Clinical impact of capsulectomy during cardiac implantable electronic device generator replacement: a prospective randomized trial.

BACKGROUND: The avascular capsule around the generator of the cardiac implantable electronic device (CIED) could be susceptible to bacterial colonization and source of infection. Capsulectomy during CIED generator replacement may be beneficial in preventing device infection, but there is a lack of evidence. METHODS: This prospective randomized trial, conducted from December 2013 to December 2019, included 195 patients divided equally into two groups. In the intervention group (n = 97), capsule removal was performed on the floor of the pocket, while it was not performed in the control group (n = 98). In both groups, swab culture was performed in the pocket. The primary outcome was the occurrence of device infection requiring pocket revision. RESULTS: A total of 195 patients were included (mean age 70.2 ± 13.6 years, 55.4% women), with an average follow-up period of 54.3 ± 28.9 months. Among 182 patients undergoing microbiological cultures of pockets, 19 (10.4%) were confirmed positive, and Staphylococcus species were identified most frequently. The primary outcome occurred in 4 (2.1%), and there was no significant difference between the two groups (3.1% vs. 1.0%, p = 0.606). Hematoma has occurred in 10 patients (3.1% vs. 7.1%, p = 0.338), one of them required wound revision. In multivariable analysis, the occurrence of hematoma was the only independent risk factor associated with device infection (HR 13.6, 95% CI 1.02-181.15, p = 0.048). CONCLUSIONS: In this long-term prospective study, capsulectomy during the replacement of the generator did not reduce the incidence of device infection. There was no association between bacterial colonization in the capsule around the generator and CIED infection.

A prospective case-control validation of procalcitonin as a biomarker diagnosing pacemaker and implantable cardioverter-defibrillator pocket infection.

BACKGROUND: The diagnosis of device infections, especially pocket infections, is challenging and relies primarily on clinical presentation. The prospective DIRT (Device associated Infections Role of new diagnostic Tools) study identified procalcitonin (PCT) as the most promising biomarker among other 14 biomarkers to aid the diagnosis of pocket infection. It also identified an optimized cut-off value of 0.05 ng/ml for a localized generator pocket infection. AIMS: The present study aims to validate the proposed PCT cut-off value of 0.05 ng/ml for the diagnosis of pocket infection in an independent cohort. METHODS: We prospectively enrolled 81 patients with pocket infections and 81 controls matched for age and renal function presenting for elective device exchange or lead revision. Patients with concomitant infectious or inflammatory diseases, end-stage renal failure, current active malignancy, or receiving immunosuppressive therapy were excluded. RESULTS: An elevated PCT over 0.05 ng/ml was found in 68% (n = 55) of pocket infections and 24% (n = 19) of controls, corresponding to a sensitivity of 68% and a specificity of 77% for diagnosing a pocket infection. In receiver operating characteristic (ROC) analysis, PCT showed an area under the curve of 0.75 (95% confidence interval, 0.68-0.83; P < 0.001). Sensitivity remained high with antibiotic pretreatment (65% compared to 69% without pretreatment) and in cases with minimal inflammatory signs (67% compared to 70% with extensive inflammation). CONCLUSION: Our study validates the cut-off value of 0.05 ng/ml PCT for diagnosis of a pocket infection, even in patients pre-treated with antibiotics or with minimal clinical signs of inflammation.

Leadless AV pacemaker after RF ablation for treatment of bundle branch reentrant ventricular tachycardia: A case report.

In the present article we report the case of a patient at high risk of infection wearing a subcutaneous ICD (S-ICD) due to previous system extractions, hospitalized for symptomatic BBR VT and underwent radiofrequency catheter (RF) ablation. Afterwards, to prevent the possible progression of the infra-His conduction disease to a complete block, it was decided to implant a pacemaker system. Since the high infectious risk, and the patient's firm refusal to implant another transvenous system given the previous extractions he underwent in the past, it was decided to implant a leadless pacemaker with atrioventricular synchrony.

Best Practices for Imaging Cardiac Device-Related Infections and Endocarditis: A JACC: Cardiovascular Imaging Expert Panel Statement.

The diagnosis of cardiac device infection and, more importantly, accurate localization of the infection site, such as defibrillator pocket, pacemaker lead, along the peripheral driveline or central portion of the left ventricular assist device, prosthetic valve ring abscesses, and perivalvular extensions, remain clinically challenging. Although transthoracic and transesophageal echocardiography are the first-line imaging tests in suspected endocarditis and for assessing hemodynamic complications, recent studies suggest that cardiac computed tomography (CT) or CT angiography and functional imaging with 18F-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) with CT (FDG PET/CT) may have an incremental role in technically limited or inconclusive cases on echocardiography. One of the key benefits of FDG PET/CT is in its detection of inflammatory cells early in the infection process, before morphological damages ensue. However, there are many unanswered questions in the literature. In this document, we provide consensus on best practices among the various imaging studies, which includes the detection of cardiac device infection, differentiation of infection from inflammation, image-guided patient management, and detailed recommendations on patient preparation, image acquisition, processing, interpretation, and standardized reporting.

Local device infection successfully treated without pacemaker removal in a neonate: a case report.

AIMS: Local device infection is a serious complication, especially in neonates. Complete device removal is the gold standard treatment for cardiac device infection; however, in selected cases alternative strategies could be adopted. We describe a case of a 14-day-old neonate, weighing 2.5kg, who had undergone epicardial double chamber pacemaker implantation for a congenital complete atrioventricular block. The generator pocket was created in the epigastric area below the rectus abdominis. At six days after implantation, pocket infection was found; blood cultures and the transoesophageal echocardiogram were normal. Due to the low weight of the neonate, and the limited possibility of finding a new comfortable site for housing the generator far from the infected area, we opted for a conservative strategy. We successfully applied a combination of antibiotic therapy, a vacuum-assisted wound closure system (KCI, Germany) for 40 days, and then skin transfer flap from the right flank without device removal. At one-year follow-up there were no local or systemic signs of infection.

Management of patients explanted for implantable cardioverter defibrillator infections: Bridge therapy with external temporary ICD.

AIMS AND METHODS: In case of cardiacimplantable electronicdevice (CIED)-related infections, it is mandatory to completely remove the device and administer prolonged antibiotic therapy. The management of patients explanted for an implantable defibrillator (ICD) infection is complex especially in patients needing anti-bradycardia pacing or tachyarrhythmia protection. We tested the efficacy and safety of a conventional ICD externally connected to a transvenous dual-coil lead as bridging therapy before the reimplant, comparing outcomes with a historical cohort of patients (N = 113) treated with temporary transvenous pacing. We enrolled 18 patients explanted for ICD infection and needing prolonged antibiotic therapy in three high-volume Italian centers. They received an external ICD stand-by for a mean of 16.5 (4-30) days before the reimplant. RESULTS: No patient experienced malfunction of the system, with a significant reduction of this complication versus temporary transfemoral pacing (37%, p = .004). Post-procedural occurrence of other complications (infection, relevant local bleeding, ventricular tachycardia during insertion of the lead, cardiac perforation, and venous thromboembolism) was low and not different in the two groups. One patient experienced an electrical storm, effectively recognized by the external ICD and treated with anti-tachycardia pacings (ATPs) and shocks. CONCLUSIONS: An approach with an external ICD seems to be a safe and viable option as bridging therapy in patients requiring ICD explant for CIED infection.

Anti-biofilm activity of antibiotic-loaded Hylomate®.

INTRODUCTION: Antibiotic envelopes are being developed for cardiac implantable electronic device (CIED) wrapping to reduce the risk of infections. METHODS: Fifteen CIED infection-associated bacterial isolates of Staphylococcus aureus, Staphylococcus epidermidis and Cutibacterium acnes were used to assess in vitro biofilm formation on Hylomate® compared to titanium, silicone and polyurethane coupons pre-treated with vancomycin (400 µg/ml), bacitracin (1000 U/ml) or a combination of rifampin (80 µg/ml) plus minocycline (50 µg/ml). Scanning electron microscopy (SEM) was performed to visualize bacteria on Hylomate®. RESULTS: There was significantly less (p < 0.05) S. aureus and S. epidermidis on Hylomate® pre-treated with vancomycin, bacitracin or rifampin plus minocycline after 24 h of incubation (≤1.00 log10 CFU/cm2) compared with titanium, silicone or polyurethane pre-treated with vancomycin, bacitracin or rifampin plus minocycline. C. acnes biofilms were not detected (≤1.00 log10 CFU/cm2) on pre-treated Hylomate® coupons. CONCLUSIONS: This study showed that Hylomate® coupons pre-treated with antibiotics reduced staphylococcal and C. acnes biofilm formation in vitro.

Differences in outcomes for hospitalizations of systemic and non-systemic infections associated with vascular and cardiac grafts and devices: a population-based study.

BACKGROUND: Use of vascular and cardiac devices has expanded and is associated with a relative, though disproportionate, increase in device-associated infections. AIM: To describe the association between cardiac/vascular device infections and outcomes in those with, and without systemic infections. METHODS: We used the 2016 National Inpatient Sample and the International Classification of Diseases - 10th revision codes to identify hospitalized individuals with vascular and cardiac device infections. Linear and logistic regression models were utilized to compare outcomes of death, length of stay (LOS) and hospitalization costs between individuals with and without systemic infection. FINDINGS: There were a total of 65,110 hospitalizations associated with device infections with a mean age of 61.3 ± 15.9 years (standard deviation); 28,650 (44%) had systemic infections. Elixhauser comorbidity scores of three or greater were observed in 91.2% of individuals with systemic infections along with a higher prevalence of diabetes, renal disease and heart failure. The primary outcome of mortality was observed in 3965 individuals with an odds ratio of 3.97 (95% confidence interval (CI), 2.92-3.95) in those with systemic infections compared with those without. Mean LOS was 3.44 days longer (95% CI, 2.92-3.95) and mean cost was US$11,776 greater (95% CI, US$9826-12,727) in the systemic infection cohort. CONCLUSION: Systemic cardiac and vascular device infections were associated with increased mortality, LOS and costs. Considering the increasing use of these life-saving devices, further work is needed to identify those at risk for infectious complications, particularly systemic infection, in order to enhance preventative strategies and improve health outcomes.

An unusual case of fungal ball on implantable cardioverter defibrillator wire and literature review.

Cardiac Implantable Electronic Device (CIED) includes pacemakers and implantable cardioverter defibrillators (ICD). The device infection is classified into pocket and systemic infection. We present a case of candida fungemia secondary to dissemination from the fungal ball found on an ICD. Patient was successfully managed with IV fluconazole, ICD explantation and reimplantation. The purpose of this report is to highlight rare complications of ICD implantation and guide its clinical course and management.

In Full Flow: Left Ventricular Assist Device Infections in the Modern Era.

With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.

Clinical outcomes of patients undergoing a cardiac implantable electronic device implantation following a recent non-device-related infection.

BACKGROUND: Clinical outcomes of patients undergoing a cardiac implantable electronic device (CIED) implantation following a recent non-device related infection are unknown. AIM: To evaluate the clinical outcomes of patients with recent infection before CIED implantation. METHODS: Consecutive patients (N = 1237) were classified as patients with recent infection (N = 72) and without recent infection (N = 1165). A recent infection was established by reviewing medical records, including symptoms and clinical manifestations, diagnosis of systemic inflammatory response syndrome, and quick Sequential Organ Failure Assessment (qSOFA) score. Multiple stepwise logistic regression analysis was used to identify independent predictors of in-hospital all-cause mortality. FINDINGS: During nearly three years of follow-up, 17 patients had CIED infection (1.4%), and the incidence of CIED infection did not significantly differ between patients with and without recent infection according to symptoms and clinical manifestations (2.8% vs 1.3%, respectively; not significant). However, patients with recent infection had a significantly higher in-hospital mortality rate compared to those without recent infection (22.2% vs 0.9%, respectively; P < 0.05). In multivariate analysis, predictors of in-hospital mortality were recent infection before CIED implantation (odds ratio: 20.3; 95% confidence interval: 8.4-49.3; P < 0.001) and end-stage renal disease (4.3; 1.4-12.8; P = 0.009). CONCLUSION: A CIED implantation is feasible in patients with recent infection if the patient is afebrile and has received an adequate duration of antibiotic therapy. Participants in shared decision-making before implant should be advised that recent infection increases in-hospital mortality risk, especially in patients with a qSOFA score of ≥2.

Extraction of infected cardiac implantable electronic devices and the need for subsequent re-implantation.

BACKGROUND: Little is known about rates of re-implantation and outcomes of patients not implanted with a device after transvenous lead extraction (TLE) in cardiac device related infections (CDRI). METHODS: All patients with CDRI were included in a prospective registry. After TLE, the indication for re-implantation was evaluated according to the patients' history and most recent cardiac examinations. All patients were followed for complications and mortality. In addition, in patients discharged without device the frequency of device implantations was analyzed. RESULTS: Among 302 patients, only 123 (40.7%) met the indication for implantation of the same cardiac implantable electronic device (CIED), 68 (22.5%) received a different device and 111 (36.8%) patients were discharged without CIED. Reimplanted patients were younger (70 ±â€¯11 vs. 73 ±â€¯13 years; p = 0.004), more often male (83 vs. 69%, p = 0.006), had less systemic infection (38 vs. 60%; p < 0.001) and a higher prevalence of complete heart block (28 vs. 7%, p < 0.001). Reasons against re-implantation were: loss of indication (45%), never met indication (27%), patients' preference (17%), persistent infection (8%) and advanced age (3%). During 26 ±â€¯18 months of follow-up, mortality in both groups was similar after adjusting for cofactors (HR 0.79; 95% CI 0.49-1.29; p = 0.352). CONCLUSION: More than one third of patients undergoing TLE for CDRI in our study are not implanted with a new device. Careful evaluation of the initial CIED indication allows for detection of over treated patients and may avoid unnecessary device-related complications.

Lead-Related Infective Endocarditis in Latvia: A Single Centre Experience.

Background and Objectives: Over the last five decades cardiac implantable electronic devices (CIED) have become established as the mainstay for the treatment of permanent bradycardias, chronic heart failure and dangerous heart rhythm disturbances. These devices improve survival and quality of life in many patients. However, infections associated with CIED implantation, particularly lead-related infective endocarditis (LRIE), can offset all benefits and make more harm than good for the patient. To date, there are no other studies in Latvia, addressing patients with lead-related infective endocarditis. The objective of this study was to identify the most common pathogens associated with LRIE and their antimicrobial resistance and to identify possible risk factors of patients who present with LRIE. Materials and Methods: The study was performed retrospectively at Pauls Stradins Clinical University Hospital (PSCUH). The study included patients who were referred to PSCUH due to LRIE for lead extraction. Patients were identified from procedural journals. Information about isolated microorganisms, patient comorbidities and visual diagnostics data was taken from patient records. Results: Forty-nine patients with CIED related infective endocarditis were included in the study, 34 (69.4%) were male, median age of all patients was 65.0 (50.5-73.0) years, median hospital stay was 15.5 (22.0-30.5) days. Successful and complete lead extraction was achieved in all patients. Thirty-two (65.3%) had received antibiotics prior to blood sample. Only in 31 (63.3%) positive culture results were seen. The most common isolated pathogens were Staphylococcus aureus (23.5%) and coagulase negative staphylococci (23.5%). Other bacteria were isolated considerably less often. The atrial lead was most common location for lead vegetations, seen in 50.0% of cases. Five (10.2%) patients have died due to the disease. Conclusions: Lead-related infective endocarditis is a major complication of cardiac implantable electronic devices with considerable morbidity and mortality, which in our study was as high as 10.2%.

Simultaneous suction debulking of lead vegetation prior to percutaneous lead extraction.

The infection rates of implanted cardiac devices have increased disproportionate to the dramatic increase in implantation rates, possibly related to rising patient comorbidities. Optimum strategy in cases with larger size vegetations, however, remains to be ascertained. In the absence of an effective and less invasive alternative, such patients usually undergo open thoracotomy for lead extraction. We describe the case of a 50-year-old female presenting with recurrent methicillin-resistant Staphylococcus aureus bacteremia found to have 3 cm highly mobile vegetation on the right ventricular lead of her implanted defibrillator. While being intermediate-to-low surgical risk, she underwent AngioVac-directed suction debulking (AngioDynamics, Latham, NY, USA) of the vegetation simultaneously preceding percutaneous laser lead extraction in a single session. This less invasive alternative to open thoracotomy has been described in high surgical risk patients, but its widespread role remains unexplored. .

Use of MPH hemostatic powder for electrophysiology device implantation reduces postoperative rates of pocket hematoma and infection.

BACKGROUND: Surgical site bleeding and infection are potential complications after electrophysiology (EP) device implantation procedures. To date, there is a wide variety of tools for management of intraoperative bleeding but it still remains unclear what methods are preferred. OBJECTIVE: The aim of our study is to compare the rate of complications in patients who underwent cardiac implantable electronic device (CIED) implantation utilizing MPH hemostatic powder to the rate of complications in those patients who underwent standard procedure protocol without MPH hemostatic powder. METHODS: In our study, a new plant-derived microporous polysaccharide hemostatic powder (Arista) was used. A total of 283 consecutive patients were retrospectively studied to assess the rate of complications in patients who underwent CIED implantation with MPH hemostatic powder (n = 77, MPH hemostatic powder) and without (n = 206, no MPH hemostatic powder). Patients were followed for 12 months. RESULTS: The MPH hemostatic powder group of patients had a lower complication rate when compared to no MPH hemostatic powder, 0.3% vs. 1.7% (p < .05), respectively. The rate of device implantation site MPH hematoma in the MPH hemostatic powder group was 0.4%, versus 0.9% in the other group. There were no postoperative infections in the MPH hemostatic powder group versus 3.2% infections in the other group. The main predictor of increased risk of post-procedural complication was the usage of anticoagulation with a hazard ration of 2.7. CONCLUSION: Using MPH hemostatic powder for post-procedural hemostasis was shown to result in a significant reduction in the rate of overall post-procedural complications (a composite endpoint of hematoma and infections), and a trend in reduction of the infections rates and device implantation site hematoma rates.

Staphylococcus aureus bloodstream infection in patients with ventricular assist devices-Management and outcome in a prospective bicenter cohort.

OBJECTIVES: Ventricular assist devices (VAD) are increasingly implanted in patients with terminal heart failure. Here we describe the clinical course, management and outcome of VAD patients with S. aureus bloodstream infection (SAB). METHODS: We conducted a post hoc analysis of data from 1073 patients who had been prospectively enrolled in two consecutive SAB bicenter cohort studies. Patients with VAD in situ at the onset of SAB were identified. Follow-up of patients was at least 90 days. RESULTS: Twelve VAD patients with SAB were identified. Compared to the overall cohort, patients with VAD presented more often with fever (92% vs. 65%) and septic shock (33% vs. 23%) and showed higher C-reactive protein levels (mean 244 vs. 132 g/ml). The median time to onset of SAB after device implantation was 161 days (range 24-790 days). 30-day mortality was comparable to the whole cohort (17% vs. 19%). Infection-related surgical interventions were performed in six patients. Hematogenous dissemination to distant foci was not found in any patient. One out of nine surviving patients required continuous suppressive antibiotic therapy. CONCLUSIONS: Mortality rates for VAD patients with SAB were comparable to SAB without VAD. No hematogenous disssemination or persistent infections were recorded, which might be associated with the prompt and aggressive antibiotic and surgical management in VAD patients. SAB per se does not preclude successful transplantation.

18F-FDG-PET/CT Imaging to Diagnose Septic Emboli and Mycotic Aneurysms in Patients with Endocarditis and Cardiac Device Infections.

PURPOSE OF REVIEW: This review analyzes recent studies evaluating the diagnostic value of 18F-FDG-PET/CT for the detection of peripheral emboli and secondary infectious foci in patients with infective endocarditis and cardiac device infections. RECENT FINDINGS: Detection of extracardiac septic localizations in patients with infective endocarditis and cardiac device infections is crucial, as it may impact the diagnosis, prognosis, and therapeutic management. Recent literature substantiated the clinical usefulness of 18F-FDG-PET/CT in this setting. 18F-FDG-PET/CT has proven its high diagnostic value for the detection of peripheral emboli in patients with infective endocarditis and cardiac device infections, substantially affecting patients' outcome and treatment. A multimodal approach, combining the high sensitivity of 18F-FDG-PET/CT with morphological imaging seems promising.

A Roadmap for Reducing Cardiac Device Infections: a Review of Epidemiology, Pathogenesis, and Actionable Risk Factors to Guide the Development of an Infection Prevention Program for the Electrophysiology Laboratory.

PURPOSE OF REVIEW: Cardiovascular implantable electronic device (CIED) infections are highly morbid, common, and costly, and rates are increasing (Sohail et al. Arch Intern Med 171(20):1821-8 2011; Voigt et al. J Am Coll Cardiol 48(3):590-1 2006). Factors that contribute to the development of CIED infections include patient factors (comorbid conditions, self-care, microbiome), procedural details (repeat procedure, contamination during procedure, appropriate pre-procedural prep, and antimicrobial use), environmental and organizational factors (patient safety culture, facility barriers, such as lack of space to store essential supplies, quality of environmental cleaning), and microbial factors (type of organism, virulence of organism). Each of these can be specifically targeted with infection prevention interventions. RECENT FINDINGS: Basic prevention practices, such as administration of systemic antimicrobials prior to incision and delaying the procedure in the setting of fever or elevated INR, are helpful for day-to-day prevention of cardiac device infections. Small single-center studies provide proof-of-concept that bundled prevention interventions can reduce infections, particularly in outbreak settings. However, data regarding which prevention strategies are the most important is limited as are data regarding the optimal prevention program for day-to-day prevention (Borer et al. Infect Control Hosp Epidemiol 25(6):492-7 2004; Ahsan et al. Europace 16(10):1482-9 2014). Evolution of infection prevention programs to include ambulatory and procedural areas is crucial as healthcare delivery is increasingly provided outside of hospitals and operating rooms. The focus on traditional operating rooms and inpatient care leaves the vast majority of healthcare delivery-including cardiac device implantations in the electrophysiology laboratory-uncovered.

A cardiac implantable device infection by Raoultella planticola in an immunocompromized patient.

Introduction. Infection of cardiac implantable electronic devices is a severe condition associated with high mortality, particularly in patients who are dependent upon heart-pacing devices. Staphylococci are found in 70 % of reported cases. Case presentation. We report the case of a cardiac-pacemaker infection in a 79-year-old man, cumulating a history of rheumatoid arthritis treated by corticosteroids and methotrexate by a recently identified micro-organism: Raoultella planticola. He presented local signs of infection on his VVI pacemaker implantation site and underwent urgent pocket device replacement under cefamandole antibioprophylaxis. On incision thick pus oozed out. It was necessary to perform a complete hardware extraction comprising the pulse generator and the ancient lead. Pus was inoculated into aerobic and anaerobic culture vials and Gram staining unveiled Gram-negative rods. Microbiology analysis identified the organism as R. planticola. A new pacing device was inserted on the contrlateral pectoral region. Ciprofloxacin enabled full recovery. A literature review concerning this pathogen revealed that it is involved in severe infections such as bloodstream infections, peritonitis, cellulitis, pneumonia and lung abscesses, and urinary tract infections. In these case reports, underlying co-morbidities were identified such as solid active neoplasia, recent chemotherapy, corticosteroids, solid-organ-recipient patients and recent open surgery. Conclusion.R. planticola is a serious emerging pathogen and contributes to the burden of various infectious conditions. Its pathogenicity and occurrence should be known by clinicians and a high level of awareness is necessary to precisely identify it provide the correct antibiotic regimen.

Challenges in Infective Endocarditis.

Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. It is frequently acquired in the health care setting, and more than one-half of cases now occur in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. It is heterogeneous in etiology, clinical manifestations, and course. Staphylococcus aureus, which has become the predominant causative organism in the developed world, leads to an aggressive form of the disease, often in vulnerable or elderly patient populations. There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. The present article reviews the challenges posed by infective endocarditis and outlines current and future strategies to limit its impact.