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The objectives of this study were to describe and compare the clinical characteristics and outcomes of patients with definite and possible infective endocarditis (IE) involving prosthetic heart valve, and to identify prognostic factors for long-term mortality, using data from an unselected cohort of consecutive patients. We studied data from 133 consecutive patients with IE involving prosthetic heart valve seen in an academic institution between 1990 and 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 47, 35%) and patients with definite IE (n = 86, 65%). Overall, 55 patients died over a mean ± SD follow-up of 3.6 ± 4.1 years (median 1.8, interquartile range 4.4 years). Patients with definite IE had a higher risk of death (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.20 to 4.17 p = 0.01). Independent predictors of long-term mortality were increasing age (HR 1.05, 95% CI 1.02 to 1.08, p = 0.002), Staphylococcus aureus infection (HR 3.40, 95% CI 1.00 to 11.76; p = 0.05), infection with unknown microorganism (HR 12.50, 95% CI 2.97 to 52.63; p = 0.0006), and definite IE (HR 8.70, 95% CI 3.55 to 21.28; p <0.0001), whereas infection on pacemaker or defibrillator (HR 0.30, 95%CI 0.10 to 0.87; p = 0.03) was associated with a better prognosis. Patients with definite IE and those with possible IE who underwent surgery had a nonsignificantly better prognosis than their counterparts with no surgery. In conclusion, patients with definite IE (Duke criteria) on a prosthetic heart valve independently had a worse prognosis than those with possible IE., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and has been independently related to increased morbidity and mortality. AF is a frequent arrhythmia in infective endocarditis (IE). Nevertheless, there are no data on how AF affects the clinical outcome of patients with endocarditis. Our purpose was to investigate patient characteristics, microbiology, echocardiographic findings, in-hospital course, and prognosis of patients with IE who develop new-onset AF (NAF) and compare them with those who remained in sinus rhythm (SR) or had previous AF (PAF). From 1997 to 2014, 507 consecutive patients with native left-sided IE were prospectively recruited at 3 tertiary care centers. We distinguished 3 groups according to the type of baseline heart rhythm during hospitalization and previous history of AF: NAF group (n = 52), patients with no previous history of AF and who were diagnosed as having NAF during hospitalization; SR group (n = 380), patients who remained in SR; and PAF group (n = 75), patients with PAF. Patients with NAF were older than those who remained in SR (68.3 vs 59.6 years, p <0.001). At admission, heart failure was more common in NAF group (53% vs 34.3%, p <0.001), whereas stroke (p = 0.427) was equally frequent in all groups. During hospitalization, embolic events occurred similarly (p = 0.411). In the multivariate analysis, NAF was independently associated with heart failure (odds ratio 3.56, p <0.01) and mortality (odds ratio 1.91, p = 0.04). In conclusion, the occurrence of NAF in patients with IE was strongly associated with heart failure and higher in-hospital mortality independently from other relevant clinical variables., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The aim of this study was to assess the impact of an operative protocol with a multidisciplinary approach on the outcome of patients with prosthetic valve endocarditis (PVE). A formal policy for the care of PVE was introduced at our hospital in 2003 in which patients were referred to and managed by a preexisting team involving a cardiologist, a specialist in infectious diseases, and a cardiac surgeon. All patients underwent transesophageal echocardiography as soon as clinical suspicion of PVE arose. If high-risk conditions such as heart failure, ring abscess, conditions associated with impending malfunctioning of the prosthesis, or vegetations at high risk for systemic embolization were found during the initial multidisciplinary evaluation (performed within 12 hours of admission), patients were operated on within 48 hours. Stable patients were evaluated weekly by the multidisciplinary team, and on-treatment surgery was performed whenever high-risk conditions developed or when there was persistent fever/bacteremia after 1 week of adequate antibiotic therapy. Comparing the period 2003 through 2009 with 1996 through 2002 (when a multidisciplinary policy was not followed), patients with PVE were more numerous (61 vs 38), older (mean age 68.3 vs 63.1, p = 0.01), and had more co-morbidities (mean Charlson index 3.15 vs 2.42, p = 0.03). The most frequent causative organisms were Staphylococci in both periods. In the second period, fewer patients had delayed diagnosis (39% vs 71%, p = 0.03), heart failure (20% vs 45%, p = 0.01), abscess (20% vs 39%, p = 0.04), culture-negative infective endocarditis (11% vs 29%, p = 0.03), and worsened renal function (21% vs 42%, p = 0.04). A significant reduction in in-hospital mortality (53% to 23%, p = 0.04) and 3-year mortality (60% to 28%, p = 0.001) was observed, driven by the increased number of patients successfully treated with medical therapy alone (44% vs 16%, p = 0.04). In conclusion, formalized, collaborative management led to significant improvement in PVE-related mortality., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Cardiac device infections (CDIs) represent a serious complication after the implantation of pacemakers and defibrillators. In addition to antimicrobials, complete hardware removal, mostly with percutaneous lead extraction (PLE), is necessary to limit recurrences. However, CDI diagnosis is often difficult and is sometimes delayed, and scarce data exist on how the timing of PLE may affect clinical outcomes. In this study, the in-hospital outcomes of 52 consecutive patients with CDIs who underwent PLE were retrospectively analyze. Co-morbidities such as diabetes mellitus, congestive heart failure, renal insufficiency, and end-stage renal disease were highly prevalent in the study cohort. Patients were divided into group A (bacteremia or device endocarditis) and group B (localized pocket infection). In-hospital mortality was 29% in group A and 5% in group B (p = 0.02) and was due mostly to sepsis. Hospital stays were shorter in group B patients (5.7 vs 21.7 days, p <0.001). Presentation with hypotension was more commonly observed in group A patients and was associated with higher in-hospital mortality, whereas pocket findings correlated with better survival. Postoperative courses after PLE were uneventful in most patients, and no fatal complications were observed. PLE was performed significantly earlier in group B patients (hospitalization day 1.3 vs 7.6, p <0.001). PLE performed within 3 hospitalization days was associated with lower in-hospital mortality (p = 0.01). In conclusion, PLE performed within 3 days from admission is associated with shorter hospitalization and better survival. A timely diagnosis is crucial, particularly in the absence of local findings, because early treatment with PLE is likely to prevent the catastrophic outcomes of unrelenting CDIs., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Troponin levels have been correlated with adverse outcomes in multiple disease processes, including congestive heart failure, acute coronary syndromes, sepsis, and, in a few small series, infective endocarditis. We hypothesized that a novel measurement of troponin using a highly sensitive assay would correlate with adverse outcomes when prospectively studied in patients with infective endocarditis. At a single center in the International Collaboration on Endocarditis, 42 patients met the inclusion criteria and underwent testing for cardiac troponin T (cTnT) using both a standard and a highly sensitive precommercial assay. The cTnT levels were associated with the prespecified primary composite outcome of death, central nervous system event, and cardiac abscess. Secondary outcomes included the individual components of the composite outcome and the need for cardiac surgery. A receiver operating characteristic curve was derived and used to identify the optimal cutpoint for cTnT using the highly sensitive assay. cTnT was detectable with the highly sensitive assay in 39 (93%) of 42 patients with infective endocarditis and with the standard assay in 25 (56%) of 42 (p <0.05). Of the 42 patients, 15 experienced the composite outcome, 4 died, 9 had a central nervous system event, and 5 had a cardiac abscess. With the hs-cTnT assay, the median cTnT was greater in the patients who experienced the primary outcome (0.12 vs 0.02 ng/ml, p <0.05). According to the receiver operating characteristic curve analysis (area under the curve of 0.74), cTnT levels of ≥0.08 ng/ml produced optimal specificity (78%) for the primary outcome. The patients with a cTnT level of ≥0.08 ng/ml were more likely to experience the primary outcome (odds ratio 7.0, 95% confidence interval 1.7 to 28.6, p <0.01) and a central nervous system event (odds ratio 9.3, 95% confidence interval 1.3 to 24.1, p = 0.02). In conclusion, cTnT is detectable in 93% of patients with infective endocarditis using a novel highly sensitive assay, with higher levels correlating with poor clinical outcomes., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This study analyzed the profile and outcome of surgically versus medically treated patients with prosthetic valve infective endocarditis (PVE). From 2000 to 2006, 80 patients >16 years of age (median 71) with definite PVE according to modified Duke criteria were included. The medically treated group was separated into deliberately conservative and perforce conservative treatments, the latter group including patients with contraindications to a cardiosurgical intervention. The most frequent causative micro-organisms were staphylococci. Forty-six percent of patients were surgically treated, 34% had deliberately conservative treatment, and 20% had perforce conservative treatment. Six-month mortality was 29%; 27% of surgically treated patients died, 4% deliberately conservatively patients died, and 75% perforce conservatively treated patients died. Septic shock, multiorgan failure, and type of treatment were significantly associated with death in univariable analysis. Multivariable analysis revealed that type of treatment (perforce conservative) and septic shock predicted death in patients with PVE. Survival was most favorable in deliberately conservatively treated patients, including PVE due to Staphylococcus aureus. In conclusion, there remains a role for watchful waiting in patients with PVE without evidence of major complications. Moreover, patients with uncomplicated S. aureus PVE can be treated successfully without cardiac surgery. Conversely, patients with major complicated PVE should preferentially undergo surgery. Predictors of mortality in patients with PVE included septic shock and perforce conservative treatment.

Despite developments in preventative and medical therapy, infective endocarditis (IE) carries a high rate of mortality. Risk factors for mortality are unknown in pediatric and adult patients with congenital heart disease (CHD). We determined the risk factors for in-hospital mortality in pediatric and adult patients with CHD. A retrospective observational cohort study was conducted from January 1997 to December 2001 in Japan. Of the 239 patients for whom complete data were available, 216 patients with CHD were identified. Outcomes were alive or deceased. The proposed modified Duke's criteria identified 137 patients, aged 1 month to 62 years with a median of 12 years, with IE. In-hospital mortality was 10%. Four risk factors were independently associated with mortality by stepwise logistic regression analysis: (1) vegetation size > or =20 mm (odds ratio 40.6, 95% confidence interval 2.42 to 681); (2) age <1 year (odds ratio 19.5, 95% confidence interval 1.74 to 219); (3) presence of heart failure (odds ratio 7.16, 95% confidence ratio 1.34 to 38.4); and (4) Staphylococcus aureus as a causative organism (odds ratio 5.68, 95% confidence interval 1.16 to 27.9). Surgical intervention emerged as a predictive factor for lower in-hospital mortality (odds ratio 0.045, 95% confidence interval 0.003 to 0.70) by stepwise logistic regression analysis. In conclusion, surgical intervention, which decreases the risk of in-hospital mortality, should always be considered.

Little is known about the incidence and clinical outcomes of infective endocarditis (IE) involving native valves in Asian countries. This nationwide study investigated epidemiologic features and in-hospital mortality associated with IE in adults (age > or =18 years) based on Taiwan's National Health Insurance database from 1997 through 2002. Of 7,240 enrolled patients with IE involving native valves, the mean age was 53 +/- 19 years and 70% were men. The mean annual crude incidence was 7.6 per 100,000 inhabitants. The incidence was significantly higher in men than in women (10.4 vs 4.6 per 100,000; p <0.001). The incidence of IE increased steadily with age, ranging from 3.8 per 100,000 persons in patients <30 years of age to 33 per 100,000 persons in patients > or =80 years of age (p <0.001). Staphylococcal (32%) and streptococcal species (61%) were the most common causative pathogens. The mean in-hospital mortality rate was 18%. Multivariate analysis showed that male gender, older age (> or =50 years), diabetes mellitus, heart failure, neurologic complications, renal insufficiency, respiratory failure, shock, and Staphylococcus species as the causative microorganism were independent predictors of in-hospital mortality. In conclusion, this Taiwanese study revealed a high incidence of IE in men and elderly subjects. The in-hospital mortality rate remained high. Patients with IE who also developed shock and respiratory failure were the most likely to have a poor outcome.

The aims of this study were to determine the clinical characteristics and outcome of patients who had definite infective endocarditis (IE) complicated by aortic ring abscess formation that was detected with transesophageal echocardiography (TEE) and to determine the prognostic significance of abscess formation in aortic valve IE. Patients who had aortic valve IE were selected from the International Collaboration on Endocarditis Merged Database (ICE-MD) if they underwent TEE. Among 311 patients who had definite aortic valve IE, 67 (22%) had periannular abscesses. They were more likely to have infection in the setting of a prosthetic valve (40% vs 19%, p <0.001) and coagulase-negative staphylococcal IE (18% vs 6%, p < 0.01) and less likely to have streptococcal IE than were patients who did not develop abscess (28% vs 46%, p = 0.01). Systemic embolization, central nervous system events, and heart failure did not differ between those who developed abscess and those who did not, but power was limited. Patients who had abscess were more likely to undergo surgery (84% vs 36%, p <0.001), and their in-hospital mortality rate was higher (19% vs 11%, p = 0.09). Multivariate analysis of prognostic factors of mortality in aortic IE identified age (odds ratio [OR] 1.6, 95% confidence interval [CI]1.2 to 2.1), Staphylococcus aureus (S. aureus) infection (OR 2.4, 95% CI 1.1 to 5.2), and heart failure (OR 2.9, 95% CI 1.4 to 6.1) as variables that were independently associated with increased risk of death. Periannular abscess formation showed a nonsignificant trend toward an increased risk of death (OR 1.9, 95% CI 0.9 to 3.8). Multivariate analysis of prognostic factors of mortality in complicated aortic IE with abscess formation identified S. aureus infection (OR 6.9, 95% CI 1.6 to 29.4) as independently associated with increased risk of death. In conclusion, in the current era of TEE and high use of surgical treatment, periannular abscess formation in aortic valve IE is not an independent risk factor for mortality. S. aureus infection is an independent prognostic factor for mortality in patients who have abscess formation.

In 82 patients with infective endocarditis, including 11 with a perivalvular abscess detected by transesophageal echocardiography, age was a significant predictor of in-hospital mortality (p <0.001). At 3.8-year follow-up, 5 of 7 patients with an abscess who had valve replacement and 2 of 4 patients with an abscess who did not have surgery survived (p = NS); 13 of 22 patients (59%) with no abscess who had valve replacement and 20 of 49 patients (41%) with no abscess who did not have surgery survived (p = NS).

A prospective series of 78 cases of prosthetic valve endocarditis (PVE) was studied (35 cases of early PVE and 43 cases of late PVE). The in-hospital mortality rate was significantly higher in patients with early PVE (31% vs 9%, p <0.01) because the onset of heart failure was more common in these patients (55% vs 37%, p <0.05). However, event-free survival at 4 years in survivors to the active phase was not different (74% and 82%, respectively).

The aim of our study was to compare the clinical, echographic, and prognostic features of Streptococcus bovis (S. bovis) endocarditis with those caused by other streptococci and pathogens in a large sample of patients with definite endocarditis by Duke criteria, using transesophageal echocardiography. Two hundred six patients (149 men, mean age 57 +/- 15 years) with a diagnosis of infective endocarditis formed the study population. All patients underwent multiplane transesophageal echocardiography and blood cultures. Cerebral, thoracoabdominal computed tomographic scan was performed in almost all patients (95%). All patients with S. bovis endocarditis underwent colonoscopy. Incidence of S. bovis endocarditis in our sample was 19%. Patients with S. bovis endocarditis were older than other groups. Multiple valve involvement, native valves, and large vegetations (>10 mm) were more frequent in patients with S. bovis. There was a significantly higher occurrence of embolism in the S. bovis group. Splenic embolism and multiple embolisms were significantly more frequent in patients with S. bovis. Gastrointestinal lesions, anemia, and spondylitis were observed more frequently with S. bovis endocarditis. In addition to the requirement for gastrointestinal examination for S. bovis endocarditis, our study underlines the need for systematic screening for vertebral and splenic localizations, and suggests the use of early surgery to prevent the high risk of embolism in these patients.

When active infective endocarditis (IE) involves a bioprosthetic valve, the infective process may involve only the cusps or sewing ring or both. We studied 34 patients with infected bioprostheses to determine whether the infection involved the cusps or ring, or both, because these locations could affect prognosis. In the 5 patients in whom active IE began < 60 days after operation, the infection involved the cusps only in 2, the ring only in 2, and both in 1. The 29 patients in whom signs and symptoms of active IE appeared > 60 days after valve replacement were subdivided into 3 categories based on the valve or valves replaced. In the 16 patients with isolated aortic valve replacement, the infection involved the cusps only in 6, the ring only in 4, and both in 6. In the 6 patients with isolated mitral valve replacement, the infection involved the cusps only in 2, the ring only in 1, and both in 3. In the remaining 7 patients, 15 native valves were replaced with bioprostheses, and 10 of them were infected. The infection involved the cusps only in 7, and both the cusps and ring in 3. Of all 34 patients, 13 had operative excision of the infected bioprosthesis: 1 died within 60 days of the bioprosthetic excision, and 1 was lost to follow-up; of the remaining 11 patients, 4 died late (1.5, 3, 5 and 14 years), and the other 7 are alive 5 to 10 years after bioprosthetic excision (all in New York Heart Association functional class I or II). Thus, although infection limited to the bioprosthetic cusps may reasonably allow a better outlook, reoperation with infection involving the annular ring (8 of 13 reoperation patients) does not prevent successful outcome.

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p less than 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p less than 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p less than 0.005) and long-term (p less than 0.0005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation. Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.

Eighty opiate addicts were studied at necropsy. Fifty-nine patients had anatomic evidence of active infective endocarditis (IE); 11 had healed IE; and 10 had both. Of the 80 patients, the first episode of IE involved a single right-sided cardiac valve in 24 patients (30%); both a right- and a left-sided valve in 13 patients (16%); a single left-sided valve in 33 patients (41%); and both left-sided valves in 10 patients (13%). Of the 320 cardiac valves in the 80 patients, 103 were sites of vegetations, an average of 1.3 of the 4 valves. Of the 80 patients, the tricuspid valve was infected in 35 (44%), mitral in 34 (43%), aortic in 32 (40%) and pulmonic in 2 (3%). Of the 103 infected cardiac valves, the infection caused sufficient damage to cause dysfunction in 70 (68%): in 28 (88%) of 32 infected aortic valves; in 22 (63%) of 35 infected tricuspid valves; in 19 (56%) of the 34 infected mitral valves; and in 1 of the 2 infected pulmonic valves. Of the 80 patients, 57 (71%) had sufficient valvular damage to cause valvular dysfunction. Of the 80 patients, gross examination of the valves at necropsy indicated that the infected valve almost certainly had been anatomically normal in 65 patients (81%) and abnormal in 15 patients (19%) before the onset of IE. Of the 65 patients with previously anatomically normal valves, 86 (33%) of their 260 cardiac valves were sites of infection (average 1.3 valves/patient); of the 15 patients with infection superimposed on a previously abnormal valve, the infection in each involved previously abnormal valves (21 in the 15 patients) or 17 (28%) of their 60 cardiac valves were sites of infection (average 1.1 valve/patient). Of the 15 patients with abnormal cardiac valves before the infection, 7 had congenitally bicuspid aortic valves and 8 had diffuse fibrous thickening of the mitral valve typical of rheumatic heart disease with (6 patients) or without (2 patients) diffuse fibrous thickening of tricuspid aortic valves. Of the 80 patients, 42 (53%) died during their first episode of active IE, 17 (21%) underwent operative excision with or without valve replacement during the active IE, and in 21 patients (26%) the first episode of active IE healed. In 10 of the latter 21 patients, active IE recurred and was fatal. A total of 19 patients had cardiac valve excision with or without replacement, 17 during active IE and 2 after healing.(ABSTRACT TRUNCATED AT 250 WORDS)