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Aim: The mortality of patients with infective endocarditis (IE) is high. The management of patients with large vegetations is controversial. This study sought to investigate the association of vegetation size on outcomes including valve destruction, embolism and mortality., Methods and Results: One hundred and forty-two (142) patients with definite IE and transoesophageal echocardiography (TEE) imaging available for analysis were identified and data retrospectively reviewed. Vegetation length, width and area were measured. Severe valve destruction was defined as the composite of one or more of severe valve regurgitation, abscess, pseudoaneurysm, perforation or fistula. Associations with 6-month mortality were identified by Cox regression analysis. Eighty (80) (56.3%) patients had evidence of valve destruction on TEE. Vegetation length ≥10 mm and vegetation area ≥50 mm 2 were significantly associated with increased risk of valve destruction, (both odds ratio OR 1.21, p=0.03 and p=0.02 respectively). Thirty-nine (39) (72.2%) patients who had an embolic event, did so prior initiation of antibiotics. Six (6)-month mortality was 18.3%. In the surgically managed group, vegetation size was not associated with mortality. In the medically managed group, vegetation area (mm 2 ) was associated with increased mortality (HR 1.01, p<0.01) along with age (HR 1.06, p=0.03)., Conclusion: Vegetation length ≥10 mm or area ≥50 mm 2 are associated with increased risk of valve destruction. Vegetation size may also predict mortality in medically managed but not surgically managed patients with IE. Further studies to evaluate whether surgery in patients with large vegetation size improves outcomes is warranted., (Copyright © 2020 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Objectives: This study aimed to evaluate the safety and mid-term efficacy of transcatheter aortic valve replacement (TAVR) in the setting of aortic valve (AV) infective endocarditis (IE) with residual lesion despite successful antibiotic treatment., Background: Patients with AV-IE presenting residual lesion despite successful antibiotic treatment are often rejected for cardiac surgery due to high-risk. The use of TAVR following IE is not recommended., Methods: This was a multicenter retrospective study across 10 centers, gathering baseline, in-hospital, and 1-year follow-up characteristics of patients with healed AV-IE treated with TAVR. Matched comparison according to sex, EuroSCORE, chronic kidney disease, left ventricular function, prosthesis type, and valve-in-valve procedure was performed with a cohort of patients free of prior IE treated with TAVR (46 pairs)., Results: Among 2,920 patients treated with TAVR, 54 (1.8%) presented with prior AV-IE with residual valvular lesion and healed infection. They had a higher rate of multivalvular disease and greater surgical risk scores. A previous valvular prosthesis was more frequent than a native valve (50% vs. 7.5%; p < 0.001). The in-hospital and 1-year mortality rates were 5.6% and 11.1%, respectively, comparable to the control cohort. After matching, the 1-year III to IV aortic regurgitation rate was 27.9% (vs. 10%; p = 0.08) and was independently associated with higher mortality. There was only 1 case of IE relapse (1.8%); however, 18% of patients were complicated with sepsis, and 43% were readmitted due to heart failure., Conclusions: TAVR is a safe therapeutic alternative for residual valvular lesion after successfully healed AV-IE. At 1-year follow-up, the risk of IE relapse was low and mortality rate did not differ from TAVR patients free of prior IE, but one-fourth presented with significant aortic regurgitation and >50% required re-admission., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting., Methods: We formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS., Results: The cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010)., Conclusions: An increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background To evaluate changes in patient characteristics and outcomes for infective endocarditis (IE) related to opioid use disorder (OUD), we used the National (Nationwide) Inpatient Sample (NIS) to characterize the trend in hospitalizations for patients with IE with and without OUD and those treated medically and surgically. Methods and Results Temporal trends in hospitalization characteristics for patients with IE with and without OUD and those treated medically and surgically were estimated via the NIS data in 2005-2014. Hospitalizations for OUD and IE increased from 119 to 202 and from 12 to 15 cases per 100 000 between 2005 and 2014, respectively. Hospitalizations with OUD among all IE hospitalizations increased from 6.3% in 2005 to 11.6% in 2014. Among all IE hospitalizations, patients being admitted for IE in the setting of OUD were younger compared with the cohort of IE without OUD (aged 37.6±0.21 years versus 60.9±0.16 years). Myocardial infarction, diabetes mellitus, chronic kidney disease, peripheral vascular disease, and heart failure were more common in patients without OUD. The OUD cohort more frequently had liver disease (46.0% versus 10.8%) and immunosuppressed status (4.3% versus 2.1%). Valve operations for IE accounted for 10.2% of all valve operations in 2005, and this increased to 12.7% in 2014. These proportions were similar between OUD (11.4%) and non-OUD (11.1%) cohorts. Operative mortality was lower in patients with OUD (4.3% versus 9.4%, P <0.001). Conclusions IE associated with OUD has a distinct phenotype and has become more prevalent. Surgical outcomes are favorable and operations were performed in similar proportions of patients who had IE with OUD compared with patients who had IE without OUD.

Objective: Right-sided infective endocarditis is increasing because of increasing prevalence of predisposing conditions, and the role and outcomes of surgery are unclear. We therefore investigated the surgical outcomes for right-sided infective endocarditis., Methods: From January 2002 to January 2015, 134 adults underwent surgery for right-sided infective endocarditis. Patients were grouped according to predisposing condition. Hospital outcomes, time-related death, and reoperation for infective endocarditis were analyzed., Results: A total of 127 patients (95%) had tricuspid valve and 7 patients (5%) pulmonary valve infective endocarditis; 66 patients (49%) had isolated right-sided infective endocarditis, and 68 patients (51%) had right- and left-sided infective endocarditis. Predisposing conditions included injection drug use (30%), cardiac implantable devices (26%), chronic vascular access (19%), and other/none (25%). One native tricuspid valve was excised, 76% were repaired or reconstructed, and 23% were replaced. Intensive care unit and postoperative hospital stays were similar among groups. Injection drug users had the best early survival (no hospital mortality), and patients with chronic vascular access had the worst late survival (18% at 5 years). Survival was worst for concomitant mitral valve versus isolated right-sided infective endocarditis or concomitant aortic valve infective endocarditis. Survival after tricuspid valve replacement was worse than after repair/reconstruction. Estimated glomerular filtration rate was the strongest risk factor for death, not predisposing condition. Eleven patients underwent 12 reoperations for infective endocarditis; more reoperations occurred in injection drug users (P = .03)., Conclusions: Overall outcomes after surgery are variable and affected by patient condition, not predisposing condition. Injection drug use carries a higher risk of reoperation for infective endocarditis. Earlier surgery may permit more valve repairs and improve outcomes. Whenever possible, tricuspid valve replacement should be avoided., (Copyright © 2018. Published by Elsevier Inc.)

Background: Pericardial effusion is a frequent finding in the setting of infective endocarditis. Limited data exists on clinical characteristics and outcomes in this group of patients. We aimed to determine the associated factors, clinical characteristics, and outcomes of patients who had pericardial effusion and native valve infective endocarditis., Methods and Results: A total of 1205 episodes of infective endocarditis from 25 Spanish centers between June 2007 and March 2013 within the Spanish Collaboration on Endocarditis (GAMES) registry were included. Echocardiogram at admission, clinical and microbiological variables, and one-year follow-up were analyzed. Pericardial effusion was observed in 7.8% (94/1205 episodes) of episodes of infective endocarditis, most of them being mild or moderate (93.6%). The presence of pericardial effusion was associated with a higher risk of heart failure during admission (OR 1.9; CI 95% 1.2-3.0). Patients with pericardial effusion had a higher rate of surgery (53.2% vs. 41.1%; p = 0.02); however, this association was no longer significant after adjusting for possible confounders (OR 1.4; CI 95% 0.9-2.2; p = 0.10). The presence of pericardial effusion was not associated with a higher in-hospital or one-year mortality (33.0% vs. 25.2%; p = 0.10 and 40.2% vs. 37.3%; p = 0.60 respectively)., Conclusions: The prevalence of pericardial effusion in patients with infective endocarditis was lower than previously reported. The presence of pericardial effusion is associated with the development of heart failure during hospitalization making it a warning sign, possibly reflecting indirectly a mechanical complication, which, however, if treated surgically in a timely manner does not change the final outcome of patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To study the characteristics and misdiagnosis of infective endocarditis (IE). Methods: Clinical and pathological data of 15 IE patients diagnosed by autopsy were collected, compared with the cohort of 29 regular IE cases. Results: In the autopsy patients, IE in the left heart was predominat (14/15, 93.3%). Arterial embolism was the most common comorbidity (10/15, 66.7%), followed by pneumonia, malignancies, pyelonephritis (9/15, 60.0%; 7/15, 46.7%; 6/15, 40.0% respectively). The age was elder [(64.0±21.2)years vs(50.8±18.3)years, t =-2.15, P =0.037] in autopsy patients than in control group. More patients of missed diagnosis were combined with malignancies or deep vein catheterization [7/15(46.7%)vs 1/29(3.4%); 5/15(33.3%)vs 0/29(0)respectively]. Fever and cardiac murmur were rare in misdiagnosed cases[11/15(73.7%)vs 28/29(96.9%), 0/15(0)vs 15/29(51.7%) respectively]. Echocardiography and blood culture were performed in only 33.3%(5/15) and 26.7%(4/15) cases of missed diagnosis with low positive rates compared with regular IE patients [0/15(0) vs 27/29 (93.1%); 1/15(6.7%) vs 15/29(55.6%)]. Conclusions: Infective endocarditis should be suspected in patients with the risk factors of IE even without fever or cardiac murmur. Echocardiography and blood culture should be done as screening tests of IE.

Objective: An embolic ischemic stroke occurs in 10% to 40% of patients with valvular infective endocarditis (IE) and confers significant morbidity. The optimal timing of valve surgery in this population is not well defined., Methods: With the use of PubMed, EMBASE, Ovid, and Cochrane databases, a systematic review identified 14 studies through October 2015 that compared early versus delayed surgery for valvular IE complicated by an ischemic stroke. Early surgery was defined as 3 days or less in one, 7 days or less in eight, and 14 days or less in five studies. Risk ratios (RRs) were calculated by the Mantel-Haenszel method under a fixed- or random-effects model, for the outcomes of perioperative stroke, operative mortality, and 1-year survival., Results: A total of 833 patients (early surgery, 330; delayed surgery, 503) were included. The majority of operations were for aortic and/or mitral valve IE, with prosthetic valve IE present in 0% to 60%. Infection with Staphylococcus aureus ranged from 19% to 66%, and heart failure prevalence at the time of operation was 24% to 66%. Early surgery was associated with an increased risk of operative mortality (RR, 1.72; 95% confidence interval [CI], 1.27-2.34; P = 0.0005), which was significant regardless of surgery within the first 7 days (RR, 2.19; 95% CI, 1.45-3.31; P = 0.0002) or 14 days (RR, 1.72; 95% CI, 1.12-2.64; P = 0.01) after stroke. Surgical timing did not affect the risk of perioperative ischemic or hemorrhagic stroke or 1-year survival., Conclusions: In patients with valvular IE complicated by ischemic stroke, early surgery is associated with an increased risk of operative mortality, with no observed benefit in 1-year survival.

Background: Staphylococcus aureus infective endocarditis (SAIE) is a serious and common disease., Aims: To assess the clinical and echocardiographic characteristics and prognostic factors of left-sided native-valve SAIE, and to compare these characteristics between two periods (1990-2000 vs. 2001-2010)., Methods: This was a retrospective analysis of 162 cases of left-sided native-valve SAIE among 1254 patients hospitalized for infective endocarditis (IE) between 1990 and 2010., Results: SAIE represented 18.1% of all cases of IE and 22.9% of cases of native-valve IE. Complications included heart failure in 44.7% of cases, acute renal failure in 23.3%, sepsis in 28.5%, neurological events in 35.8%, systemic embolic events in 54.9% and in-hospital mortality in 25.3%. Factors associated with in-hospital mortality were heart failure (odds ratio [OR] 2.5; P=0.04) and sepsis (OR 5.3; P=0.001). Long-term 5-year survival was 49.6±4.9%. Factors associated with long-term mortality were heart failure (OR 1.7; P=0.032), sepsis (OR 3; P=0.0001) and delayed surgery (OR 0.43; P=0.003). Comparison of the two periods revealed a significant increase in bivalvular involvement, valvular incompetence and acute renal failure from 2001 to 2010. No significant difference was observed in terms of in-hospital mortality rates (28.1% vs. 23.5%; P=0.58) and long-term 5-year survival (45.0±6.6% vs. 57.1±6.4%; P=0.33)., Conclusion: Mortality as a result of left-sided native-valve SAIE remains high. Factors associated with in-hospital mortality are heart failure and sepsis. Factors associated with long-term mortality are heart failure, sepsis and delayed surgery. Despite progress in surgical techniques, in-hospital mortality and long-term mortality have not decreased significantly between the two periods., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Background: Infective endocarditis (IE) causes substantial morbidity and mortality. Patient and pathogen profiles, as well as microbiological and operative strategies, continue to evolve. The impact of these changes requires evaluation to inform optimum management and identify individuals at high risk of early mortality., Aim: Identification of clinical and microbiological features, and surgical outcomes, among patients presenting to a UK tertiary cardiothoracic centre for surgical management of IE between 1998 and 2010., Design: Retrospective observational cohort study., Methods: Clinical, biochemical, microbiological and echocardiographic data were identified from clinical records. Principal outcomes were all-cause 28-day mortality and duration of post-operative admission., Results: Patients (n = 336) were predominantly male (75.0%); median age 52 years (IQR = 41-67). Most cases involved the aortic (56.0%) or mitral (53.9%) valves. Microbiological diagnoses, obtained in 288 (85.7%) patients, included streptococci (45.2%); staphylococci (34.5%); Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella (HACEK) organisms (3.0%); and fungi (1.8%); 11.3% had polymicrobial infection. Valve replacement in 308 (91.7%) patients included mechanical prostheses (69.8%), xenografts (24.0%) and homografts (6.2%). Early mortality was 12.2%, but fell progressively during the study (P = 0.02), as did median duration of post-operative admission (33.5 to 10.5 days; P = 0.0003). Multivariable analysis showed previous cardiothoracic surgery (OR = 3.85, P = 0.03), neutrophil count (OR = 2.27, P = 0.05), albumin (OR = 0.94, P = 0.04) and urea (OR = 2.63, P < 0.001) predicted early mortality., Conclusions: This study demonstrates reduced post-operative early mortality and duration of hospital admission for IE patients over the past 13 years. Biomarkers (previous cardiothoracic surgery, neutrophil count, albumin and urea), predictive of early post-operative mortality, require prospective evaluation to refine algorithms, further improve outcomes and reduce healthcare costs associated with IE., (© The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: The high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE., Methods: Data were retrospectively collected for consecutive patients undergoing aortic valve surgery for AIE diagnosed according to modified Duke criteria between October 1994 and January 2011. Characteristics and outcomes of patients receiving preoperative chronic hemodialysis were analyzed., Results: Aortic valve AIE was present in 992 patients. Forty-five (4.5%) of the aortic valve AIE patients were receiving long-term hemodialysis preoperatively, 19 of whom (42.2%) had diabetes mellitus. Mean logistic EuroSCORE was 64.2% ± 32.2%. Twenty-four preoperative septic emboli were found in 15 patients. Results of microbiologic cultures were positive in 36 patients, with the major causative organisms identified as Staphylococcus aureus (n = 17) and Enterococcus faecalis (n = 10). Isolated aortic valve replacement was performed in 19 patients (42.2%), and 26 patients (57.8%) underwent concomitant procedures. The mean follow-up was 5.3 ± 5.2 years (range, 0.1 to 17.1 years). Postoperative complications occurred in 30 patients (66.7%). Nineteen patients (42.2%) died within 30 days of surgery, which in 8 patients was attributable to a cardiac cause., Conclusions: In patients receiving chronic hemodialysis who undergo aortic valve replacement for acute AIE, postoperative mortality is high, especially in patients undergoing aortic root replacement or culture-negative AIE., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: At our institutions, mitral valve vegetation with a high risk for embolism is surgically treated as soon as possible to maintain the quality of life of patients, and valve repair has been actively performed. We reviewed the surgical outcome for active mitral infective endocarditis (AMIE) following this treatment policy., Methods: Fifty-seven patients underwent surgery for native AMIE between April 1999 and December 2012 (repair 36, replacement 21). We retrospectively investigated the risk factors for in-hospital death, the prognosis of patients with cerebral infarction, and the short- and long-term outcomes of valve repair and replacement., Results: The preoperative conditions and the intraoperative findings in the replacement group were more complicated. But, no significant differences were observed in in-hospital mortality, 4-year survival, or 4-year reoperation-free rate between the groups (repair 8, 88.2, and 92.4%; replacement 9, 90.5, and 94.7%, respectively). The incidence of postoperative cardiac-related events including heart failure, thromboembolism, and major bleeding was higher in the replacement group. Although our study failed to identify predictors of in-hospital mortality, uncontrolled and nosocomial infections were responsible for high in-hospital mortality of 17 and 33%, respectively. Nine patients with symptomatic non-hemorrhagic cerebral infarction underwent early surgery within 2 weeks of the onset of stroke (median maximum infarct diameter and volume: 18.2 mm and 0.72 cm(3), respectively). No patients had severe hemorrhagic conversion., Conclusion: Mitral valve repair is appropriate to prevent postoperative cardiac-related events. Reducing in-hospital mortality due to uncontrolled infection remains challenging. Early surgery may be reasonable for patients with small non-hemorrhagic infarction.

Objective: Whether sex-related differences in the prognosis of infective endocarditis (IE) are due to differences in disease severity or comorbid patterns, physiological specificities or a treatment indication bias is unclear. We conducted an analysis of the pooled database of two population-based cohorts of IE to reassess the relationships between sex, early valve surgery (EVS) and outcome in patients with IE., Methods: Demographic and baseline characteristics, complications and outcome were compared in men and women with Duke-definite left-sided IE. A propensity model for EVS was constructed using multivariate logistic regression. Factors associated with 1-year mortality were identified using multivariate Cox models adjusted for EVS factors., Results: The study population included 466 (75%) men and 154 (25%) women. Compared with men, women were older (p=0.005), were more often on haemodialysis (p=0.04), more often had a mitral valve IE (50.0% vs 35.8%, p=0.02), less often developed a septic shock (p=0.05), less often underwent EVS (p=0.001) yet had comparable inhospital mortality rates (20.1% vs 20.0%, p=0.96) and similar 1-year survival probability (logrank p=0.68). Female sex was neither associated with EVS (OR 0.76 (95% CI 0.49 to 1.16)) nor mortality (HR 1.17 (95% CI 0.80 to 1.69)). However EVS was associated with an increased risk of death in women in the early postoperative period (HR 8.72 (95% CI 3.42 to 22.24), p=<0.0001)., Conclusions: Women underwent EVS less often than men. However female sex was independently associated with neither EVS nor 1-year mortality. The reasons for a higher risk of early postoperative mortality in women must still be elucidated., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: Streptococcus bovis can lead to bacteraemia, septicaemia, and ultimately endocarditis. The objective of this study was to evaluate the long-term implications of S. bovis endocarditis on cardiac morbidity and mortality., Methods: A retrospective cohort study was performed between January 2000 and March 2009 to assess all patients diagnosed with S. bovis bacteraemia from the Belfast Health and Social Care Trust. The primary end-point for cardiac investigations was the presence of endocarditis. Secondary end-points included referral for cardiac surgery and overall mortality., Results: Sixty-one positive S. bovis blood cultures from 43 patients were included. Following echocardiography, seven patients were diagnosed with infective endocarditis (16.3 % of total patients); four patients (9.3 %) had native valve involvement while three (7.0 %) had prosthetic valve infection. Five of these seven patients had more than one positive S. bovis culture (71.4 %). Three had significant valve dysfunction that warranted surgical repair/replacement, one of whom was unfit for surgery. There was a 100 % recurrence rate amongst the valve replacement patients (n = 2) and six patients with endocarditis had colorectal pathology. Patients with endocarditis had similar long-term survival as those with non-endocarditic bacteraemia (57.1 % alive vs. 50 % of non-endocarditis patients, p = 0.73)., Conclusion: Streptococcus bovis endocarditis patients tended to have pre-existing valvular heart disease and those with prosthetic heart valves had higher surgical intervention and relapse rates. These patients experienced a higher rate of co-existing colorectal pathology but currently have reasonable long-term outcomes. This may suggest that they represent a patient population that merits consideration for an early surgical strategy to maximise long-term results, however, further evaluation is warranted.

Objectives: We examined the characteristics and outcomes of patients requiring valve surgery during active infective endocarditis (IE), focusing on the impact of antimicrobial therapy., Methods: In this retrospective study, medical charts of all consecutive patients admitted to our cardiovascular surgery department from January 1998 to December 2010, with a diagnosis of IE requiring surgical management, were reviewed. Adult patients were enrolled in the study if they had definite or possible active IE and if the antimicrobial treatment was evaluable., Results: After initial screening of medical records, we selected 173 surgically treated patients (135 men; mean age, 55.8 years). Native valves were involved in 150 (87%) patients. IE mainly involved the aortic valve (n = 113) and then mitral (n = 83), tricuspid (n = 13), and pulmonary (n = 3) valves. The most common causative pathogens were streptococci (n = 70), staphylococci (n = 60), and enterococci (n = 29). Operative mortality was 15%. Multivariate logistic regression analysis demonstrated that adequacy of the overall antimicrobial treatment (adjusted odds ratio, 0.292; 95% confidence interval, 0.117-0.726; P = .008) and temperature greater than 38°C at the time of diagnosis (adjusted odds ratio, 0.288; 95% confidence interval, 0.115-0.724; P = .008) were independently associated with a lower risk of mortality. Conversely, age greater than 60 years (adjusted odds ratio, 4.42; 95% confidence interval, 1.57-12.4; P = .005) was associated with a greater risk of operative mortality., Conclusions: Surgery for active IE is still associated with a high mortality rate, but its prognosis is significantly improved by adequate antimicrobial therapy., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Bacterial endocarditis in dialysis patients is associated with high mortality rates. The literature is limited on the long-term outcomes of valvular replacement surgery and the choice of prosthesis in dialysis patients with bacterial endocarditis., Methods and Results: Dialysis patients hospitalized for bacterial endocarditis from 2004 to 2007 were studied retrospectively using data from the United States Renal Data System. Long-term survival of patients undergoing valve replacement surgery with tissue or nontissue valves was compared by use of the Kaplan-Meier method. A Cox proportional hazards model was used to identify independent predictors of mortality in patients undergoing valvular replacement surgery. During the study period, 11 156 dialysis patients were hospitalized for bacterial endocarditis and 1267 (11.4%) underwent valvular replacement surgery (tissue valve, 44.3%; nontissue valve, 55.7%). In the valve replacement cohort, 60% were men, 50% were white, 54% were 45 to 64 years of age, and 36% were diabetic. Estimated survival with tissue and nontissue valves at 0.5, 1, 2, and 3 years was 59% and 60%, 48% and 50%, 35% and 37%, and 25% and 30%, respectively (log-rank P=0.42). Staphylococcus was the predominant organism (66% of identified organisms). Independent predictors of mortality in patients undergoing valve replacement surgery included older age, diabetes mellitus as the cause of end-stage renal disease, surgery during index hospitalization, staphylococcus as the causative organism, and dysrhythmias as a comorbid condition., Conclusions: Valve replacement surgery is appropriate for well-selected dialysis patients with bacterial endocarditis but is associated with high mortality rates. Survival does not differ with tissue or nontissue prosthesis.

Background and Aim of the Study: Prosthetic valve endocarditis (PVE) is considered a time-related event. The study aim was to compare the clinical characteristics and outcomes of early- and late-onset PVE, and to investigate potential preventive measures for each condition., Methods: A total of 47 consecutive patients undergoing surgery for PVE between January 1986 and December 2011 were analyzed retrospectively, and classified as an early-onset group (n = 26; PVE occurring within 12 months after previous surgery) and late-onset group (n = 21; PVE occurring after 12 months)., Results: The prosthetic valve position significantly affected the incidence of endocarditis: 21 cases (80.7%) in the early-onset group had infected aortic prostheses, while 18 (85.7%) in the late-onset group had infected mitral prostheses (p = 0.028). PVE significantly affected bioprosthetic valves in the early-onset group (18 cases, 69.2%) and mechanical valves in the late-onset group (17 cases, 80.9%) (p < 0.01). Staphylococcus spp. infections were predominant in the early-onset group (21 cases, 80.7%), and Streptococcus spp. in the late-onset group (five cases, 23.8%) (p = 0.03). Operative deaths occurred in both the early-onset (n = 6; 23.0%) and late-onset (n = 2; 9.5%) groups (p = 0.11). The long-term mortality in the early-onset and late-onset groups, respectively, was 40.3 +/- 17.7% and 85.1 +/- 7.9% at 10 years, and 40.3 +/- 17.7% and 72.9 +/- 13.1% at 15 years (p 0.047). Freedom from recurrent endocarditis after two years in the early- and late-onset groups, respectively, was 67.8 +/- 10.1% and 88.8 +/- 7.4% (p = 0.048)., Conclusion: Clinical characteristics and outcomes differed significantly between early- and late-onset PVE. The clinical outcomes of patients with early PVE tend to be serious, and therefore stringent care should be taken to avoid contamination during the initial surgery and hence to reduce the incidence of the condition.

Background and Aim of the Study: Isolated bacterial tricuspid valve (TV) endocarditis is usually managed medically. Whilst the indications and optimal timing for surgical treatment of the condition have not been clearly defined, it is hypothesized that early surgery in patients who are bacteremic and/or have evidence of systemic seeding is superior to medical treatment., Methods: All cases of isolated TV endocarditis reported between 2006 and 2011 at the authors' institution were reviewed. Patients with bacteremia and/or systemic seeding who were treated surgically after short-term medical therapy were compared to an equivalent group of patients who remained under long-term medical treatment only., Results: A total of 45 patients with isolated TV endocarditis showed evidence of bacteremia and/or systemic seeding. Of these patients, 10 (22.2%) were treated surgically with valve repair or replacement, and 35 (77.8%) received long-term medical therapy only. The 30-day and one-year survival rates in both groups were comparable (100% versus 88.6%, p = 0.27). Patients treated surgically had clear blood cultures sooner (2.0 versus 6.7 days, p = 0.04), defervesced earlier (0 versus 9.0 days, p = 0.02), and demonstrated a complete resolution of TV vegetations (100% versus 30.0%, p = 0.003). Change in creatinine clearance (+22.1 versus +11.6 ml/min, p = 0.40) and durations of vasopressor support (6.8 versus 8.9 h, p = 0.86), mechanical ventilation (8.5 versus 32.2 h, p = 0.44), ICU stay (148.1 versus 53.8 h, p = 0.14) and total hospital stay (32.1 versus 24.6 days, p = 0.22) were not different between groups. Long-term echocardiogram surveillance demonstrated a higher prevalence of moderate-severe tricuspid regurgitation in the medically treated patients (75.0 versus 0.0%, p < 0.001). None of the patients treated surgically was readmitted with prosthetic valve endocarditis., Conclusion: Early surgery is warranted in patients with isolated TV endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy.

Background: The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity., Methods: Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete., Results: Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up., Conclusions: Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Infective endocarditis is a rare disease in the pediatric population. We sought to define patient characteristics and outcomes of surgical therapy for endocarditis in children., Methods: We performed a retrospective review of all patients with infective endocarditis who received surgical therapy between January 1, 1990, and March 1. 2011. We were interested in their congenital heart defect, prior surgical procedures, and outcome of the operation., Results: We identified 35 cases of endocarditis in 34 patients requiring surgical intervention. Mean age was 10.7 ± 8.8 years. There was a bimodal age distribution at presentation: 11 (31%) were younger than 1 year and 15 (43%) were 10 to 21 years. Of the 34 patients, 22 (63%) had no history of prior cardiac operation. The infective organism was identified in 30 (86%), with Staphylococcus aureus (n = 8) and Streptococcus viridans (n = 6) predominating. Valve replacement was performed in 22 patients and valve repair in 10. All patients received 6 weeks of postoperative intravenous antimicrobial therapy. Operative mortality was 15% (5 of 34). The 5 deaths occurred in infants who were a mean age of 2.5 months, and 3 of the 5 infants (60%) were premature. Of 4 patients with fungal infection, 3 patients died. The Ross operation was performed successfully in 5 patients with severe aortic valve disease. Reoperations (n = 10 [28%]) included valve replacement in 5 and conduit replacement in 3, all but 1 due to somatic growth resulting in functional stenosis., Conclusions: The outcome of surgical therapy for endocarditis in children was similar to that reported for adults, with an overall mortality of 15%. The Ross operation was very effective in patients with aortic valve endocarditis. There is a significant incidence of late reoperation for valve and conduit replacement due to somatic growth. Age younger than 1 year, prematurity, and fungal organisms appear to be risk factors for death. Patients surviving to discharge had good outcomes, with no episodes of recurrent endocarditis., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Systematic long-term data on tricuspid valve (TV) endocarditis are limited. The aim of this study was to investigate the outcome of surgery for isolated TV endocarditis., Methods and Results: A total of 637 patients who underwent TV surgery between June 1996 and September 2012 at Hannover Medical School were retrospectively investigated. Of the 637 patients, 33 (14 female, mean age, 49 ± 21 years) underwent isolated TV surgery for endocarditis: biological TV replacement, n=14; mechanical TV replacement, n=4; TV reconstruction, n=15. A total of 28 cases were associated with i.v. drug abuse (n=14) or pacemaker infection (n=14). Staphylococcus (S.) aureus was the most common microorganism detected on preoperative blood culture. Mean follow-up was 6.0 ± 4.1 years (83% completed). Three patients (9%) died during the first 30 postoperative days. Survival at 1, 5 and 10 years was 88%, 73%, and 73%, respectively. Freedom from reoperation was 100%, 95%, and 88%, respectively. During follow-up New York Heart Association class improved significantly, and echocardiography identified remaining TV insufficiency grade ≥ II° only in 2 patients. Statistical analysis identified advanced age, logistic EuroSCORE and positive blood culture for S. aureus as significant risk factors for long-term mortality., Conclusions: Isolated TV endocarditis is strongly associated with i.v. drug abuse or pacemaker infection. Long-term outcome is acceptable, independent of the surgical procedure.

Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70-80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into 'prosthetic' (valve replacement or prosthetic annular implantation) or 'non-prosthetic' ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival.

Aims: The aim of this study was to evaluate the effect of valve surgery (VS) in infective endocarditis (IE) on 5-year mortality and to evaluate whether conflicting results reported by previous studies could be due to differences in their methodological approaches., Methods and Results: Four hundred and forty-nine patients with a definite left-sided IE were selected from a prospective, population-based study. Association between VS and 5-year mortality was examined with a Cox model. To determine the impact of different methodological approaches, we also analysed the relationship between VS and mortality in our database, according to each method used in the five previous studies. Valve surgery was performed in 240 patients (53%). It was associated with an increase in short-term mortality [within the first 14 post-operative days; adjusted hazard ratio (HR), 3.69; 95% confidence interval (CI), 2.17-6.25; P<0.0001] and a decrease in long-term mortality (adjusted HR, 0.55; 95% CI, 0.35-0.87; P=0.01). At least 188 days of follow-up were required for VS to provide an overall survival advantage. When applying each study's method to our database, we obtained results similar to those reported., Conclusion: Previous conflicting results appear to be related to differences in statistical methods. When using appropriate models, we found that VS was significantly associated with reduced long-term mortality.

Background: Surgical treatment for endocarditis is still challenging and only a handful of studies have analyzed surgical outcomes in patients with active multivalvular endocarditis., Methods: From June 1996 to October 2007, 152 patients underwent surgery for active native valve endocarditis; 117 patients with single-valve endocarditis and 35 patients with multivalvular endocarditis. Preoperative and postoperative data were retrospectively reviewed to determine risk factors for early and late mortality., Results: One-year and 5-year survival were 78.6%±3.8% and 54.8%±5.3% in the single-valve group, and 74.3%±7.4% and 64.8%±8.3% in the multivalve group, respectively (log-rank 0.64). The rates of valve replacement were significantly higher in the single-valve group than in the multivalve group in all sites except the pulmonary valve. Freedom from reoperation was 90.0%±3.6% in the single-valve group and 79.5%±8.5% in the multivalve group in 5 years (log-rank 0.30). No recurrence of endocarditis was noted in the multivalve group, while 4 patients (3.4%) had recurrence in the single-valve group during the follow-up period (p=0.57). There was no significant difference in postoperative complications between the two groups. Multivariate analysis of the multivalve group identified postoperative renal failure as a predictor of late mortality with no predictors identified for early mortality, reoperation, and recurrence. Statistical analysis of the overall cohorts showed multivalve endocarditis was not an independent predictor of early and late mortality., Conclusions: Surgical treatment for active, native, and noncomplicated multivalve endocarditis was associated with respectable early and late morbidity and mortality comparable with single-valve endocarditis, and was not an independent predictor of early and late mortality., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mitral valve repair is preferred to replacement in infective endocarditis, but in the active phase, it often requires extensive debridement of infected tissue and complex reconstruction. We investigated 22 consecutive native mitral valve operations during active-phase infective endocarditis. The time from initiation of medical treatment to operation was 16.8 ± 16.4 days. Mitral valve repair was performed in 15 (68.2%) patients, using prosthetic annuloplasty in 14, an autologous pericardial patch in 11, and artificial chordal replacement in 9. Hospital mortality was 9.1% (2 patients), due to subarachnoid hemorrhage and pneumonia. One patient died 26 months after valve replacement due to congestive heart failure. The postoperative left ventricular end-diastolic dimension was significantly smaller (45.7 ± 5.6 vs. 53.3 ± 10.2 mm) and ejection fraction was significantly higher (57.0% ± 14.7% vs. 40.1% ± 8.2%) in patients who underwent valve repair compared to those who had valve replacement. Mitral regurgitation requiring reoperation occurred in 3 patients during follow-up. Mitral valve repair is feasible in active-phase infective endocarditis, and results in improved regression of left ventricular dimensions compared to valve replacement. However, complex mitral valve repair with extensive leaflet resection may not have long-term durability.

Background and Aim of the Study: The study aim was to describe the characteristics and operative mortality of patients requiring valve surgery during active infective endocarditis (IE)., Methods: This retrospective analysis involved 141 surgically treated patients with active IE. All cardiac operations were performed by the same surgical team between January 1998 and July 2009. All patients had definite (n = 128) or possible (n = 13) endocarditis according to modified Duke criteria. The IE was considered active if surgery was required before completion of a standard course of antimicrobial therapy. Operative mortality included any death occurring within the same hospital admission as surgery., Results: Among the patients (108 males, 33 females; mean age 56.3 +/- 14.9 years), native valve endocarditis was present in 122 cases (87%). Multiple valve involvement was observed in 27 patients. The infected valves were the aortic (n = 81), mitral (n = 70), tricuspid (n = 15), or pulmonary (n = 2). The most common pathogens were staphylococci (n = 49), streptococci (n = 46) and enterococci (n = 27). The operative mortality was 16%. In univariate analysis, factors linked to operative mortality were age, prosthetic valve endocarditis (PVE) and inadequate antimicrobial therapy. In multivariate analysis, only PVE was an independent adverse predictor (adjusted Odds Ratio = 4.16; 95% confidence intervals 1.14-12.2; p = 0.01)., Conclusion: Surgery for active IE is associated with a high mortality rate. The prognosis is impaired in patients with PVE, but might be improved by adequate antimicrobial therapy.

We reviewed our department's experience with the perioperative features and surgical treatment of isolated right-sided infective endocarditis. From January 2000 through July 2010, 35 patients underwent surgery for isolated right-sided infective endocarditis in our department. The mean pathologic course was 3.6 months. Preoperative transthoracic echocardiography had revealed intracardiac vegetations in all 35 patients: the tricuspid valve was involved in 28, and preoperative cultures were positive in 31. The median follow-up time was 5.8 years, and the follow-up rate was 85.3%. All the operations were performed with the patients on cardiopulmonary bypass, with or without cardiac arrest. All concomitant congenital heart defects were repaired, and vegetations and foreign materials were removed as part of intensive débridement of the infected area. After vegetation removal, 4 tricuspid valve replacements with tissue valves and 24 tricuspid valve reconstructions were performed. One patient who underwent tricuspid valve replacement died of uncontrollable infection and multiple-organ failure. Two patients required mechanical ventilation for more than 1 week, and 3 needed dialysis for acute renal failure. Of the excised vegetations, 31.4% were positive for microorganisms. Of the patients who underwent tricuspid valvuloplasty, 23 had no valvular incompetence and 11 had mild or moderate regurgitation before discharge from the hospital. During follow-up, no patient needed reoperation because of reinfection, and 1 underwent reoperation for severe tricuspid regurgitation. We conclude that surgery can yield satisfactory immediate and midterm results in the treatment of isolated right-sided infective endocarditis.

Objective: To analyse characteristics and outcomes of infective endocarditis (IE) on bicuspid aortic valves (BAV) and to compare the risk of death according to the presence or absence of BAV., Design: 5-year observational study., Setting: Population of 856 patients with definite IE according to the Duke criteria from two tertiary centres (Amiens and Marseille, France)., Patients: 310 consecutive patients with definite native aortic valve IE enrolled between 1991 and 2007., Interventions: Patients underwent transthoracic and transoesophageal echocardiography during hospitalisation. Surgery was performed on a case-by-case basis according to conventional guidelines., Main Outcome Measures: In-hospital mortality and 5-year overall mortality., Results: Patients with BAV IE (n=50, 16%) were younger, had fewer comorbidities and a higher frequency of aortic perivalvular abscess (50%). Presence of BAV (OR 3.79 (1.97-7.28); p<0.001) was independently predictive of abscess formation. Early surgery was performed in 36 BAV patients (72%) with a peri-operative mortality of 8.3%, comparable to that of patients with tricuspid aortic valve IE (p=0.89). BAV was not independently predictive of in-hospital mortality (OR 0.89 (0.28-2.85); p=0.84) or 5-year survival (HR 0.71 (0.37-1.36); p=0.30). Age, comorbidities, heart failure, Staphylococcus aureus and uncontrolled infection were associated with increased 5-year mortality in BAV patients., Conclusion: BAV is frequent in adults with native aortic valve IE. Patients with BAV IE incur high risk of abscess formation and require early surgery in almost three-quarters of cases. IE is a severe complication in the setting of BAV and warrants prompt diagnosis and treatment.

Background: Brucella endocarditis is a life-threatening complication of human brucellosis. In this study, our aim was to evaluate the effects of combined medical and surgical treatment in the midterm to long term., Methods: We retrospectively analyzed 13 patients (mean age 44 +/- 18 years; 8 males) who were operated on from January 1993 to June 2009. Duke criteria were used for the diagnosis of endocarditis. The primary endpoint was defined as the overall mortality and readmission to the hospital during early and late follow-up periods. The other collected data included baseline and follow-up clinical findings, along with echocardiographic and laboratory measurements., Results: No patients died in the early period (up to 1 month) and 2 patients (15.3%) died during the late follow-up period. Aortic valve disease was observed in 11 of 13 patients (85%). The most commonly performed procedure was aortic valve replacement (10 of 13 patients; 77%) during a mean follow-up period of 95 +/- 60 months (range, 10 to 184; median, 74)., Conclusions: For Brucella endocarditis, perioperative antibiotic therapy combined with surgical treatment (prosthetic valve replacement) has satisfactory results and increases the quality of life in the long-term follow-up., (Copyright (c) 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim of the Study: Despite recent improvements in diagnostic and therapeutic interventions, infective endocarditis (IE) is still associated with high in-hospital mortality rates. The study aim was to determine the clinical, laboratory and echocardiographic features of IE, and to evaluate the risk factors for in-hospital mortality., Methods: A retrospective cohort study design was employed, with a main outcome measure of in-hospital mortality. A total of 107 patients (79 males, 28 females; mean age 45 +/- 16 years) admitted with the modified Duke criteria for definitive IE were included in the study during a five-year period between January 2004 and December 2008., Results: Among the patients, the mitral valve alone was involved in 45% of cases, the aortic valve in 36%, tricuspid valve in 11%, and multiple valves in 8%. Forty-seven patients (44%) had prosthetic valves. Blood cultures were positive in 71 patients (66%). The most common isolated microorganisms were staphylococci, streptococci and Brucella melitensis. The in-hospital mortality rate was 27%. Leading causes of death were multi-organ failure and heart failure. In univariate analysis, factors associated with death were a longer duration of symptoms before hospitalization, previous history of IE, white blood cell count > or = 10,000/mm3, serum creatinine level > or = 2 mg/dl, vegetation size >15 mm, involvement of multiple valves, existence of severe regurgitation, cardiac abscess, and neurologic complications. Multivariate analysis showed that risk factors for mortality were multivalvular involvement (hazard ratio (HR) 4.7; 95% confidence interval (CI) 1.3-17.6; p = 0.021), vegetation size >15 mm (HR 5.5; 95% CI 2.1-14.6; p = 0.001), serum creatinine > or = 2 mg/dl (HR 4.1; 95% CI 1.8-9.4; p = 0.001), and previous history of IE (HR 3.5; 95% CI 1.2-11; p = 0.026)., Conclusion: Multivalvular involvement, vegetation length >15 mm, serum creatinine level > or = 2 mg/dl on admission, and a previous history of IE, were independent predictors for in-hospital mortality in IE.

Background and Aim of the Study: A retrospective analysis was conducted of the early and long-term results of mitral valve repair (MVRep) and mitral valve replacement (MVR) in patients with isolated infective mitral valve endocarditis., Methods: Between May 1986 and December 2007, a total of 1,163 patients with active infective endocarditis (AIE) were operated on. Of these patients, 497 showed an endocarditic involvement of the mitral valve. Sixty-one of these patients underwent MVRep and 219 MVR, with 24% cases of prosthetic valve endocarditis (PVE). The patients' perioperative characteristics, cumulative survival, freedom from recurrence and reoperation and independent risk factors for early mortality were analyzed. Follow up (0-21 years) was complete in 96.5% of cases; the total follow up was 348 and 810 patient-years (pt-yr) in the MVRep and MVR groups, respectively., Results: Typically, the MVR patients were significantly older (p < or = 0.001), preoperatively more often intubated (p = 0.008) and in cardiogenic shock (p = 0.045), and more often underwent emergency surgery (p = 0.023). MVRep was associated with a significantly better survival, with 30-day, one-, five- and 10-year survival rates of 90.1 +/- 3.9%, 83.2 +/- 4.8%, 77.0 +/- 5.7% and 60.5 +/- 8.0%, respectively (p = 0.002). Survival after MVR was significantly worse with abscess formation (p = 0.0002) and PVE (p = 0.038). Freedom from reoperation due to reinfection after 10 years was 89.4 +/- 7.0% after MVRep, with early endocarditis recurrence in two patients (3%), and 91.0 +/- 2.5% after MV, with early recurrence in four patients (2%) (p = 0.46). Multivariate analysis identified preoperative ventilation (OR = 6.3), mitral valve abscess formation (OR = 5.3), PVE (OR = 3.1) and age > or = 60 years (OR = 2.8) as independent risk factors for early mortality., Conclusion: Compared to the MVRep group, patients requiring MVR had more advanced endocarditis and were more critically ill. These results suggest that the early outcome might have been improved if patients had been operated on before either heart failure or the development of septic shock. MVRep for AIE showed a low operative mortality and provided satisfactory freedom from recurrent infection and repeat operation. If all infected material could be resected such that the remaining tissue would allow the re-shaping of a competent valve, then MVRep could be performed also in infective endocarditis, in line with the general recommendations for mitral valve surgery.

Objective: Brucellosis is frequently seen in Mediterranean and Middle East countries, including Turkey. We report the medical and surgical management of 31 cases of native endocarditis., Material and Method: Thirty-one patients were admitted to our clinic with suspected Brucella Endocarditis. The diagnosis was established by either isolation of Brucella species, or the presence of antibodies. Following preoperative antibiotic therapy patients underwent valve replacement with excessive tissue debridement. Patients were followed up with Brucella titers, blood cultures, and echocardiography., Results: On admission all patients were febrile and mostly dyspneic (NYHA Class 3 or 4). The blood tests were normal except for elevated ESR, CRP and serological tests. The aortic valve was involved in 19 patients, mitral valve in 7 patients, and both valves in 5. After serological confirmation of BE, antibiotic therapy was maintained. Twenty-five of the patients received rifampicine, doxycycline, and cotrimaxozole; 2 of them received a combination of rifampicine, streptomycin, and doxycycline; and 4 of them received rifampicine, tetracycline, and cotrimaxozole. Tissue loss in most of the affected leaflets and vegetations were presenting all patients. Valve replacements were performed with mechanical and biologic prostheses. All the patients were afebrile at discharge but received the antibiotics for 101, 2+/-16, 9 days. The follow-up was 37, 1+/-9, 2 months., Discussion: In our retrospective study, combination of adequate medical and surgical therapy resulted in declined morbidity and mortality rate. The valve replacement with aggressive debridement is the most important part of the treatment, which should be supported with efficient preoperative and long term postoperative medical treatment., (Copyright 2010 Wiley Periodicals, Inc.)

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.

Objective: In active infective endocarditis the need for operating simultaneously on the aortic and mitral valves is frequent. There are no studies in the literature documenting long-term outcomes of double valve surgery for active endocarditis., Methods: Ninety patients underwent double valve surgery for active endocarditis over a 26-year period (mean age, 53 +/- 16 years; 71% male patients). Prosthetic endocarditis was seen in 32 patients. Staphylococcus species was isolated in 29%. Forty-six (51%) patients had abscesses. Surgical intervention consisted of valve repair or replacement with limited infection or radical resection, patch reconstruction, and valve replacement for abscesses. Mean follow-up was 5.9 +/- 4.7 years (range, 0-18 years) and was complete., Results: There were 14 (15.6%) in-hospital deaths and 29 (32.2%) late deaths. Overall survival at 5, 7, and 10 years was 68% +/- 5%, 59% +/- 6%, and 49% +/- 6%, respectively, and was reduced in those undergoing operations for prosthetic compared with native endocarditis (7-year survival, 39% +/- 9% vs 71% +/- 7%; P < .001). Freedom from recurrent endocarditis was 84% +/- 5% at 10 years. Freedom from reoperation was 91% +/- 4% at 10 years. Event-free survival at 7 and 10 years was 60% +/- 6% and 47% +/- 7%, respectively. No difference was observed between the native and prosthetic groups for recurrent endocarditis, late reoperation, or event-free survival. Prosthetic endocarditis, increasing age, preoperative shock, and diabetes mellitus were independent predictors of death from all causes., Conclusions: Double valve surgery for active endocarditis remains technically challenging and associated with significant morbidity and mortality perioperatively and in the longer term. Outcomes are worse in those who have prosthetic valve endocarditis.

Objective: Little information is available about surgical outcomes in patients with multivalvular endocarditis. The aim of this article is to review the 21-year experience with surgical treatment of patients with multivalvular endocarditis at our institution and, in particular, to determine the incidence, pathologic status, diagnosis, surgical strategies, and outcomes of patients with this disease., Methods: From January 1986 to December 2006, a total of 48 patients (40 men, 8 women), with a mean age of 42 +/- 12 years, underwent surgery for multivalvular endocarditis. Endocarditis was active in 32 patients and healed in 16. Preoperative transthoracic echocardiographic evaluation was performed in all 48 patients with addition of transesophageal echocardiography in 22 (45.8%). Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (40/48 patients). Triple or quadruple valve involvement was found in 1 and 2 patients, respectively. Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors for early and late survival were determined., Results: In only 24 (50.0%) patients was multivalvular endocarditis diagnosed by preoperative transthoracic echocardiography; 17 (77.3%) patients had multivalvular endocarditis confirmed by preoperative transesophageal echocardiography. The 30-day hospital mortality was 12.5% (n = 6). Preoperative renal failure, New York Heart Association class IV, and emergency surgery were identified as independent risk factors for hospital mortality. Overall long-term survival was 74% +/- 6% at 5 years and 62% +/- 3% at 10 years. Multivariate analysis revealed that renal failure and recurrent endocarditis were associated with increased late mortality. Ten-year freedom from recurrent endocarditis was 74% +/- 5% and 10-year freedom from reoperation was 73% +/- 6%., Conclusions: In our institution, multivalvular endocarditis was diagnosed by transthoracic echocardiography in only half of the patients. Intraoperative transesophageal echocardiography provided a more effective means to identify this disease. Radical resection of all infected tissues for patients with multivalvular endocarditis and additional intraoperative interventions, depending on the intraoperative pathologic condition, produced satisfactory in-hospital and long-term results, similar to those in patients with a single infected heart valve.

Introduction: Aortic allograft implantation into the aortic position in adults is standard procedure with some controversary. The most popular indication is bacterial endocarditis. We would like to present our midterm results., Results: We implanted 61 allografts in 60 patients (between 10/2002 and 04/2008). Men were 46 (76.8%) and average age was 57 +/- 10.76 year. 30 days mortality was 9 people (15.0%, all with bacterial endocarditis). Late mortality 1 man (1.6%). Follow up 1-66 months, average 39.18 SD +/- 14.3 months, median 42 months., Conclusion: Implantation of aortic allograft into the aortic position is standard procedure with good midterm results. Relative high early mortality is dependent on preoperative status in patiens with acute bacterial endocarditis--all early death people were people with acute bacterial endocarditis and minimally one vital organ severe dysfunction.

Objectives: To investigate the association of increased cardiac troponin I levels with in-hospital mortality and valve replacement in patients with infective endocarditis (IE)., Methods: The 62 patients included 36 men and 26 women, with a mean age of 60 +/- 9 years, with IE diagnosed by the Duke criteria. All 62 patients had blood drawn for measurement of cardiac troponin I levels. A cardiac troponin I level >0.4 ng/ml was considered increased. All 62 patients underwent transesophageal echocardiography. Student's t tests were used to analyze continuous variables. chi(2) tests were used to analyze dichotomous variables., Results: Transesophageal echocardiography diagnosed valvular vegetations in 56 of the 62 patients (90%). Cardiac troponin I levels were increased in 35 of the 62 patients (57%). In-hospital mortality or valve replacement occurred in 18 of 35 patients (51%) with increased cardiac troponin I levels versus 4 of 27 patients (15%) with normal cardiac troponin I levels (p < 0.005)., Conclusions: Patients with IE and increased cardiac troponin I levels have a higher incidence of in-hospital mortality or valve replacement than those with normal cardiac troponin I levels., (Copyright 2008 S. Karger AG, Basel.)

Moxifloxacin (MXF) is an 8-methoxyquinolone with high activity against Gram-positive bacteria. In an experimental model of aortic valve endocarditis (EAVE), the efficacy of MXF was evaluated against a strain of methicillin-resistant Staphylococcus aureus (MRSA). Rabbits with catheter-induced aortic valve vegetations were randomly assigned to a control group or to groups receiving MXF 20 mg/kg intravenous (i.v.) twice a day (bid) or vancomycin (VAN) 30 mg/kg i.v. bid for a total of eight doses (4 days). Rabbits were sacrificed 15 h after the last dose of antibiotics. In another group, treatment with MXF was extended to 5 days and rabbits were sacrificed 5 days after the last dose (10th dose) of MXF in order to detect possible relapses of endocarditis after the end of treatment (test-of-cure (TOC) study). Both MXF and VAN significantly reduced the bacterial load in vegetations (P < 0.001 vs. controls). All animals in the MXF-TOC group had sterile vegetations. MXF given at a dose of 20 mg/kg i.v. bid for 4 days was equally effective as VAN in the treatment of EAVE due to MRSA. When treatment with MXF was extended to 5 days, the cure rate reached 100% and no relapses of endocarditis were observed.

Background: This study was performed to identify risk factors for hospital death in patients with acute and active infective endocarditis (AAIE) after surgical intervention., Methods and Results: From 1980 to 2004, 94 patients underwent surgery for AAIE (age range, 3-77 years; 76% males). Congestive heart failure (CHF) was present in 44 patients, as well as vegetations in 64, septicemia in 16, abscesses in 17, and emboli in 22; 16 patients had prosthetic valve endocarditis. Streptococci were the most common bacteria (34 patients), followed by staphylococci (17 patients). Mechanical valves were selected for 73 patients and bioprosthetic valves for 16. Mitral valve plasty was performed in 4 patients. Aortic root or aorto-mitral discontinuity was repaired in 17 patients, including Manouguian's double valve replacement in 6 and aortic root replacement in 4. Overall hospital mortality was 15% (14 patients). Univariate analysis identified CHF (p=0.016), abscess (p=0.014), and prosthetic valve endocarditis (p=0.043) as risk factors. However, multivariate analysis only identified CHF (p=0.019) as an independent risk factor., Conclusion: In AAIE, early surgical intervention is advisable before the occurrence of complications such as root abscess and CHF, particularly before the onset of CHF.

Background: The optimal timing of cardiac operations in patients with infective endocarditis continues to be debated. This observational study analyzed the profile and outcome of patients with active infective endocarditis undergoing operations., Methods: Between June 2000 and June 2006, 95 surgically treated patients with definite infective endocarditis by the modified Duke criteria were included., Results: Fifty-eight patients were operated on within the first 7 days after diagnosis of infective endocarditis and 37 at more than 7 days after diagnosis up to immediately after completion of antibiotic treatment. Staphylococci predominated and were significantly associated with embolism, abscess, and septic shock. The most frequent indication for operation was severe regurgitation with heart failure. The 6-month mortality was 15%. Early operation showed a trend towards increased mortality vs late operation. In univariable analysis, factors associated with 6-month mortality included staphylococci and septic shock. Multivariable analysis revealed that septic shock predicted 6-month mortality. Despite early operation in patients experiencing septic shock, 57% died. No patients without heart failure died after undergoing (early or late) procedures for severe regurgitation., Conclusions: The prognosis in surgically treated patients was determined by the occurrence of septic shock. The outcome in patients who underwent late operations was favorable compared with the early group. This difference was probably not due to the timing of the surgical intervention but to the severity of infective endocarditis. In patients with severe regurgitation without heart failure, early operation may offer benefit in length of hospitalization and prevention of development of new heart failure.

Background: The clinical course of left-sided native valve infective endocarditis varies from uncomplicated disease to fulminant infection. Although several factors are known to affect clinical outcome, it is difficult to predict morbidity and mortality in individual patients. The objective of this study was to determine the value of serial C-reactive protein (CRP) measurements as a predictor of clinical outcome., Methods: One hundred twenty-three consecutive patients who fulfilled the Duke criteria for definite left-sided native valve infective endocarditis were prospectively enrolled. Poor outcome was defined as serious infectious complications or death. Patients were followed up for 12 weeks after the end of antimicrobial therapy. Multivariate analysis was used to examine the relative importance of the CRP level as a predictor of poor outcome after adjusting for age, abscess, multivalvular involvement, and Staphylococcus aureus infection., Results: After 1 week of therapy, the adjusted odds ratio for poor outcome was 10.3 (95% confidence interval, 2.2-49.4) for patients with CRP levels in the highest tertile (>122 mg/L [to convert to nanomoles per liter, multiply by 9.524]) vs the lowest tertile (1-69 mg/L). A low percentage decline during the first week of treatment was statistically significantly associated with a higher risk of poor outcome (logistic regression coefficient, 1.1; P = .009). At no point in time did CRP level predict the need for cardiac surgery., Conclusion: High CRP level after 1 week of treatment and a slow percentage decline in CRP level during the first week of treatment are indicators of poor clinical outcome.

Background: Surgery for active endocarditis is indicated in cases of congestive heart failure (CHF), persistent sepsis, systemic embolization and paravalvular involvement., Aim: To assess and report the long term results of surgery in adult patients., Patients and Methods: Retrospective review of clinical records and operative procedures of 32 patients aged 43+/- 13 years (28 women) subjected to reparative surgery for complications of endocarditis between 1993 to 2005., Results: In 25% of cases, endocarditis presented as a prolonged sepsis syndrome and in 31% as a CHF or both. The causative bacteria was Gram (+) in 53% and blood cultures were negative in 47%. Preoperative echocardiography showed vegetations in 56% of cases. An annular abscess, aortic valve rupture and bicuspid valve, was observed in 13% of patients. Post operative mortality was due to persistent sepsis and multi-organic dysfunction in 16%. Mean long term follow up was 43.8+/-47.2 months. Actuarial survival was 78% at 146 months., Conclusion: Surgical management of active endocarditis provides a good symptomatic recovery, with an excellent long term actuarial survival.

Background: Surgery for mitral valve endocarditis in children is relatively uncommon. This study assesses its operative outcome and reoperation and long-term survival rates., Methods: We reviewed the cases of 8 consecutive children who underwent mitral valve repair for infective endocarditis between 1989 and 2005 at our institution. Mean age was 13.8 years (range, 9.4 to 16.9 years). The mitral valve was affected in all 8 patients, and both aortic and mitral valve in 2. Congenital cardiac malformation was the predisposing factor in 3 patients. Three patients had floppy mitral valve owing to leaflet perforation. All 8 patients had severe mitral regurgitation. Indications for operations were cardiac failure in 2, septic embolization in 2, and severe mitral regurgitation in 4. Four surgical interventions were elective, two were urgent, and two were emergencies. The offending microorganism was identified in 7 of the 8 patients. Mitral valve repair or reconstruction was performed in all 8, and 2 patients had additional aortic valve replacement. Follow-up was complete (mean, 9.5 years; range, 0.67 to 16 years; total, 76.7 patient-years)., Results: There were no operative deaths. Actuarial freedom from reoperation and actuarial survival rate at 1, 5, 10, and 15 years were 100%. Early echocardiographic follow-up showed 4 patients to have mild mitral valve regurgitation, 2 had mild to moderate, and 2 had no regurgitation. Long-term follow-up showed no progression of the lesions., Conclusions: Mitral valve repair achieves excellent results and can be performed without morbidity or mortality. Functional improvement and follow-up echocardiography evaluating the degree of mitral valve regurgitation and stenosis are satisfactory.

Background: Surgical treatment of active aortic infective endocarditis is challenging, and the type of prosthesis to be implanted during the active phase remains controversial., Methods: All consecutive patients with definite diagnosis of aortic infective endocarditis operated on during the active phase were included. Endpoints were in-hospital mortality and a combined endpoint including infective endocarditis recurrence, prostheses dysfunction, or long-term cardiovascular mortality., Results: Among 127 consecutive patients, mean age 57 +/- 15 years, 87% male, 30% with preexisting aortic prosthesis, and 63 (50%) with annulus abscess, 54 (43%) were treated with aortic homograft and 73 (57%) with conventional prosthesis. Median time between diagnosis and surgery was 10 days. In-hospital mortality was 9%, not different between homograft and conventional prostheses (11% versus 8%, p[ = 0.6). By multivariable analysis, prosthetic valve endocarditis (8.5 95% confidence interval: 2.2 to 33.6, ]p = 0.001) was the only variable independently associated with in-hospital mortality, which was not influenced by type valvular substitute (p = 0.6), even in the subset with annulus abscess (p = 0.2). Ten-year survival free from the combined endpoint was 44% +/- 10%, not different between homograft and conventional prostheses (log rank p = 0.2). By multivariable analysis, comorbidity index (2.6 [1.05 to 6.3], p = 0.04) and prosthetic valve endocarditis (2.3 [1.2 to 4.6], p = 0.02) were independently predictive of the combined endpoint, which was not determined by type of valvular substitute (p = 0.6) even in the subset with annulus abscess (p = 0.5)., Conclusions: Implantation of conventional prostheses during the active phase of aortic endocarditis yields similar low operative mortality and long-term prognosis as compared with aortic homografts, even in patients with annulus abscess.

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.