Pulmonary Valve Endocarditis during and beyond Euro ENDO Registry: A Single Center Case Series.

Background: Pulmonary valve infective endocarditis (PVIE) is a rare form of infective endocarditis (IE) and is associated with high mortality and severe complications. Guidelines for treatment of this form of IE are scarce and based on general recommendations. We report a case series of PVE. Detailed Case Description: Case 1-A 36-year-old female with congenital pulmonary artery stenosis, dyspnea and leg edema symptoms for 2 months. Blood cultures yielded Staphylococcus spp. and Corynebacterium sp., and echocardiography revealed multiple floating vegetation at the pulmonic valve and surrounding structures. The clinical course was complicated with sepsis and multi-organ failure. Urgent surgery with pulmonary homograft implantation resulted in successful five-year outcome. Case 2-In a 38-year-old male with previous tetralogy of Fallot correction and symptoms of fatigue, fever, myalgia, and photophobia, echocardiography was suggestive of PVIE. The clinical course was complicated with septic shock, multi-organ failure, ischemic stroke with hemorrhagic transformation and death on the 12th day of hospitalization. Case 3-A 41-year-old male without previous medical history was hospitalized due to prolonged fatigue, fever, dyspnea, and leg edema. He was diagnosed with multi-valve infective endocarditis, affecting the aortic, tricuspid, and pulmonary valve. Acute heart failure and hemodynamic instability indicated urgent surgery with aortic valve replacement and reconstruction of the tricuspid and pulmonary valves. At four-year follow up he was doing well. Conclusion: Symptoms in PVIE may be versatile, and diagnosis is often delayed. High level of suspicion, early recognition, and echocardiography are cornerstones in diagnostics. Despite the standpoint that medical therapy is first-line, the role of surgery needs to be advocated in particular cases.

The clinical value of the endocarditis team: insights from before and after guidelines implementation strategy.

PURPOSE: To evaluate the impact of a multidisciplinary the "Endocarditis Team" (ET) on the course and outcome of infective endocarditis (IE) patients. METHODS: A retrospective before-after study, including hospitalized patients with definite IE, managed before (01.2013-12.2015) and after (01.2016-07.2019) the introduction of an ET. The primary outcomes were defined as 30-day and 1-year mortality and the secondary as conservative vs. invasive strategy, the interval from clinical suspicion of IE to the performance of echocardiography, utilization of multimodality evaluation, time to an invasive procedure, and the duration of hospitalization. RESULTS: Study population included 92 pre-ET and 128 post-ET implementation patients. Baseline characteristics were similar. During the post-ET period compared with pre-ET, we found higher rates of abscesses and extra-cardiac emboli (27.8% vs. 16.3%, p = 0.048); and a higher invasive procedures rate, including lead extraction (15.6% vs. 6.5%, p = 0.035) and noncardiac surgeries (14.8% vs. 6.5%, p = 0.05). Patients managed during the post-ET period had reduced short (8.5% vs. 17.4%, p = 0.048) and long-term mortality (Log-rank = 0.001). In multivariate analysis of risk factors for long-term mortality, period (pre- or post-ET) was not found to be significantly associated with the mortality. CONCLUSION: Establishment of an ET was associated with faster and more intensive evaluation of patients with IE. During the period of an ET activity, mortality rates were reduced compared with the previous period.

The impact of implementing an endocarditis team in comparison to the classic heart team in a tertiary referral centre.

BACKGROUND: Infective endocarditis (IE) is a complex disease for which the European Society of Cardiology guideline recommends a dedicated multidisciplinary endocarditis team (ET) approach since 2015. It is currently unknown whether this ET approach is beneficial compared to a classic heart team approach including bedside consultation by an infectious disease specialist in Western Europe. METHODS: This retrospective single centre, observational cohort study was conducted at the Radboudumc, a tertiary referral centre in the Netherlands. Consecutive patients treated for IE were included from September 2017 to September 2018 before implementation of a dedicated ET and from May 2019 to May 2020 afterwards. RESULTS: In total, 90 IE patients (45 patients before and 45 patients after the implementation of the ET) were included. No significant differences were found in diagnostic workup, surgical treatment (surgery performed 69% vs. 71%, p = 0.82), time to surgery because of an urgent indication (median 4 vs. 6 days, p = 0.82), in-hospital complications (53% vs. 67%, p = 0.20), and 6-month mortality (11% vs. 13%, p = 0.75) between IE patients treated before and after the implementation of the ET. CONCLUSION: Formalization of the recommended multidisciplinary endocarditis team might not significantly improve the complication rate nor the short term outcome.

Diagnostic challenges in infective endocarditis: is PET/CT the solution?

PURPOSE: Despite developments in both imaging and microbiological techniques, the final diagnosis of IE often remains challenging. In this single-center cohort study, we aimed to identify the specific indications for request of 18F-FDG-PET/CT in clinical practice and to evaluate the diagnostic benefit of this nuclear imaging technique. METHODS: A total of 235 patients with possible (n = 43) or definite (n = 192) IE according to the revised Duke criteria were prospectively studied from July 2013 until December 2016. Echocardiography was generally used as the primary cardiac imaging technique. All patients were treated by a multidisciplinary Endocarditis Team. Diagnostics with 18F-FDG-PET/CT were undertaken on request by at least one member of the multidisciplinary team when overall diagnostics were inconclusive. RESULTS: In 20 patients, 18F-FDG-PET/CT scan was performed for additional diagnostic evaluation. Hereof, 15 patients had a history of implanted cardiac prosthetic material. In six patients with definite IE, the use of 18F-FDG-PET/CT was helpful for further clarification of the diagnosis. In one patient with possible IE, the diagnosis could be reclassified to definite IE. In addition, one case of vertebral osteomyelitis as well as upper and lower leg abscesses and knee empyema were detectable as extracardiac foci. Furthermore, 18F-FDG-PET/CT leads to a modification of the management in five patients. CONCLUSION: Our findings support the utility of 18F-FDG-PET/CT as an adjunctive diagnostic tool especially in the evaluation of prosthetic valve-/cardiac device-related IE and for the detection of extracardiac foci in some cases. However, due to remaining limitations also of this imaging technique, a multidisciplinary clinical evaluation still remains the essential basis for the diagnostic assessment.

[ESC and AHA guidelines 2015 on endocarditis : In competition or synchrony?] / ESC/AHA-Endokarditisleitlinien 2015 : Wettstreit oder Gleichklang?

In the 2015 guidelines of the European Society of Cardiology (ESC) and the American Heart Association (AHA) on infective endocarditis, the diagnostics are based on the modified Duke criteria. The diagnosis can be confirmed by a combination of micro-organisms demonstrated in culture or in situ, with the detection of valvular lesions or abscess formation by an imaging modality using echocardiography, positron emission tomography computed tomography (PET/CT), cardio-CT or nuclear medical methods. The management should be further improved by an interdisciplinary endocarditis team in a specifically designated reference center. Pharmaceutical treatment is largely unchanged and based on classical antibiotics in monotherapy or as combination therapy but for staphylococcal endocarditis, gentamycin is no longer required. As cardiac surgery is needed in 50 % of the cases during the course of the disease, the urgency for surgery depends on the extent of cardiac insufficiency, the persistence of the pathogen despite antibiotic treatment and on neurological complications.

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4.

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Surgical outcomes of infective endocarditis in pediatrics: Moving the needle to a contemporary, multidisciplinary approach.

BACKGROUND: Infective endocarditis (IE) is an uncommon disease in children that, when present, is accompanied by significant morbidity and mortality. The presence of congenital heart disease often complicates management. The aim of the present study is to describe the characteristics and outcomes of children undergoing surgery for IE. METHODS: A retrospective chart review from 2004 to 2020 was conducted to identify consecutive patients younger than age 20 years with IE undergoing surgery. RESULTS: A total of 94 patients with IE were identified, of whom 47 underwent surgery at a median age of 16.7 years. Thirty-one patients (65.95%) had congenital heart disease. Vegetation and embolic phenomena occurred in 41 and 29 patients (87.23% and 61.7%), respectively, with the brain as most common location (57.1%). Native valve involvement had a greater tendency to embolize (P < .001). Staphylococcus spp was the most common organism (49%). The mitral valve was the most affected (31.9%). Seven (14.9%) patients had multivalvar involvement and valve replacement was the most common procedure performed (37 patients; 78.7%). There were 3 operative deaths (6.4%). Median length of hospital stay was 21 days. Risk factors for prolonged hospital stay were time to surgery in days (P < .001) and native valvar involvement (P = .05). Five patients (10.6%) had postoperative recurrent IE. Survival at 1 and 5 years was 93.6% and 89.4%, respectively. CONCLUSIONS: Children with IE can undergo surgery with acceptable results. The morbidity, but not mortality, is driven by embolic complications. Staphylococcus spp and native valve involvement are significant risk factors. VIDEO ABSTRACT.

Grayken lessons: the role of an interdisciplinary endocarditis working group in evaluating and optimizing care for a woman with opioid use disorder requiring a second tricuspid valve replacement.

BACKGROUND: Injection drug use-related endocarditis is increasingly common among hospitalized patients in the United States, and associated morbidity and mortality are rising. CASE PRESENTATION: Here we present the case of a 34-year-old woman with severe opioid use disorder and multiple episodes of infective endocarditis requiring prosthetic tricuspid valve replacement, who developed worsening dyspnea on exertion. Her echocardiogram demonstrated severe tricuspid regurgitation with a flail prosthetic valve leaflet, without concurrent endocarditis, necessitating a repeat valve replacement. Her care was overseen by our institution's Endocarditis Working Group, a multidisciplinary team that includes providers from addiction medicine, cardiology, infectious disease, cardiothoracic surgery, and neurocritical care. The team worked together to evaluate her, develop a treatment plan for her substance use disorder in tandem with her other medical conditions, and advocate for her candidacy for valve replacement. CONCLUSIONS: Multidisciplinary endocarditis teams such as these are important emerging innovations, which have demonstrated improvements in outcomes for patients with infective endocarditis and substance use disorders, and have the potential to reduce bias by promoting standard-of-care treatment.

Dismal prognosis of patients with operative indication without surgical intervention in active left-sided infective endocarditis.

Introduction: Around 25% of patients with left-sided infective endocarditis and operative indication do not undergo surgery. Baseline characteristics and outcomes are underreported. This study describes characteristics and outcomes of surgical candidates with surgical intervention or medical treatment only. Methods: Retrospective analysis of ongoing collected data from a single-center from an observational cohort of patients with infective endocarditis (ENVALVE). Kaplan-Meier estimates for survival was calculated. Factors associated with survival were assessed using a bivariable Cox model. To adjust for confounding by indication, uni- and multivariable logistic regression for the propensity to receive surgery were adjusted. Results: From January 2018 and December 2021, 154 patients were analyzed: 116 underwent surgery and 38 received medical treatment only. Surgical candidates without surgery were older (70 vs. 62 years, p = 0.001). They had higher preoperative risk profile (EuroSCORE II 14% (7.2-28.6) vs. 5.8% (2.5-20.3), p = 0.002) and more comorbidities. One patient was lost-to-follow-up. Survival analysis revealed a significant higher one-year survival rate among patients following surgery (83.7% vs. 15.3% in the non-surgical group; log-rank test <0.0001). In the final multivariable adjusted model, surgery was less likely among patients with liver cirrhosis [OR = 0.03 (95% CI 0.00-0.30)] and with hemodialysis [OR = 0.014 (95% CI 0.00-0.47)]. Conclusion: Patients with left-sided infective endocarditis who do not undergo surgery despite an operative indication are older, have more comorbidities and therefore higher preoperative risk profile and a low 1-year survival. The role of the Endocarditis Team may be particularly important for the decision-making process in this specific group.

An Unusual Case of a Double Tricuspid and Mitral Valves Infective Endocarditis Complicated by Multiple Septic Embolisms Secondary to an Atrial Septal Defect: A Case Report and Review of Literature.

Multivalvular endocarditis (MVE) is an uncommon infection that mostly involves mitral and aortic valves, and it is related to a higher risk of congestive heart failure and a higher mortality. We described a case of a bilateral MVE and performed a review of the literature on similar clinical cases. We reported an unusual case of a 68-year-old male patient with a tricuspid and mitral infective endocarditis due to a methicillin-resistant Staphylococcus aureus complicated by multiple right- and left-sided septic embolization (lungs, brain, spleen, L2-L3 vertebral bones) due to an unknown atrial septal defect identified and repaired during cardiac surgery. Despite the severity of the clinical case, the patient experienced a good clinical outcome also thanks to a multidisciplinary approach. We identified 21 case reports describing bilateral MVE. A multidisciplinary approach is essential in the management of valve diseases to improve the prognosis of patients, especially in bilateral MVE.

Acute coronary syndrome complicating infective endocarditis: A case report with an etiological review.

Introduction: Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis. It requires prompt and appropriate management to cure the patient. Cases presentation: We report the case of a 52-year-old patient, initially admitted for an acute non-ST-segment elevation coronary syndrome at very high ischemic risk, in whom coronary exploration was negative, and whose echocardiography showed a mobile image on the aortic valve, suggesting infective endocarditis. The patient benefited from an aortic valve replacement because of the size and the embolic complications he presented, with a favorable evolution. Discussion: Acute coronary syndrome during infective endocarditis is a rare complication with a high mortality rate. Several mechanisms are possible: the embolic mechanism, coronary extraluminal compression due to coronary mycotic aneurysm and obstruction of the coronary ostium by a large vegetation. The management remains multidisciplinary and personalized according to the phenotype of the patient, with the need to have the endocarditis team to be able to take the best therapeutic choice. Conclusion: Infective endocarditis must be evoked in any patient without usual cardiovascular risk factors who presents with an ACS that is accompanied by fever and elevated inflammatory markers, and a thorough clinical examination as well as the performance of additional tests.

Early surgery determines prognosis in patients with infective endocarditis: outcome in patients managed by an Endocarditis Team-a prospective cohort study.

Background: Infective endocarditis (IE) in South Africa is associated with significant morbidity and mortality, despite occurring in younger patients with fewer co-morbidities. Possible contributors include the high rates of blood culture negative endocarditis, high rates of mechanical valve replacement and the lack of inter-disciplinary coordination during management. Methods: The Tygerberg Endocarditis Cohort (TEC) study prospectively enrolled patients with IE between November 2019 and April 2021. All patients were managed by an Endocarditis Team with a set protocol for organism detection and a strategy of early surgery limiting the use of prosthetic material. Results: Seventy-two consecutive patients with IE were included, with a causative organism identified in 86.1% of patients. The majority of patients had a guideline indication for surgery (n=58; 80.6%). The in-hospital mortality rate was 18%, with a 6-month mortality rate of 25.7%. Surgery was performed in 42 patients (58.3%), with prosthetic valve (PVE) replacement in 32 (76.2%), conventional repair surgery in 8 (19.1%) and mitral valve reconstruction in 2 (4.8%) of patients. Patients who underwent surgery had a significantly lower in-hospital (4.8% vs. 56.3%; P<0.01) and 6-month (4.9% vs. 75.0%; P<0.01) mortality rate as compared with patients with an indication for surgery who did not undergo surgery. Conclusions: We have observed a reduction in the 6-month mortality rate in patients with IE following the establishment of an Endocarditis Team, adhering to a set protocol for organism detection and favouring early repair or reconstruction surgery. Patients who underwent surgery had a significantly lower mortality rate than patients with an indication for surgery who did not undergo surgery. Preventable residual mortality was driven by surgical delay.

Poor long-term outcomes of intravenous drug users with infectious endocarditis.

Objectives: The optimal management of active endocarditis in intravenous (IV) drug users is still lacking. Methods: From the years 1997 to 2017, 536 patients with active infectious endocarditis were surgically treated, including 83 (15%) with IV drug use (IVDU) and 453 (85%) without IV drug use (non-IVDU). Initial data were obtained from the Society of Thoracic Surgeons database and supplemented with chart review and national death index data. Results: The IVDU group was significantly younger (43 vs 56 years old) than the non-IVDU group and had greater rates of psychiatric disorders, drug use, and tricuspid valve endocarditis (28% vs 8.6%). Hypertension, dyslipidemia, and diabetes mellitus were significantly more common in the non-IVDU group. Perioperative complications and operative mortality (7.2% vs 7.9%) were similar. IVDU was not a significant risk factor for operative mortality. Kaplan-Meier survival was significantly lower in the IVDU group (5-year survival, 46% vs 67%). Significant risk factors for long-time mortality included IV drug use (hazard ratio [HR], 1.92), age ≥65 years (HR, 1.78), congestive heart failure (HR, 1.87), and enterococcus endocarditis (HR, 1.54). The 5-year rate of reoperation was similar between IVDU and non-IVDU groups (2.4% vs 2.7%). Conclusions: IVDU is a significant risk factor for long-term mortality. A multidisciplinary approach was preferred for IVDU patients to treat both endocarditis and substance use disorder and improve long-term survival.

Multimodality Imaging in the Diagnosis of Prosthetic Valve Endocarditis: A Brief Review.

Infective endocarditis is a common and treatable condition that carries a high mortality rate. Currently the workup of infective endocarditis relies on the integration of clinical, microbiological and echocardiographic data through the use of the modified Duke criteria (MDC). However, in cases of prosthetic valve endocarditis (PVE) echocardiography can be normal or non-diagnostic in a high proportion of cases leading to decreased sensitivity for the MDC. Evolving multimodality imaging techniques including leukocyte scintigraphy (white blood cell imaging), 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), multidetector computed tomographic angiography (MDCTA), and cardiac magnetic resonance imaging (CMRI) may each augment the standard workup of PVE and increase diagnostic accuracy. While further studies are necessary to clarify the ideal role for each of these imaging techniques, nevertheless, these modalities hold promise in determining the diagnosis, prognosis, and care of PVE. We start by presenting a clinical vignette, then evidence supporting various modality strategies, balanced by limitations, and review of formal guidelines, when available. The article ends with the authors' summary of future directions and case conclusion.

Impact of an In-Hospital Endocarditis Team and a State-Wide Endocarditis Network on Perioperative Outcomes.

BACKGROUND: Infective endocarditis (IE) requires multidisciplinary management. We established an endocarditis team within our hospital in 2011 and a state-wide endocarditis network with referring hospitals in 2015. We aimed to investigate their impact on perioperative outcomes. METHODS: We retrospectively analyzed data from patients operated on for IE in our center between 01/2007 and 03/2018. To investigate the impact of the endocarditis network on referral latency and pre-operative complications we divided patients into two eras: before (n = 409) and after (n = 221) 01/2015. To investigate the impact of the endocarditis team on post-operative outcomes we conducted multivariate binary logistic regression analyses for the whole population. Kaplan-Meier estimates of 5-year survival were reported. RESULTS: In the second era, after establishing the endocarditis network, the median time from symptoms to referral was halved (7 days (interquartile range: 2-19) vs. 15 days (interquartile range: 6-35)), and pre-operative endocarditis-related complications were reduced, i.e., stroke (14% vs. 27%, p < 0.001), heart failure (45% vs. 69%, p < 0.001), cardiac abscesses (24% vs. 34%, p = 0.018), and acute requirement of hemodialysis (8% vs. 14%, p = 0.026). In both eras, a lack of recommendations from the endocarditis team was an independent predictor for in-hospital mortality (adjusted odds ratio: 2.12, 95% CI: 1.27-3.53, p = 0.004) and post-operative stroke (adjusted odds ratio: 2.23, 95% CI: 1.12-4.39, p = 0.02), and was associated with worse 5-year survival (59% vs. 40%, log-rank < 0.001). CONCLUSION: The establishment of an endocarditis network led to the earlier referral of patients with fewer pre-operative endocarditis-related complications. Adhering to endocarditis team recommendations was an independent predictor for lower post-operative stroke and in-hospital mortality, and was associated with better 5-year survival.

Recurrent strokes in an occult case of recurrent Cutibacterium acnes prosthetic valve infective endocarditis: a case report.

BACKGROUND: Infective endocarditis (IE) is a known but uncommon cause of cardioembolic stroke and there are rare but recognized cases of IE without an inflammatory response. Cutibacterium acnes is an increasingly recognized source of invasive infections, including IE, but diagnosis is challenging due to its low virulence and fastidious nature. CASE SUMMARY: A 47-year-old man presented with a multi-focal stroke suggestive of a cardioembolic source. Outpatient transoesophageal echocardiography (TOE) was concerning for vegetation or thrombus associated with his previous mitral valve repair. He remained clinically well, with no evidence of an inflammatory response and sterile blood cultures. Computed tomography-positron emission tomography (CT-PET) corroborated the TOE findings, however, given the atypical presentation, he was treated for valvular thrombus. Following discharge, he quickly re-presented with further embolic phenomena and underwent emergency mitral valve replacement. Intraoperative findings were consistent with prosthetic valve IE (PVE) and a 6-week course of antibiotics commenced. C. acnes was identified on molecular testing. Eighteen months later, he re-presented with further neurological symptoms. Early TOE and CT-PET were consistent with IE. Blood cultures grew C. acnes after prolonged incubation. Given the absence of surgical indications, he was managed medically, and the vegetation resolved without valvular dysfunction. He continues to be followed up in an outpatient setting. DISCUSSION: In patients presenting with multi-territory stroke, IE should be considered despite sterile blood cultures and absent inflammatory response. C. acnes is an increasingly recognized cause of PVE in this context, often requiring surgical intervention. A high index of suspicion and collaboration with an Endocarditis Team is therefore essential to diagnose and treat.

Infective endocarditis - can we treat it more effectively?

Infective endocarditis (IE), despite the diagnostic and therapeutic advances, still remains a serious disease associated with high mortality and serious complications. The present guidelines of the European Cardiology Society of 2015 recommend administration of the antibiotics indicated in empirical therapy for multiple weeks and in targeted treatment often for 6-8 weeks. This is associated with a risk of adverse effects of antibiotic therapy in the form of nephro- and/or hepatotoxicity and an increased risk of infections with Clostridioides difficile, while long-term hospitalisation is associated with high non-drug costs. The recommendations developed by the Austrian Society for Infectious Diseases and Tropical Medicine list dalbavancin among the new antibiotics that may find application in the treatment of IE of staphylococcal aetiology. This antibiotic is a lipoglycopeptide antibiotic alternative to vancomycin in the treatment of Staphylococcus aureus MRSA infections, especially in a situation where the minimum inhibitory concentration for vancomycin is high but below the breakpoint. Dalbavancin has very good pharmacokinetic and pharmacodynamic properties, with a long duration of action of up to 14 days after administration of a single dose (1500 mg in a 30-minute infusion). This antibiotic is characterised by high clinical efficacy with good treatment tolerance and safety profile, without causing toxic effects in internal organs in comparison with vancomycin. In view of its safety, clinical efficacy and convenient dosing, dalbavancin may prove a useful therapeutic option in the treatment of IE.

Infective endocarditis: A contemporary update.

Infective endocarditis (IE) remains a rare condition but one with high associated morbidity and mortality. With an ageing population and increasing use of implantable cardiac devices and heart valves, the epidemiology of IE has changed. Early clinical suspicion and a rapid diagnosis are essential to enable the correct treatment pathways to be accessed and to reduce complication and mortality rates. In the current review, we detail the latest guidelines for the evaluation and management of patients with endocarditis and its prevention.

Redo aortic valve replacement for prosthesis endocarditis in patients previously classified as high or prohibitive risk: a narrative review.

Transcatheter aortic valve implantation (TAVI) and sutureless aortic valve replacement (Su-AVR) enabled in the last years many patients at high or prohibitive risk to be treated for their severe symptomatic aortic valve stenosis. As often happens in medicine, new techniques bring not only new hopes, but also new problems. In recent years, alongside the lengthening of the life of these patients treated with TAVI or Su-AVR, cardiologists and cardiac surgeons have had to face the long-term complications associated with the implantation of these devices, such as the prosthetic infective endocarditis. The correct management of prosthesis valve endocarditis after TAVI or Su-AVR in high risk patients, and the possible role of surgery are a matter of debate because pushing the limits of the modern medicine and becoming a new challenge for cardiac surgeons of 21st century. In this review, we summarized the incidence, characteristics and evidences for this new and controversial problem of the cardiovascular community. Moreover, we investigated the outcomes reported in literature of the conservative and the surgical strategy. Although the reported mortality rate of surgical treatment is high, seems not prohibitive, mostly if compared to conservative medical therapy. The collaborative exchange between cardiologist, cardiac surgeons, clinical microbiologists and expert of imaging is mandatory to face this challenge.

Multimodality Imaging in the Diagnostic Work-Up of Endocarditis and Cardiac Implantable Electronic Device (CIED) Infection.

Infective endocarditis (IE) is a serious cardiac condition, which includes a wide range of clinical presentations, with varying degrees of severity. The diagnosis is multifactorial and a proper characterization of disease requires the identification of the primary site of infection (usually the cardiac valve) and the search of secondary systemic complications. Early depiction of local complications or distant embolization has a great impact on patient management and prognosis, as it may induce to aggressive antibiotic treatment or, in more advanced cases, cardiac surgery. In this setting, the multimodality imaging has assumed a pivotal role in the clinical decision making and it requires the physician to be aware of the advantages and disadvantages of each imaging technique. Echocardiography is the first imaging test, but it has several limitations. Therefore, the integration with other imaging modalities (computed tomography, magnetic resonance imaging, nuclear imaging) becomes often necessary. Different strategies should be applied depending on whether the infection is suspected or already ascertained, whether located in native or prosthetic valves, in the left or right chambers, or if it involves an implanted cardiac device. In addition, detection of extracardiac IE-related lesions is crucial for a correct management and treatment. The aim of this review is to illustrate strengths and weaknesses of the various methods in the most common clinical scenarios.