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In patients receiving hemodialysis, infective endocarditis (IE) may present in a similar way to other causes of bacteremia, which may delay early diagnosis and can lead to worse outcomes. In this study, we aimed to identify the risk factors for IE in hemodialysis patients with bacteremia. This study was conducted on all patients diagnosed with IE and receiving hemodialysis between 2005 and 2018 in Salford Royal Hospital. Patients with IE were propensity score matched with similar hemodialysis patients with episodes of bacteremia between 2011 and 2015 (non-IE bacteremic (NIEB)). Logistic regression analysis was used to predict the risk factors associated with infective endocarditis. There were 35 cases of IE, and these were propensity matched with 70 NIEB cases. The median age of the patients was 65 years with a predominance of males (60%). The IE group had higher peak C-reactive protein compared to the NIEB group (median, 253 mg/L vs. 152, p = 0.001). Patients with IE had a longer duration of prior dialysis catheter use than NIEB patients (150 vs. 28.5 days: p = 0.004). IE patients had a much higher 30-day mortality rate (37.1% vs. 17.1%, p = 0.023). Logistic regression analysis showed previous valvular heart disease (OR: 29.7; p < 0.001), and a higher baseline C-reactive protein (OR: 1.01; p = 0.001) as significant predictors for infective endocarditis. Bacteremia in patients receiving hemodialysis through a catheter access should be actively investigated with a high index of suspicion for infective endocarditis, particularly in those with known valvular heart disease and a higher baseline C-reactive protein.

Background: Infective endocarditis (IE) may present with a broad spectrum of symptoms and signs and several tools can be used for diagnosis. Many protocols can be used for in-hospital and out-patient management. The aim of this study was to assess the clinical features, tools used and outcomes of patients diagnosed with IE in one of the tertiary-care university hospitals., Methods: This study included 90 consecutive patients admitted to the Cardiology Department in a tertiary-care university hospital in Egypt with a diagnosis of IE., Results: The mean age of the studied population was 36.72 years and 76.67% were males. The most common underlying condition was valvular heart disease (48.89%), followed by intravenous drug use (26.67%) and the most common risk factor was smoking (48.89%). The most common clinical presentation was fever (69.67%), followed by dyspnoea (55.56%), and the mean duration from symptom onset until admission was 13.28 ± 9.29 days. Positive cultures were encountered in 45.56% of patients. Surgery was indicated in 91.11% of the patients but it was performed in only 28.89%. Almost a third of patients (34.44%) died in the hospital. After one year of follow up, a further 8.47% of the patients had died, 11.86% had heart failure and 6.78% had undergone a re-do surgery., Conclusions: Nowadays IE tends to affect a younger group of patients and valvular heart disease is the main underlying condition. The mortality rate due to IE is high in developing countries and IE does not have only immediate and short-term complications, its effects extend to a longer period of time.

Patients with the underlying valvular heart disease are at the high risk of developing sub-acute or chronic endocarditis secondary to Coxiella burnetii. Q fever endocarditis is the most common manifestation along with persistent the infection. There is some serologic and molecular evidence of C. burnetii infection in humans and livestock in Iran. As it is possible to observe chronic Q fever in Iran, it seems necessary to study the prevalence of Q fever endocarditis in this country. In the present study, Infective Endocarditis (IE) patients (possible or definite based on Duke Criteria) hospitalized in Rajaie Cardiovascular Medical and Research Center were enrolled from August 2016 to September 2018. Culture-negative endocarditis patients were evaluated by Raoult criteria for diagnosis Q fever endocarditis. The serological results for brucellosis were negative for all subjects. All blood and tissue samples including valve samples were tested for C. burnetii infection using serology and Polymerase Chain Reaction (PCR). In this study, 126 patients who were admitted to the hospital were enrolled; of which 52 subjects were culture-negative IE. Among the participants, 16 patients (30.77%) were diagnosed with Q fever IE and underwent medical treatment. The mean age of patients was 46.6 years ranging from 23 to 69 years and 75% of them were male. Considering the high prevalence of Q fever IE, evaluation of the patients with culture-negative IE for C. burnetii infections was highly recommended.

Objectives: We retrospectively analysed our 20-year experience on surgical treatment of native mitral valve (MV) endocarditis in a single institution using an early and repair-oriented surgical approach., Methods: From August 1991 to December 2015, 192 consecutive patients underwent MV surgery for active endocarditis. Of these, 81% (n = 155) had MV repair while 19% had MV replacement. In-hospital and late outcomes were analysed in the 2 groups and in the subgroups of repair with and without the use of a patch. Study end points were overall survival, MV reoperation and valve-related events. The median follow-up was 122 and 146 months in the repair and replacement groups, respectively., Results: Patients undergoing MV replacement were significantly older with more severe preoperative comorbidities and clinical conditions compared to patients undergoing MV repair (P < 0.05). When the repair and replacement groups were compared, hospital mortality was 11.6% and 29.7%, respectively (P = 0.006); at 15 years, overall survival was 57 ± 6% and 36 ± 12%, respectively (P = 0.03); freedom from MV reoperation was 81 ± 6% and 73 ± 18%, respectively (P = 0.46); linearized rate of recurrent endocarditis was 0.1% and 2.4%, respectively. Fifteen-year freedom from reoperation was 75.4 ± 8.6% vs 92 ± 4.5% in the patch versus no-patch repair subgroups, respectively (P = 0.33)., Conclusions: Active MV endocarditis remains a life-threatening disease. In experienced centres, an early and repair-oriented surgical approach can achieve relatively high reparability rates with good long-term durability of the repair and a very low recurrence rate of endocarditis. Patients could benefit from MV repair even if patch material is necessary to repair the valve.

Background: Endocarditis has emerged as one of the most concerning adverse outcomes in patients with congenital anomalies involving the right ventricular outflow tract (RVOT) and prosthetic valves., Objectives: The aim of this study was to evaluate rates and potential risk factors for endocarditis after transcatheter pulmonary valve replacement in the prospective Melody valve trials., Methods: All patients in whom a transcatheter pulmonary valve (TPV) was implanted in the RVOT as part of 3 prospective multicenter studies comprised the analytic cohort. The diagnosis of endocarditis and involvement of the TPV were determined by the implanting investigator., Results: A total of 309 patients underwent transcatheter pulmonary valve replacement (TPVR) and were discharged with a valve in place. The median follow-up duration was 5.1 years, and total observation until study exit was 1,660.3 patient-years. Endocarditis was diagnosed in 46 patients (median 3.1 years after TPVR), and a total of 35 patients were reported to have TPV-related endocarditis (34 at the initial diagnosis, 1 with a second episode). The annualized incidence rate of endocarditis was 3.1% per patient-year and of TPV-related endocarditis was 2.4% per patient-year. At 5 years post-TPVR, freedom from a diagnosis of endocarditis was 89% and freedom from TPV-related endocarditis was 92%. By multivariable analysis, age ≤12 years at implant (hazard ratio: 2.3; 95% confidence interval: 1.2 to 4.4; p = 0.011) and immediate post-implant peak gradient ≥15 mm Hg (2.7; 95% confidence interval: 1.4 to 4.9; p = 0.002) were associated with development of endocarditis and with development of TPV-related endocarditis (age ≤12 years: 2.8; 95% confidence interval: 1.3 to 5.7; p = 0.006; gradient ≥15 mm Hg: 2.6; 95% confidence interval: 1.3 to 5.2; p = 0.008)., Conclusions: Endocarditis is an important adverse outcome following TVPR in children and adults with post-operative congenital heart disease involving the RVOT. Ongoing efforts to understand, prevent, and optimize management of this complication are paramount in making the best use of TPV therapy. (Melody Transcatheter Pulmonary Valve [TPV] Study: Post Approval Study of the Original Investigational Device Exemption [IDE] Cohort; NCT00740870; Melody Transcatheter Pulmonary Valve Post-Approval Study; NCT01186692; and Melody Transcatheter Pulmonary Valve [TPV] Post-Market Surveillance Study; NCT00688571)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe the demographic, clinical, and microbiological profile of native vertebral osteomyelitis (NVO) in aged patients as compared to that of younger patients, to identify differences that could motivate changes in clinical management., Methods: Retrospective, observational cohort study (1990-2015) including all adult patients with microbiologically confirmed NVO divided into 2 groups: aged (≥ 65 years) vs younger (18-64 years)., Results: 247 patients included, 138 aged and 109 younger. Relative to younger patients, the aged had higher rates of healthcare-related infection (40.6 vs 25.7%, p = 0.014), previous known heart valve disease (29.7 vs 9.2%, p < 0.001), and concomitant infective endocarditis (38.4 vs 20.2%, p = 0.002). The groups showed similar rates of symptomatic spinal cord compression (14.5 vs 11.9%, p = 0.556) and paraspinal abscesses (62.3 vs 68.8%, p = 0.288) at presentation. There was a trend to lower spine surgery rates in the aged (11.6 vs 17.4%, p = 0.192). On univariate analysis, Staphylococcus aureus infection was associated with higher in-hospital mortality in aged (29%, OR 4.3, 95% CI 1.61-11.45). In-hospital mortality was higher among the aged (14.5 vs 6.4%, p = 0.044) as well as relapse rate due to treatment failure (3.4 vs 1%, p = 0.377)., Conclusions: The findings underscore the importance of preventing healthcare-related infection and maintaining high clinical suspicion of infective endocarditis in aged NVO patients to implement proper management. S. aureus infection had a poorer prognosis in this population. As compared to younger patients, spinal surgery rates were slightly lower and overall prognosis poorer in the aged, despite similar rates of symptomatic spinal cord compression and abscesses at presentation.

Objectives: Minimal access mitral valve surgery (MVS) has already proved to be feasible and effective with low perioperative mortality and excellent long-term outcomes. However, experience in more complex valve diseases such as infective endocarditis (IE) still remains limited. The aim of this retrospective study was to evaluate early and long-term results of minimal access MVS for IE., Methods: Data were entered into a dedicated database. Analysis was performed retrospectively for the 8-year period between January 2007 and April 2015., Results: During the study period, 35 consecutive patients underwent minimal access MVS for IE at our department. Twenty-four had diagnosis of native MV endocarditis (68.6%) and 11 of mitral prosthesis endocarditis (31.4%).Thirty patients underwent early MVS (85.7%), and 5 patients were operated after the completion of antibiotic treatment (14.3%). Seven patients underwent MV repair (20%), 17 patients underwent MV replacement (48.6%), and 11 patients underwent mitral prosthesis replacement (31.4%). Thirty-day mortality was 11.4% (4 patients). No neurological or vascular complications were reported. One patient underwent reoperation for prosthesis IE relapse after 37 days. Overall actuarial survival rate at 1 and 5 years was 83%; freedom from MV reoperation and/or recurrence of IE at 1 and 5 years was 97%., Conclusions: Minimally invasive MVS for IE is feasible and associated with good early and long-term results. Preoperative accurate patient selection and transoesophageal echocardiography evaluation is mandatory for surgical planning., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Mitral annular calcification (MAC) is a chronic inflammatory process with similarities to atherosclerosis. It is common in elderly patients and those with renal dysfunction. Although MAC is associated with cardiovascular morbidity, its relationship to infective endocarditis is unclear. The aim of this study was to test the hypothesis that MAC would be prevalent in patients with mitral valve vegetations and that vegetations would frequently occur on calcific nodules. A secondary aim was to look for possible bacteriological differences between vegetations attached to the calcified annulus versus leaflet vegetations., Methods: We retrospectively reviewed all echocardiographic studies of patients with native mitral valve vegetations from January 2007 to August 2015 (N = 56). We searched for (1) presence of MAC, (2) location of MAC, and (3) vegetation location (on calcium deposits or distant). MAC was defined as focal echo brightness in a nodular or band-like pattern. The modified Duke criteria were used to confirm the diagnosis of infective endocarditis. Transthoracic, transesophageal, and three-dimensional echocardiograms (when available) at the time of infection were evaluated by a single reader., Results: Twenty-eight subjects were infected with Staphylococcus aureus, 17 with a streptococcal species, and five with other organisms; blood cultures were sterile in 6. Thirty-four (61%) subjects had some degree of MAC, while 22 (39%) had none. Among those with MAC, the vegetation was located on the calcium deposits in 22 (65%), versus in 12 (35%) where it was not. Among all 56 subjects, when S. aureus was the infecting organism it was present on MAC in 16/28 (57%) versus 6/28 (21%; P = .01) for other bacterial species. By contrast, streptococcal infections more frequently involved the leaflets (16/17 [94%]) versus nonstreptococcal infections (18/39 [46%]; P = .0008)., Conclusions: MAC may act as a nidus for infection especially with S. aureus. Differences in mechanism of attachment between S. aureus and streptococci may account for the observed difference in frequency of attachment of vegetations to MAC., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Efficacy and safety of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) in patients with predisposing cardiac condition (PCC) undergoing invasive procedures is still debated. We sought to assess the prevalence of PCC, the type of interventional procedures preceding the onset of symptoms, and the usefulness of AP in a large cohort of consecutive patients with definite IE., Methods: We examined 677 (median age 65.34 years; male 492 [73%]) consecutive patients with IE enrolled from July 2007 through 2010 into the Italian Registry of Infective Endocarditis., Results: Predisposing cardiac condition was present in 341 patients (50%).Thirty-two patients (4.7%) underwent dental procedures. Of 20 patients with PCC undergoing dental procedure, 13 had assumed AP. Viridans group streptococci were isolated from blood cultures in 8 of 20 patients with PCC and prior dental procedure. Nondental procedures preceded IE in 139 patients (21%). They were significantly older and had more comordibities compared with patients undergoing dental procedures. Predisposing cardiac condition was identified in 91 patients. Perioperative antimicrobial prophylaxis was administered to 67 patients. Staphylococcus aureus was the most frequent causative agent. Cardiac surgery was necessary in 85 patients (20 with prior dental and 65 with nondental procedure). Surgical mortality (12% vs 0%, P = .03) and hospital mortality (23% vs 3%, P = .001) were significantly larger among patients with nondental procedures., Conclusions: In a large unselected cohort of patients with IE, the incidence of preceding dental procedures was minimal. The number of cases potentially preventable by means of AP was negligible. Nondental procedures were more frequent than dental procedures and were correlated with poorer prognosis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Aim of the Study: Q fever, caused by the rickettsia Coxiella burnetii, is a worldwide zoonotic disease with both acute and chronic manifestations. Endocarditis is the principal chronic manifestation. Q fever can easily be mistaken for degenerative valve disease due to its indolent presentation, the fastidious nature of the organism (routine cultures are negative), and the absence of a typical echocardiographic and macroscopic appearance for endocarditis. Prosthetic valve failure, with associated morbidity and mortality, have been described following unrecognized infections., Methods: Previous studies have documented the value of screening strategies in areas of high prevalence. Hence, a pilot study was conducted in a low-prevalence setting, in which 139 patients at two tertiary cardiac centers attending for elective valve replacement for degenerative valvular disease underwent testing for chronic Q fever infection by serological and molecular methods on blood and valve tissue., Results: Five patients (3.7%) had serological evidence of past exposure to Q fever (consistent with rates in the literature). None had evidence of chronic Q fever endocarditis. The cost of adopting a universal screening strategy is around £40,000 per case (if serology is used to screen patients prior to surgery)., Conclusions: Alternative and more cost-effective methods for identifying clinically quiet cases of chronic Q fever endocarditis are required.

The prevalence and characteristics of right heart endocarditis in Africa are not well known. The aim of this study was to describe the epidemiological, clinical and laboratory profiles of patients with right-heart infective endocarditis. This was a 10-year retrospective study conducted in 2 cardiology departments in Dakar, Senegal. All patients who met the diagnosis of right heart infective endocarditis according to the Duke's criteria were included. We studied the epidemiological, clinical as well as their laboratory profiles. There were 10 cases of right-heart infective endocarditis representing 3.04% of cases of infective endocarditis. There was a valvulopathy in 3 patients, an atrial septal defect in 1 patient, parturiency in 2 patients and the presence of a pacemaker in one patient. Anaemia was present in 9 patients whilst leukocytosis in 6 patients. The port of entry was found to be oral in three cases, ENT in one case and urogenital in two cases. Apart from one patient with vegetations in the tricuspid and pulmonary valves, the rest had localized vegetation only at the tricuspid valve. However, blood culture was positive in only three patients. There was a favorable outcome after antibiotic treatment in 4 patients with others having complications; three cases of renal impairment, two cases of heart failure and one case of pulmonary embolism. There was one mortality. Right heart infective endocarditis is rare but associated with potentially fatal complications.

Population-based studies including systematic echocardiographic examinations are required to assess the prevalence of valvular heart disease. In industrialized countries, the prevalence of valvular heart disease is estimated at 2.5%. Because of the predominance of degenerative etiologies, the prevalence of valvular disease increases markedly after the age of 65 years, in particular with regard to aortic stenosis and mitral regurgitation, which accounts for 3 in 4 cases of valvular disease. Rheumatic heart disease still represents 22% of valvular heart disease in Europe. The prevalence of secondary mitral regurgitation cannot be assessed reliably but it seems to be a frequent disease. The incidence of infective endocarditis is approximately 30 cases per million individiuals per year. Its stability is associated with marked changes in its presentation. Patients are getting older and staphylococcus is now becoming the microorganism most frequently responsible. Heath care-associated infections are the most likely explanation of changes in the microbiology of infective endocarditis. In developing countries, rheumatic heart disease remains the leading cause of valvular heart disease. Its prevalence is high, between 20 and 30 cases per 1000 subjects when using systematic echocardiographic screening. In conclusion, the temporal and geographical heterogeneity illustrates the effect of socioeconomic status and changes in life expectancy on the frequency and presentation of valvular heart disease. A decreased burden of valvular disease would require the elaboration of preventive strategies in industrialized countries and an improvement in the socioeconomic environment in developing countries., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis (IE), and is predominantly encountered in the injecting drug user (IDU) population, where HIV and HCV coinfections often coexist. Staphylococcus aureus is the most common pathogen. The pathogenesis of RSIE is still not well understood. RSIE usually presents as a persistent fever with respiratory symptoms whilst signs of systemic embolisation as seen in left-sided IE are notably absent. The prompt diagnosis of RSIE thus requires a high index of suspicion. Transthoracic echocardiography (TTE) can detect the majority of RSIE, whilst transoesophageal echocardiography (TOE) can increase sensitivity. Virulence of the causative organism and vegetation size are the major determinants of prognosis. Most cases of RSIE resolve with appropriate antibiotic administration., (Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this retrospective multicenter study was to investigate the clinical manifestations, microbiological profile, echocardiographic findings and management strategies of infective endocarditis (IE) in Turkey., Methods: The study population consisted of 248 Turkish patients with IE treated at 13 major hospitals in Turkey from 2005 to 2012 retrospectively. All hospitals are tertiary referral centers, which receive patients from surrounding hospitals. Data were collected from the medical files of all patients hospitalized with IE diagnosed according to modified Duke Criteria., Results: One hundred thirty seven of the patients were males. Native valves were involved in 158 patients while in 75 participants there was prosthetic valve endocarditis. Vegetations were detected in 223 patients (89%) and 52 patients had multiple vegetations. Mitral valve was the most common site of vegetation (43%). The most common valvular pathology was mitral regurgitation. The most common predisposing factor was rheumatic valvular disease (28%). Positive culture rate was 65%. Staphylococci were the most frequent causative microorganisms isolated (29%) followed by enterococci (11%). In-hospital mortality rate was 33%., Conclusions: Compared to IE in developed countries younger age, higher prevalence of rheumatic heart disease, more frequent enterococci infection and higher rates of culture negativity were other important aspects of IE epidemiology in Turkey.

Whether infection in more than 1 valve worsens the prognosis for endocarditis remains untested. We conducted the current study to determine the profile of multiple-valve endocarditis, compare multiple-valve endocarditis with single-valve endocarditis, and determine predictors of outcome. We conducted a prospective and observational study including 680 episodes of infective endocarditis consecutively diagnosed at 3 tertiary centers. Multiple valve involvement was present in 115 episodes (17%), and single valve involvement in 530 (78%). In the remaining 35 cases, valvular involvement could not be documented. Mean age of patients with multiple valve endocarditis was 58 years. Clinical complications were frequent (heart failure 65%, renal failure 44%, systemic embolisms 24%). The microorganism most frequently isolated was Staphylococcus aureus (22%).Factors predictive of in-hospital mortality in the univariate analysis were septic shock, prosthetic endocarditis, heart failure, and persistent infection. In the multivariate analysis, we detected heart failure (odds ratios [OR], 4.7; 95% confidence interval [CI], 1.6-13.8) and persistent infection (OR, 4.3; 95% CI, 1.7-10.8) as predictors of in-hospital mortality. Compared to single-valve endocarditis, multiple-valve disease was associated more frequently with heart failure (65% vs. 50%, p = 0.03), perivalvular complications (41% vs. 21%, p < 0.001), and heart surgery (70% vs. 54%, p = 0.002). Despite these differences, in-hospital mortality was similar (28% vs. 30%, p = 0.647). In conclusion, multiple-valve endocarditis has a poor clinical course. Mortality is similar to that of single-valve endocarditis, probably in relation with aggressive therapy including surgery in many patients. Heart failure and persistent infection are independent predictors of death.

Introduction and Objectives: The aim of our study is to assess changes in the epidemiologic features of patients with native valve infective endocarditis., Methods: We analyzed a prospective series of 228 cases of native valve infective endocarditis in non-intravenous drug users attending our center between 1987 and 2009. We compared three subperiods: 1987-1994 (67 cases), 1995-2002 (74 cases) and 2003-2009 (87 cases)., Results: The mean age of patients has progressively increased (38±22 years in the first subperiod vs 60±16 years in the third; P<.001), as has the proportion of cases without predisposing heart disease (25%, 46% and 67%; P<.001). Incidence of mitral valve prolapse remained stable (12%, 18% and 11%). Percentages of patients with predisposing heart disease and who were aware of their condition have fallen in recent years (45%, 27% and 21%; P<.001). A portal of entry for the infection could not be identified in 64%. Overall, Staphylococcus aureus is the most frequent causative organism (26%) whereas the percentage of cases caused by Streptococcus viridans remains unaltered (22%, 20% and 24%)., Conclusions: We found significant changes in the epidemiology of native valve infective endocarditis. The incidence of patients without predisposing heart disease has increased significantly and staphylococci are the most frequent causative organisms. Full English text available from: www.revespcardiol.org., (Copyright © 2011 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Background and Objective: Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia., Methods: We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008., Results: Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication., Conclusion: Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

Introduction and Objectives: Characteristics of isolated right-sided endocarditis in patients without a pacemaker and who are not intravenous drug users (IVDU) are poorly understood. The aim of this study was to investigate the current frequency of this entity and describe its clinical, microbiological, echocardiographic and prognostic profile., Methods: We have prospectively analyzed 17 consecutive cases of isolated right-sided endocarditis in non-IVDU who did not have a pacemaker, out of a total of 583 consecutive episodes of endocarditis (2.9%)., Results: Mean age was 38+/-15 years; 11 of the 17 patients were men. Almost half of the patients had at least one predisposing disease. An intravascular catheter was the most frequent port of entry (35%). The most common signs and symptoms on admission were fever, dyspnea, septic pulmonary embolisms, pleural effusion and right-sided heart failure. The most frequent microorganism was Staphylococcus aureus (41%). In most cases (82%) the infection was located in the tricuspid valve. Recurrent pulmonary embolisms were the most frequent complication and the main cause for surgery, which was needed in 5 patients (29%). Two patients died during hospitalization (12%), both from septic shock. During follow-up one patient died of unknown causes 1 month after discharge, and other relapsed 3 months after discharge., Conclusions: Isolated right-sided endocarditis should be included in the differential diagnosis of patients with febrile syndrome, respiratory symptoms and predisposing disease, even when they do not have a pacemaker and are not IVDU. The presence of intravascular catheters and Staphylococcus bacteriemia should heighten suspicion of endocarditis.

Objectives: Injection drug users (IDUs) develop more right-sided infective endocarditis (IE) than non-IDUs, but it is not known whether this risk is specific to any particular injected drug. This study reviews the clinical characteristics of IE in an urban population and examines the association of drug type with manifestations of IE., Methods: A retrospective cohort of 247 cases of IE was analyzed. Demographic, clinical, microbiologic, and echocardiographic data were collected., Results: Our cohort featured a 74% IDU rate, most with heroin. Staphylococcus aureus was the most prevalent organism. S. aureus IE was more likely to occur in IDUs versus non-IDUs (OR 5.5, p<0.0001). Enterococcus faecalis IE was less likely to occur in IDUs (OR 0.21, p=0.02). Tricuspid valve (TV) IE was more likely to occur in IDUs (OR 4.37, p=0.001), while mitral valve (MV) IE occurred less commonly in IDUs (OR 0.40, p=0.005). TV IE occurred more frequently in heroin users vs. IDUs not using heroin (OR 4.03, p=0.033)., Conclusions: The epidemiology of IE in this cohort is different from that reported recently in other cohorts, likely due to the high prevalence of IDU. Heroin use may underlie the association between IDU and right-sided endocarditis.

Objectives: To describe the epidemiological, clinical, and prognostic characteristics of patients with left-sided native valve endocarditis (LNVE) caused by coagulase-negative staphylococci (CoNS)., Patients and Method: Prospective multicenter study of endocarditis cases reported in the Andalusian Cohort for the Study of Cardiovascular Infections between 1984 and 2005., Results: Among 470 cases of LNVE, 39 (8.3%) were caused by CoNS, a number indicating a 30% increase in the incidence of this infection over the last decade. The mean age of affected patients was 58.32 +/- 15 years and 27 (69.2%) were men. Twenty-one patients (53.8%) had previous known valve disease and half the episodes were considered nosocomial (90% of them from vascular procedures). Median time interval from the onset of symptoms to diagnosis was 14 days (range: 1-120). Renal failure (21 cases, 53.8%), intracardiac damage (11 cases, 28.2%), and central nervous system involvement (10 cases, 25.6%) were the most frequent complications. There were only 3 cases (7.7%) of septic shock. Surgery was performed in 18 patients (46.2%). Nine patients (23.1%) died, overall. Factors associated with higher mortality in the univariate analysis were acute renal failure (P = 0.023), left-sided ventricular failure (P = 0.047), and time prior to diagnosis less than 21 days (P = 0.018). As compared to LNVE due to other microorganisms, the patients were older (P = 0.018), had experienced previous nosocomial manipulation as the source of bacteremia (P < 0.001), and developed acute renal failure more frequently (P = 0.001). Mortality of LNVE due to CoNS was lower than mortality in Staphylococcus aureus infection, but higher than in Streptococcus viridans infection., Conclusions: Left-sided native valve endocarditis due to CoNS is now increasing because of the ageing of the population. This implies more frequent invasive procedures (mainly vascular) as a consequence of the concomitant disease. Nonetheless, the mortality associated with LNVE due to CoNS does not seem to be greater than infection caused by other pathogens.

Valvular heart diseases in Africa affect mainly children and young adults and are a result of rheumatic fever. Rheumatic fever is a preventable disease, but in Africa the combination of a lack of resources, lack of infrastructure, political, social and economic instability, poverty, overcrowding, malnutrition and lack of political will contributes to the persistence of a high burden of rheumatic fever, rheumatic valvular heart diseases and infective endocarditis. Combating and eradicating rheumatic fever and rheumatic heart diseases requires economic development and implementation of best practices of primary and secondary prevention measures. The barriers to achieving this goal in Africa are numerous, but not insurmountable.

Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.

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 extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.

Streptococcus agalactiae, commonly known as Group B streptococcus (GBS), was originally discovered as a cause of bovine mastitis. GBS colonizes the genital tract of up to 40% of women and has become a major pathogen in neonatal meningitis. GBS endocarditis is thought to be an uncommon manifestation of this infection and carries a higher mortality compared to other streptococcal pathogens. Studies have shown that endocarditis after abortion has an incidence of about one per million. However, this figure was published prior to routine use of echocardiography for diagnosis. The American Heart Association has recently declared transesophageal echocardiography the gold standard for endocarditis diagnosis. This case report illustrates that, given the potentially devastating consequences of endocarditis, there is a need for updated studies to adequately assess the true incidence of this infection. Pending the outcome of these studies, routine GBS screening and prophylactic antibiotics prior to abortion should be recommended.

Infective endocarditis is a microbial infection of the endocardial surface and, despite improvements in diagnostic accuracy, medical therapy and surgical techniques, mortality remains high. This review focuses on changes in epidemiology, microbiology and diagnosis, as well as changes in medical and surgical management of infective endocarditis affecting native and prosthetic valves in adults, that have evolved during the past two decades. Significant changes have included an increasing involvement of prosthetic valves and nosocomially-acquired disease, an increased involvement of staphylococci as the causative agents, and a recognition that elderly individuals with degenerative valvular disease are the most vulnerable population. Topics still requiring study include whether and when valve replacement should be performed, and how to predict perivalvular complications or embolisation based on echocardiography findings. Optimisation of antimicrobial treatment schemes (choice of the antibiotic, dose and duration) also requires further investigation.

Introduction: Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999., Material and Methods: Cases included were those classified as "probable" or "definite" by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases (< 1 year) were excluded from the analysis. Clinical characteristics, etiology, predisposing cardiac condition, source of infection, and outcome were analyzed. Results were compared with those obtained in community-acquired cases., Results: Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study., Conclusions: In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients.

Using a large cohort of patients from the International Collaboration on Endocarditis Merged Database, we compared coagulase-negative staphylococcal (CoNS) native-valve endocarditis (NVE) to NVE caused by more common pathogens. Rates of heart failure and mortality were similar between patients with CoNS NVE and patients with Staphylococcus aureus NVE, but rates for both groups were significantly higher than rates for patients with NVE due to viridans streptococci. These results emphasize the importance of CoNS as a cause of NVE and the potential for serious complications with this infection.

Objective: To identify factors associated with in-hospital outcome of adult patients admitted to the ICU with infective endocarditis (IE)., Design and Setting: Retrospective study performed in the two medical ICUs of a teaching hospital., Patients and Participants: The charts of all 228 consecutive patients aged 18 years or older admitted with infective IE between January 1993 and December 2000 were reviewed. All patients satisfied the modified Duke's criteria for definite IE., Measurements and Results: There were 146 episodes of native valve endocarditis and 82 of prosthetic valve endocarditis. Staphylococcus aureus was the predominant causative micro-organism. Most complications occurred early during the course of IE. One-half of the patients underwent cardiac surgery during the same hospitalization and had a better outcome than nonoperated patients. The overall in-hospital mortality rate was 45% (102/228). Multivariate analysis revealed the following clinical factors in patients with native valve IE as independently associated with outcome: septic shock (odds ratio 4.81), cerebral emboli (3.00), immunocompromised state (2.88), and cardiac surgery (0.475); in patients with prosthetic valve IE the factors were: septic shock (4.07), neurological complications (3.1), and immunocompromised state (3.46)., Conclusions: IE still carries high morbidity and mortality rates for the subset of patients requiring ICU admission. Most complications occur early making the decision process for optimal medical and surgical management more difficult. Surgical treatment appears to improve in-hospital outcome.

The goal of our study was to determine the prevalence of older patients with cardiac valvular abnormalities warranting endocarditis prophylaxis. We performed a retrospective analysis of 1,000 randomly selected echocardiograms (inpatients and outpatients) from our tertiary care institution. We found that the prevalence of valvular abnormalities increased significantly with age, and that 50% of patients > or =60 years of age warranted endocarditis prophylaxis using current guidelines. With the aging population of the United States and the negative consequences of widespread antibiotic prophylaxis, further investigation is needed to identify patients who are truly at risk for infectious endocarditis.

The epidemiology, and clinical and microbiological spectrum, of infective endocarditis (IE) in Greece was analysed in a prospective 4-year study in a tertiary hospital and a heart surgery centre in Athens. In total, 101 cases of IE (71 men, 30 women, aged 54.4 +/- 17.1 years) were studied, with a follow-up period of 3 months. Seventy-seven cases were definite and 24 possible; 59 involved native valves (native valve endocarditis; NVE), 31 prosthetic valves (prosthetic valve endocarditis; PVE), of which nine were early and 22 late, and 11 permanent pacemakers (pacemaker endocarditis; PME). There was a predominant involvement of aortic (48/101) and mitral (40/101) valves. Seven patients had rheumatic valvular disease, two had mitral valve prolapse, and eight had a previous history of IE. Thirteen and six patients had undergone dental and endoscopic procedures, respectively. In 13 patients, intravenous catheters were used within the 3 months before diagnosis of IE. There were three intravenous drug users among the patients. Staphylococcus aureus was the most important pathogen, isolated in 22% of cases, followed by viridans streptococci (19%) and coagulase-negative staphylococci (16%). Enterococcus spp. were responsible for 3%, HACEK group for 2%, and fungi for 6% of cases. Viridans streptococci were the leading cause of NVE (29%), Staphylococcus epidermidis of PVE (16%), and S. aureus of PME (54.5%). Six of 22 S. aureus and ten of 16 S. epidermidis isolates were methicillin-resistant. Surgical intervention, including total pacemaker removal, was performed in 51.5% of patients. Overall mortality was 16%, but was 29% with PVE, and was significantly higher with medical than with combined surgical and medical therapy (24.5% vs. 8%). Compared with previous studies, there were changing trends in the epidemiology, microbiology, treatment and prognosis of IE in Greece.

A prospective study of infective endocarditis (IE) was conducted between 1994 and 2000 in Marseilles, France, and included 170 definite cases diagnosed with the use of modified Duke criteria. Classification of IE based on the aetiological agent was related to epidemiological characteristics, including age, gender and the nature of the injured valve. Enterococci and Streptococcus bovis were identified more frequently in older subjects (p 0.02), and S. bovis was also associated with mitral valve infection (p 0.03). Streptococcus spp. were found to be associated with native valves (p < 10(-3)), whereas coagulase-negative staphylococci and Coxiella burnetii were associated with intracardiac prosthetic material (p < 0.05). S. bovis and Staphylococcus aureus were the predominant species associated with presumably healthy valves (p < 0.05), whereas oral streptococci caused IE exclusively in patients with previous valve damage. The basic host status of IE patients has been linked to specific microorganisms, and this may be of value when empirical treatment is needed in patients who have received previous antibiotic therapy and whose blood cultures are negative.

Background and Aim of the Study: Although described in a number of necropsy studies, endocarditis on mitral annular calcification (MAC) has rarely been reported during life. The study aim was to assess the frequency and specific features of bacterial endocarditis complicating MAC., Methods: Data relating to 62 cases of infective endocarditis of the native mitral valve diagnosed with multiplane transesophageal echocardiography (TEE) over a five-year period were collected prospectively., Results: Among 62 patients, 15 (24%) had vegetations originating from a calcified mitral annulus (group 1), while 47 had classic leaflet endocarditis (group 2). Group 1 patients differed significantly from group 2 patients with regard to: (i) higher incidence of diabetes mellitus and cancers; (ii) initial clinical presentation, with febrile coma or meningoencephalitis in 53% of cases; (iii) echocardiographic features, with significantly greater vegetations, presence of calcium-dense echoes within the vegetation, high frequency of ring abscess, and high frequency of para-annular ventriculoatrial leakage; and (iv) poorer clinical outcome, with 53% in-hospital mortality., Conclusion: MAC appears to be an underestimated predisposing factor for a particularly severe type of bacterial endocarditis. The use of multiplane TEE should improve current knowledge of this disease.

The aim of this study was to report the experience with infective endocarditis over the past decade, describe the changing clinical and epidemiological features of the disease, and attempt to determine the optimal number of blood culture sets required for diagnosis. All cases diagnosed during a 10-year period were reviewed clinically and microbiologically. In addition, a retrospective assessment of blood culture data was performed. From the period 1990-1999, 108 cases that met the von Reyn or Duke's criteria were recorded. The major underlying cardiac condition was the presence of a prosthetic valve ( n=33 patients, 31%). Among patients with native valves, nonrheumatic valvular heart disease of the elderly was the most common underlying factor ( n=19 patients, 25%). Overall, 13 patients (11%) died. Predictors on admission for increased mortality were shortness of breath, age >60 years, time to defervescence, erythrocyturia, hemoglobin level <10 g/dl, and leukocytosis >15,000 (all P<0.05). Analysis of blood culture data showed that the diagnostic yield among groups from whom either only one or more than six blood culture sets were drawn was reduced compared with that among groups from whom between two and five culture sets had been taken. The outcome of endocarditis in this series from a community hospital was much more favorable compared with that reported in surveys from large tertiary centers. Moreover, obtaining more than two or three blood cultures is neither helpful nor cost-effective in the initial assessment of patients with suspected endocarditis.

We analyzed 50 cases of bicuspid aortic valve endocarditis in patients who presented to St. Thomas' Hospital from 1970 through 1998. These represented 12.3% of the 408 cases of native valve endocarditis (NVE). All patients were male, and their mean age was 39 years. Forty-five of the 50 cases were pathologically proven; 47 were clinically definite according to the Duke criteria and 49 according to our modifications of the Duke criteria. Viridans streptococci and staphylococci accounted for 72% of cases. The prevalences of clinical features were similar to those seen in NVE: fever (temperature >/=38 degrees C, 74%) and malaise (70%), although dyspnea was more frequent (36%). There was a high incidence of serious complications (72% heart failure; 30% periannular abscesses). Surgery was required during the initial admission in 82% of cases. Overall mortality was 14%, and surgical mortality was 9%. Few patients knew they had a "heart condition," and a bicuspid aortic valve was detected in only 35% of echocardiograms performed before surgery.

Objective: Surgery for endocarditis in children is relatively uncommon. Our aim is to assess operative mortality, recurrent infection, re-operation and long-term survival rates following surgery for infective valve endocarditis in children., Patients: Sixteen consecutive children (ten female, six male, mean age 11.8 years, range 25 days-16 years) undergoing surgery between 1972 and 1999 in Southampton were studied. The aortic valve was affected in five, mitral in four, aortic and mitral in one, tricuspid in five and a pulmonary homograft in one patient. Prosthetic valve endocarditis was present in three. Twelve surgical interventions were emergency and four urgent. Indications for operation included cardiac failure in five, severe valvular dysfunction in nine, vegetations in nine, persistent sepsis in four and embolization in four patients. The offending micro-organism was identified in 13. Valve replacement was performed in 11 and excision of vegetations in two and excision of vegetations and repair in three. Follow-up was complete (mean 11.2 years, range 2 months to 26.3 years, total 179.5 patient years)., Results: There was one operative death (6.2%) in a 25-day-old neonate who presented in a moribund condition. Endocarditis recurred in one patient (6.25%). Freedom from recurrent infection at 10 and 20 years was 100.0 and 87.5%. Seven surgical re-interventions were required in four (25.0%) patients with no operative mortality. Freedom from re-operation at 1, 5, 10 and 20 years, was 84.6, 76.1, 76.1 and 60.9%, respectively. Two patients died 15 and 23 years after their first operation. The cause of the late deaths was non-cardiac in the first and unknown in the other. Actuarial survival, including operative mortality, at 1, 15 and 20 years was 93.7, 93.7 and 78.1%., Conclusions: Surgery in children with infective valve endocarditis can be performed with low operative mortality. Although some patients may require re-operation, freedom from recurrent infection and long-term survival are satisfactory.

Infectious endocarditis remains a serious complication of valvular heart disease, before and after surgery, and is associated with a considerable morbidity and mortality. The incidence of endocarditis in different cardiac diseases, the modern requirements for its diagnosis, with special emphasis on the importance of echocardiography, and the guidelines for prophylaxis are reviewed and comprehensively summarized.

The effect of age on the presentation and outcome of infective endocarditis (IE) is unclear. Many of the available data are based on analyses of mixed populations of patients including intravenous drug users or those with prosthetic valve endocarditis or native valve IE. We used the Duke criteria to compare the characteristics of 44 episodes of definite native valve IE in elderly patients (> 64 years old) with the characteristics of 64 similarly defined episodes of native valve IE in younger, nonintravenous-drug-using adult patients (> 29 years and < 60 years old). Our data suggest that the clinical presentation, characteristics, and outcome of native valve IE are similar for elderly patients and younger adult patients, although elderly patients were hospitalized an average of 12 days longer. Although we found that the occurrence of renal failure and cerebral embolism during an episode of IE was associated with higher rates of death (odds ratios, 4.8 and 4.0, respectively), age was not a significant contributor to mortality.

Objective: The Edwards Duromedics valve (Baxter Healthcare Corp., Edwards Division, Santa Ana, Calif.) was designed with a self-irrigating hinge mechanism to reduce thromboembolic complications. After good initial clinical results, distribution was suspended in 1988 after reports of valve fracture after 20,000 valves had been implanted. The manufacturer conducted extensive studies to improve the Edwards Duromedics and reintroduced a modified version, which is available as Edwards Tekna. The purpose of the study was the evaluation of long-term results of the original Edwards Duromedics that might be important for the current version, the Edwards Tekna valve., Methods: A prospective clinical 10-year follow-up was performed of 508 patients who underwent valve replacement with the Edwards Duromedics valve in the aortic (n = 268), mitral (n = 183), and aortic and mitral (n = 56) position., Results: The perioperative mortality rate was 6.9%; follow-up was 98% complete, comprising 3648 patient-years for a mean follow-up of 86 months (range: 33 to 144 months). The actuarial freedom from complications at the 10-year follow-up and the incidence rate (percent per patient-year) were as follows: late mortality rate, 69.2% +/- 2.4% (3.5% per patient-year); thromboembolism, 90.7% +/- 1.6% (0.96% per patient-year); anticoagulation-related hemorrhage, 87.7% +/- 1.7% (1.34% per patient-year); prosthetic valve endocarditis, 96.7% +/- 0.09% (0.38% per patient-year); valve-related mortality rate, 89.3% +/- 1.6% (1.21% per patient-year); valve failure, 86.2% +/- 1.85% (1.54% per patient-year); and valve-related morbidity and mortality rate, 71.1% +/- 2.3% (3.2% per patient-year). Three leaflet escapes were observed (one lethal, two successful reoperations; 99.1% +/- 0.05% freedom, 0.08% per patient-year). All patients functionally improved (86% in New York Heart Association classes I and II), and incidence of anemia was insignificant., Conclusions: These results confirm that the Edwards Duromedics valve shows excellent performance concerning thromboembolism, hemolysis, and functional improvement and will serve as a reference for the last version, the Edwards Tekna valve, where comparable long-term data are currently not available.

We describe the prompt diagnosis and successful treatment of mitral valve endocarditis in a 52-year-old woman due to a recently described coagulase negative staphylococcus, Staphylococcus lugdunensis. Endocarditis due to this organism has a high mortality rate with 8 out of 12 published cases ending in fatality. Review of the literature revealed that use of commercial identification systems can lead to misidentification of Staphylococcus lugdunensis and consequently delay appropriate treatment. It is clinically important to distinguish Staphylococcus lugdunensis from other coagulase negative staphylococci by detailed microbiological testing. The awareness of this from of endocarditis and its natural history is important since it differs significantly from other coagulase negative staphylococci. It highlights the need for early surgical intervention not only for haemodynamic complications but also for recurrent emboli. Multiple emboli appears to be a frequent finding on review of the literature.