PHVs were placed in a tube containing diluted iodinated contrast inside a thoracic phantom and scanned repeatedly at different angles on a DEDL-CT and PCD-CT. Two small lesions (~2 mm thickness; containing muscle and fat, respectively) were attached to the structure of 4 valves, placed inside the thoracic phantom, with and without an extension ring, and scanned again. Acquisition parameters were matched for the 2 CT systems and used for all scans. Metallic valves were scanned again with parameters adapted for tungsten K-edge imaging. For all valves, different metallic parts were measured on conventional images to assess their thickness and blooming artifacts. In addition, 6 parallelepipeds per metallic valve were drawn, and all voxels with density <3 times the standard deviation of the contrast media were recorded as an estimate of streak artifacts. For subjective analysis, 3 expert readers assessed conventional images of the valves, with and without lesions, and tungsten K-edge images. Conspicuity and sharpness of the different parts of the valve, the lesions, metallic, and blooming artifacts were scored on a 4-point scale. Measurements and scores were compared with the paired t test or Wilcoxon test. RESULTS: The objective analysis showed that, with PCD-CT, valvular metallic structures were thinner and presented less blooming artifacts. Metallic artifacts were also reduced with PCD-CT (11 [interquartile (IQ) = 6] vs 40 [IQ = 13] % of voxels). Subjective analysis allowed noticing that some structures were visible or clearly visible only with PCD-CT. In addition, PCD-CT yielded better scores for the conspicuity and for the sharpness of all structures (all Ps < 0.006), except for the conspicuity of the leaflets of the mechanical valves, which were well visible with either technique (4 [IQ = 3] for both). Both blooming and streak artifacts were reduced with PCD-CT (P ≤ 0.01). Overall, the use of PCD-CT resulted in better conspicuity and sharpness of the lesions compared with DEDL-CT (both Ps < 0.02). In addition, only with PCD-CT some differences between the 2 lesions were detectable. Adding the extension ring resulted in reduced conspicuity and sharpness with DEDL-CT (P = 0.04 and P = 0.02, respectively) and only in reduced sharpness with PCD-CT (P = 0.04). Tungsten K-edge imaging allowed for the visualization of the only dense structure containing it, the leaflets, and it resulted in images judged having less blooming and metallic artifacts as compared with conventional PCD-CT images (P < 0.01). CONCLUSIONS: With PCD-CT, objective and subjective image quality of metallic and biological PHVs is improved compared with DEDL-CT. Notwithstanding the improvements in image quality, millimetric lesions attached to the structure of the valves remain a challenge for PCD-CT. Tungsten K-edge imaging allows for even further reduction of artifacts.

The impact of transoesophageal echocardiography in elderly patients with infective endocarditis.

BACKGROUND: Infective endocarditis (IE) increasingly involves older patients. Geriatric status may influence diagnostic and therapeutic decisions. AIM: To describe transoesophageal echocardiography (TEE) use in elderly IE patients, and its impact on therapeutic management and mortality. METHODS: A multicentre prospective observational study (ELDERL-IE) included 120 patients aged ≥75 years with definite or possible IE: mean age 83.1±5.0; range 75-101 years; 56 females (46.7%). Patients had an initial comprehensive geriatric assessment, and 3-month and 1-year follow-up. Comparisons were made between patients who did or did not undergo TEE. RESULTS: Transthoracic echocardiography revealed IE-related abnormalities in 85 patients (70.8%). Only 77 patients (64.2%) had TEE. Patients without TEE were older (85.4±6.0 vs. 81.9±3.9 years; P=0.0011), had more comorbidities (Cumulative Illness Rating Scale-Geriatric score 17.9±7.8 vs. 12.8±6.7; P=0.0005), more often had no history of valvular disease (60.5% vs. 37.7%; P=0.0363), had a trend toward a higher Staphylococcus aureus infection rate (34.9% vs. 22.1%; P=0.13) and less often an abscess (4.7% vs. 22.1%; P=0.0122). Regarding the comprehensive geriatric assessment, patients without TEE had poorer functional, nutritional and cognitive statuses. Surgery was performed in 19 (15.8%) patients, all with TEE, was theoretically indicated but not performed in 15 (19.5%) patients with and 6 (14.0%) without TEE, and was not indicated in 43 (55.8%) patients with and 37 (86.0%) without TEE (P=0.0006). Mortality was significantly higher in patients without TEE. CONCLUSIONS: Despite similar IE features, surgical indication was less frequently recognized in patients without TEE, who less often had surgery and had a poorer prognosis. Cardiac lesions might have been underdiagnosed in the absence of TEE, hampering optimal therapeutic management. Advice of geriatricians should help cardiologists to better use TEE in elderly patients with suspected IE.

Heart transplantation as salvage treatment of intractable infective endocarditis.

BACKGROUND: For infective endocarditis (IE) with extensive perivalvular lesions or end-stage cardiac failure, heart transplantation (HT) may be the last resort. METHODS: We retrospectively collected all cases of HT for IE within the International Collaboration on Endocarditis (ICE) network. RESULTS: Between 1991 and 2021, 20 patients (5 women, 15 men), median age 50 years [interquartile range, 29-61], underwent HT for IE in Spain (n = 9), France (n = 6), Switzerland (n = 2), Colombia, Croatia, and USA (n = 1). IE affected prosthetic (n = 10), and native valves (n = 10), primarily aortic (n = 11) and mitral (n = 6). The main pathogens were oral streptococci (n = 8), Staphylococcus aureus (n = 5), and Enterococcus faecalis (n = 2). The major complications included heart failure (n = 18), peri-annular abscess (n = 10), and prosthetic valve dehiscence (n = 4). Eighteen patients had previous cardiac surgery for this episode of IE, and four were on circulatory support before HT (left ventricular assist-device and extra-corporeal membrane oxygenation, 2 patients each). The median time interval between first symptoms of IE and HT was 44.5 days [22-91.5]. The main post-HT complication was acute rejection (n = 6). Seven patients died (35%), four during the first month post-HT. Thirteen (81%) of the 16 patients discharged from the hospital survived with a median follow-up of 35.5 months [4-96.5] after HT, and no relapse of IE. CONCLUSIONS: IE is not an absolute contraindication for HT: Our case series and the literature review support that HT may be considered as a salvage treatment in highly-selected patients with intractable IE.

Prognostic value of cardiovascular magnetic resonance T1 mapping and extracellular volume fraction in nonischemic dilated cardiomyopathy.

BACKGROUND: Heart failure- (HF) and arrhythmia-related complications are the main causes of morbidity and mortality in patients with nonischemic dilated cardiomyopathy (NIDCM). Cardiovascular magnetic resonance (CMR) imaging is a noninvasive tool for risk stratification based on fibrosis assessment. Diffuse interstitial fibrosis in NIDCM may be a limitation for fibrosis assessment through late gadolinium enhancement (LGE), which might be overcome through quantitative T1 and extracellular volume (ECV) assessment. T1 and ECV prognostic value for arrhythmia-related events remain poorly investigated. We asked whether T1 and ECV have a prognostic value in NIDCM patients. METHODS: This prospective multicenter study analyzed 225 patients with NIDCM confirmed by CMR who were followed up for 2 years. CMR evaluation included LGE, native T1 mapping and ECV values. The primary endpoint was the occurrence of a major adverse cardiovascular event (MACE) which was divided in two groups: HF-related events and arrhythmia-related events. Optimal cutoffs for prediction of MACE occurrence were calculated for all CMR quantitative values. RESULTS: Fifty-eight patients (26%) developed a MACE during follow-up, 42 patients (19%) with HF-related events and 16 patients (7%) arrhythmia-related events. T1 Z-score (p = 0.008) and global ECV (p = 0.001) were associated with HF-related events occurrence, in addition to left ventricular ejection fraction (p < 0.001). ECV > 32.1% (optimal cutoff) remained the only CMR independent predictor of HF-related events occurrence (HR 2.15 [1.14-4.07], p = 0.018). In the arrhythmia-related events group, patients had increased native T1 Z-score and ECV values, with both T1 Z-score > 4.2 and ECV > 30.5% (optimal cutoffs) being independent predictors of arrhythmia-related events occurrence (respectively, HR 2.86 [1.06-7.68], p = 0.037 and HR 2.72 [1.01-7.36], p = 0.049). CONCLUSIONS: ECV was the sole independent predictive factor for both HF- and arrhythmia-related events in NIDCM patients. Native T1 was also an independent predictor in arrhythmia-related events occurrence. The addition of ECV and more importantly native T1 in the decision-making algorithm may improve arrhythmia risk stratification in NIDCM patients. Trial registration NCT02352129. Registered 2nd February 2015-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02352129.

Staphylococcus aureus endocarditis: Identifying prognostic factors using a method derived from morbidity and mortality conferences.

Objectives: Lethality of Staphylococcus aureus (Sa) infective endocarditis (IE) is high and might be due to yet unidentified prognostic factors. The aim of this study was to search for new potential prognostic factors and assess their prognostic value in SaIE. Materials and methods: We used a two-step exploratory approach. First, using a qualitative approach derived from mortality and morbidity conferences, we conducted a review of the medical records of 30 patients with SaIE (15 deceased and 15 survivors), randomly extracted from an IE cohort database (NCT03295045), to detect new factors of possible prognostic interest. Second, we collected quantitative data for these factors in the entire set of SaIE patients and used multivariate Cox models to estimate their prognostic value. Results: A total of 134 patients with modified Duke definite SaIE were included, 64 of whom died during follow-up. Of the 56 candidate prognostic factors identified at the first step, 3 had a significant prognostic value in multivariate analysis: the prior use of non-steroidal anti-inflammatory drugs [aHR 3.60, 95% CI (1.59-8.15), p = 0.002]; the non-performance of valve surgery when indicated [aHR 1.85, 95% CI (1.01-3.39), p = 0.046]; and the decrease of vegetation size on antibiotic treatment [aHR 0.34, 95% CI (0.12-0.97), p = 0.044]. Conclusion: We identified three potential SaIE prognostic factors. These results, if externally validated, might eventually help improve the management of patients with SaIE.

Considering health literacy in cardiovascular disease management: a qualitative study on healthcare professionals' and patients' perspectives.

BACKGROUND: Implementing practices adapted to patient health literacy (HL) is a promising avenue for improving their outcomes in the context of cardiovascular diseases (CVD). The health communication skills of healthcare professionals (HCPs) and the quality of information provided are essential for low-HL patients. We aimed to explore HCP knowledge about HL, patients' and HCPs' views on current practices regarding low-HL patients, and facilitators and barriers to adapting communication to patients' HL level, in order to prepare the implementation of a complex intervention dedicated to improve CVD management for low-HL patients. METHODS: We conducted face-to-face semi-structured interviews with HCPs practicing in cardiology units and patients hospitalized for CVD. The study design and analysis were based on the Theory of Planned Behavior for HCPs and on the framework of Health Literacy and Health Action for patients. Deductive and inductive thematic analysis were used. Barriers and facilitators were structured into an Ishikawa fishbone diagram and implementation strategies were selected to address resulting themes from the Expert Recommendations for Implementing Change (ERIC). RESULTS: Fifteen patients and 14 HCPs were interviewed. HCPs had partial knowledge of HL dimensions. Perceptions of HCPs and patients were not congruent regarding HCP-patient interactions and information provided by hospital and community HCPs. HCPs perceived they lacked validated tools and skills, and declared they adapted spontaneously their communication when interacting with low-HL patients. Patients expressed unmet needs regarding communication during hospital discharge and at return to home. CONCLUSION: To implement HL-tailored practices in this setting, our results suggest that several implementation strategies will be valuable at individual (engaging patients and their family), interactional (educating and training of HCPs about HL), and organizational levels (creating a multidisciplinary HCP interest group dedicated to HL). TRIAL REGISTRATION: ClinicalTrials.gov, (NCT number) NCT03949309, May 10, 2019.

Malassezia restricta: An Underdiagnosed Causative Agent of Blood Culture-Negative Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) is a severe disease requiring microbial identification to successfully adapt its treatment. Currently, identification of its etiological microorganism remains unresolved in 5.2% of cases. We aimed to improve IE diagnosis using an ultra-sensitive molecular technique on cardiac samples in microbiologically nondocumented (culture and conventional polymerase chain reaction [PCR]) IE (NDIE) cases. METHODS: Cardiac samples explanted in a tertiary hospital in Lyon, France, from patients with definite IE over a 5-year period were retrospectively analyzed. NDIE was defined as Duke definite-IE associated with negative explorations including cardiac samples culture, bacterial amplification, and serologies. Ultrasensitive molecular diagnosis was achieved using the Universal Microbe Detection kit (Molzym®). Fungal identification was confirmed using 26S-rDNA and internal transcribed spacer amplifications. Fungal infection was confirmed using Grocott-Gromori staining, auto-immunohistochemistry on cardiac samples, and mannan serologies. RESULTS: Among 88 included patients, microbial DNA was detected in all 16 NDIE cases. Bacterial taxa typical of IE etiologies were detected in 13/16 cases and Malassezia restricta in the 3 other cases. In these 3 cases, histological examination confirmed the presence of fungi pathognomonic of Malassezia that reacted with patient sera in an auto-immunohistochemistry assay and cross-reacted with Candida albicans in an indirect immunofluorescent assay. CONCLUSIONS: M. restricta appears to be an underestimated causative agent of NDIE. Importantly, serological cross-reaction of M. restricta with C. albicans may lead to its misdiagnosis. This is of major concern since M. restricta is intrinsically resistant to echinocandins; the reference treatment for Candida-fungal IE.

Prevalence of low health literacy levels in decompensated heart failure compared with acute myocardial infarction patients.

AIMS: Health literacy (HL) is a health determinant in cardiovascular diseases as the active participation of patients is essential for optimizing self-management of these conditions. We aimed to estimate the prevalence of low HL level in patients hospitalized for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF) and explore low HL determinants. METHODS AND RESULTS: A prospective cross-sectional study was performed in three cardiology units. HL level was assessed using Brief Health Literacy Screen (BHLS) and categorized as low or adequate. Dimensions of HL were assessed with the Health Literacy Questionnaire (HLQ). Associations with sociodemographic factors, disease history, and comorbidities were explored. A total of 208 patients were included, mean ± SD age was 68.5 ± 14.9 years, and 65.9% were men. Patients with ADHF were significantly older and more often women than AMI patients. Prevalence of low HL was 36% overall, 51% in ADHF patients, and 21% in AMI patients (P < 0.001). After adjustment for sociodemographic factors, patients with lower income (€<10 000 per year, adjusted odds ratio = 10.46 95% confidence interval [2.38; 54.51], P = 0.003) and native language other than French (adjusted odds ratio = 14.36 95% confidence interval [3.76; 66.9], P < 0.002) were more likely to have low HL. ADHF patients presented significantly lower HLQ scores than AMI patients in five out of the nine HLQ dimensions reflecting challenges in access to healthcare. CONCLUSIONS: Prevalence of low HL was higher among ADHF patients than among AMI patients. Low HL ADHF patients needed more support when accessing healthcare services, and these would require more adaptation to respond to low HL patients' needs.

Impact of Systematic Whole-body 18F-Fluorodeoxyglucose PET/CT on the Management of Patients Suspected of Infective Endocarditis: The Prospective Multicenter TEPvENDO Study.

BACKGROUND: Diagnostic and patients' management modifications induced by whole-body 18F-FDG-PET/CT had not been evaluated so far in prosthetic valve (PV) or native valve (NV) infective endocarditis (IE)-suspected patients. METHODS: In sum, 140 consecutive patients in 8 tertiary care hospitals underwent 18F-FDG-PET/CT. ESC-2015-modified Duke criteria and patients' management plan were established jointly by 2 experts before 18F-FDG-PET/CT. The same experts reestablished Duke classification and patients' management plan immediately after qualitative interpretation of 18F-FDG-PET/CT. A 6-month final Duke classification was established. RESULTS: Among the 70 PV and 70 NV patients, 34 and 46 were classified as definite IE before 18F-FDG-PET/CT. Abnormal perivalvular 18F-FDG uptake was recorded in 67.2% PV and 24.3% NV patients respectively (P < .001) and extracardiac uptake in 44.3% PV and 51.4% NV patients. IE classification was modified in 24.3% and 5.7% patients (P = .005) (net reclassification index 20% and 4.3%). Patients' managements were modified in 21.4% PV and 31.4% NV patients (P = .25). It was mainly due to perivalvular uptake in PV patients and to extra-cardiac uptake in NV patients and consisted in surgery plan modifications in 7 patients, antibiotic plan modifications in 22 patients and both in 5 patients. Altogether, 18F-FDG-PET/CT modified classification and/or care in 40% of the patients (95% confidence interval: 32-48), which was most likely to occur in those with a noncontributing echocardiography (P < .001) or IE classified as possible at baseline (P = .04), while there was no difference between NV and PV. CONCLUSIONS: Systematic 18F-FDG-PET/CT did significantly and appropriately impact diagnostic classification and/or IE management in PV and NV-IE suspected patients. CLINICAL TRIALS REGISTRATION: NCT02287792.

Impact of referral bias on prognostic studies outcomes: insights from a population-based cohort study on infective endocarditis.

PURPOSE: Prognostic studies derived from samples of patients managed in tertiary hospitals are subject to referral bias. We aimed to characterize this bias using the example of infective endocarditis. METHODS: We analyzed data from a French population-based cohort, which included 497 patients with infective endocarditis. Patients were admitted directly to a tertiary hospital (Group T), admitted to a non-tertiary hospital and referred to a tertiary hospital (Group NTT) or not (Group NT). We compared patients' characteristics, survival rates and prognostic factors between groups. RESULTS: Compared with Group T (n = 291), NTT patients (n = 144) were more often males (81.3% vs. 72.5%; P = .046), injection drug users (9.7% vs. 4.5%; P = .033), and had more frequent surgical indications (78.5% vs. 64.3%; P = .003). Compared with Group NT (n = 62), NTT patients were more often males (81.3% vs. 67.7%; P = .034) and had surgical indications more often (78.5% vs. 19.4%; P < .001). One-year survival was higher in NTT + T patients than in NT patients (73.0% vs. 56.1%; P = .01). Prognostic factors and hazard ratios estimates varied across groups. CONCLUSIONS: When derived from samples mixing patients admitted directly and those referred to tertiary hospitals, validity of characteristics description, survival estimates, and hazard ratios is threatened by referral bias.

Data on prognostic factors associated with 3-month and 1-year mortality from infective endocarditis.

This article describes supplementary tables and figures associated with the research paper entitled "Impact of referral bias on prognostic studies outcomes: insights from a population-based cohort study on infective endocarditis". The aforementioned paper is a secondary analysis of data from the EI 2008 cohort on infective endocarditis and aimed at characterising referral bias. A total of 497 patients diagnosed with definite infective endocarditis between January 1st and December 31st 2008 were included in EI 2008. Data were collected from hospital medical records by trained clinical research assistants. Patients were divided into three groups: admitted to a tertiary hospital (group T), admitted to a non-tertiary hospital and referred secondarily to a tertiary hospital (group NTT) or admitted to a non-tertiary hospital and not referred (group NT). The pooled (NTT+T) group mimicked studies recruiting patients in tertiary hospitals only. Two different starting points were considered for follow up: date of first hospital admission and date of first admission to a tertiary hospital if any (hereinafter referred to as "referral time"). Referral bias is a type of selection bias which can occur due to recruitment of patients in tertiary hospitals only (excluding those who are admitted to non-tertiary hospitals and not referred to tertiary hospitals). This bias may impact the description of patients' characteristics, survival estimates as well as prognostic factors identification. The six tables presented in this paper illustrate how patients' selection (population-based sample [pooled (NT+NTT+T) group] versus recruitment in tertiary hospitals only [pooled (NTT+T) group]) might impact Hazards Ratios values for prognostic factors. Crude and adjusted Cox regression analyses were first performed to identify prognostic factors associated with 3-month and 1-year mortality in the whole sample using inclusion as the starting point. Analyses were then performed in the pooled (NTT+T) group first using inclusion as the starting point and finally using referral time as the starting point. Figures 1 to 3 illustrate how HR increase with time for covariates that were considered as time-varying covariates (covariate*time interaction).

Using surgical risk scores in nonsurgically treated infective endocarditis patients.

BACKGROUND: The accuracy of surgical scores in predicting in-hospital mortality for nonsurgically treated patients with infective endocarditis (IE) has not yet been explored. METHODS: Patients with definite IE who did not undergo valve surgery were selected from the database of seven French administrative areas (Association pour l'Étude et la Prévention de l'Endocardite Infectieuse [AEPEI] Registry, 2008). The patients were scored using (a) six systems specifically devised to predict in-hospital mortality after surgery for IE, (b) three commonly used risk scores for heart surgery, and (c) a risk score for predicting six-month mortality in IE after either surgery or medical therapy. Calibration (Hosmer-Lemeshow test) and discriminatory power (receiver operating characteristic [ROC] analysis) were assessed for each score. Areas under ROC curves were compared one-to-one (Hanley-McNeil method). RESULTS: A total of 192 patients (mean age, 65.2±15.2 years) were considered for analysis. There were 38 (19.8%) in-hospital deaths. Age >70 years (p=0.001), Staphylococcus aureus as causal agent (p=0.05), and severe sepsis (p=0.027) were independent predictors of in-hospital mortality. Despite many differences in the number and type of variables, all but two of the investigated scores showed good calibration (p>0.66). However, discriminatory power was satisfactory (area under ROC curve >0.70) only for three of the scores specific for IE and two of the scores used to predict mortality after cardiac surgery. CONCLUSIONS: Among the 10 surgical scores evaluated in this study, five could be adopted to predict in-hospital mortality even for IE patients receiving medical treatment only.

[Infective endocarditis and specific situations: Right heart, valve prosthesis, cardiac implantable electronic device]. / Endocardites infectieuses : formes particulières (coeur droit, prothèse valvulaire, dispositif électronique intracardiaque).

Right-sided infective endocarditis (IE) represents 5-10% of IE. It may occur in patients with electronic intracardiac device, central venous catheter or congenital heart disease, but the most frequent situation is intravenous drug use. Prosthetic valve IE is the most severe form of IE. The diagnosis is more challenging than that of native valve IE, as is treatment, both antibiotic treatment and surgical indications. The infection of an electronic intracardiac device is a severe disease. Both diagnostic and therapeutic strategies are difficult.

[Diagnosis of infective endocarditis]. / Diagnostic de l'endocardite infectieuse.

Clinical presentations cliniques of infective endocarditis are highly diverse. The diagnosis is often difficult. The two key investigations are blood cultures and echocardiography.

The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis.

AIMS: In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. METHODS AND RESULTS: Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)]. CONCLUSION: Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.