Search

A 30-year-old man who is a heroin addict was diagnosed with uncontrolled tricuspid valve endocarditis and repeated lung abscesses. He underwent tricuspid valvectomy for the endocarditis. After surgery the patient had severe tricuspid regurgitation and hypoxemia develop. Due to severe tricuspid regurgitation-induced ventricular distension and persistent low cardiac output, reimplantation of the tricuspid valve was planned for 2 weeks after the first operation. To avoid lung injury caused by the cardiopulmonary bypass and to preserve right ventricular function, a self-made superior and inferior vena cava shunt was connected to the pulmonary artery. The tricuspid valve was implanted without cardiopulmonary bypass.

Background: Intravenous drug users (IDUs) are at increased risk of infective endocarditis (IE)., Patients and Methods: Episodes of IE in IDUs were retrospectively analyzed in this multicenter study. Cases were collected between 1986 and 1999. Only definite diagnosis according to the Duke criteria were analyzed., Results: Two hundred and sixty-three cases, including 100 cases in HIV-positive patients, were observed in IDUs. Any right-sided involvement was detected in 167 out of 263 cases (63.5%) and any left-sided involvement in 115 out of 263 cases (43.7%). The tricuspid valve (TV) alone was affected in 135 cases (51.3%), the mitral valve alone in 32 patients (12.1%), the aortic valve alone in 41 cases (15.6%) and the pulmonic valve alone in 3 cases. Staphylococcus aureus was isolated in 156 cases (59.3%) and Streptococcus spp. in 33 cases (12.5%). No major differences were observed between HIV-negative and HIV-positive patients. Any TV valve involvement was significantly associated with female rather than male gender (p = 0.02). There was a significant association between S. aureus etiology and TV involvement (p < 0.0001). The mortality rate was 16%. On multivariate analysis, only left-side IE (p = 0.0006; OR 5.2; 95% CI 2.0-13.5) and age greater than 35 years (p = 0.0068; OR 3.6; 95% CI 1.4-9.0) were independently associated with mortality., Conclusions: Infective endocarditis in IDUs is significantly associated with right-side localization (63.5% for any rightsided heart involvement vs 43.7% for any left-sided heart involvement; OR 2.24; 95% CI 1.55-3.23; p < 0.001). S. aureus is the microorganism most frequently isolated and is significantly associated with TV involvement. Any left-side involvement and age greater than 35 years are independently associated with mortality. HIV infection does not appear to have a significant effect on mortality.

Significant advances have been made in the management of infective endocarditis with the advent of antimicrobial therapy, surgery and transesophageal echocardiography, bringing hope to patients suffering from this once uniformly fatal illness. However, recent studies show that the mortality from infective endocarditis is still in the order of 20-30%. The prognostic determinants for adverse outcomes and the indications for surgical therapy in patients with infective endocarditis have recently received renewed attention. Our current understanding of these controversial issues will be reviewed in this paper.

Streptococcus gordonii alpha-phosphoglucomutase, which converts glucose 6-phosphate to glucose 1-phosphate, is encoded by pgm. The pgm transcript is monocistronic and is initiated from a sigma(A)-like promoter. Mutants with a gene disruption in pgm exhibited an altered cell wall muropeptide pattern and a lower teichoic acid content, and had reduced fitness both in vitro and in vivo. In vitro, the reduced fitness included reduced growth, reduced viability in the stationary phase and increased autolytic activity. In vivo, the pgm-deficient strain had a lower virulence in a rat model of experimental endocarditis.

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.

The purpose of the study was to determine peculiarities of the clinico-morphological picture of modern infective endocarditis (IE). The authors generalize the results of 100 morphological studies of acute and subacute IE (AIE and SAIE) within the last 20 years (1985--2005). AIE and SAIE had developed in 52% and 35% of cases, respectively, after operations, medical manipulations and examinations. The development of secondary AIE was favored by congenital heart defects and mitral valvular (MV) prolapse, while secondary SAIE developed in patients with congenital heart defects as well as atherosclerotic and rheumatic heart defects. The feature of contemporary IE is the prevalence of primary clinico-morphological form with isolated aortal valvular (A V) lesion. Morphological changes in organs formed as a result of multiple septic embolism, immunocomplex lesion, panarteritis, and cardiac insufficiency. The occurrence and progress of the latter was caused by prominent AV and MV insufficiency (during several weeks in patients with AIE and several months in SAIE), myocarditis, pericarditis, myocardial dystrophy, and cardiosclerosis.

Background: Previous studies described infective endocarditis (IE) in the era before highly active antiretroviral therapy (HAART); however, IE has not been well studied in the current HAART era. We evaluated the incidence of, risk factors for, clinical presentation, and 1-year outcomes of IE in HIV-infected patients., Methods: We evaluated all cases of IE diagnosed between 1990 and 2002 in patients followed at the Johns Hopkins Hospital outpatient HIV clinic. To identify factors associated with IE in the current era of HAART, a nested case-control analysis was employed for all initial episodes of IE occurring between 1996 and 2002. Logistic regression analyses were used to assess risk factors for IE and factors associated with 1-year mortality., Results: IE incidence decreased from 20.5 to 6.6 per 1000 person-years (PY) between 1990 and 1995 and 1996 and 2002. The majority of IE cases were male (66%), African American (90%), and injection drug users (IDUs) (85%). In multivariate regression, an increased risk of IE occurred in IDUs (AOR, 8.71), those with CD4 counts <50 cells/mm, and those with HIV-1 RNA >100,000 copies/mL (AOR, 3.88). Common presenting symptoms included fever (62%), chills (31%), and shortness of breath (26%). The most common etiologic organism was Staphylococcus aureus (69%; of these 11 [28%] were methicillin resistant). Within 1 year, 16% had IE recurrence, and 52% died. Age over 40 years was associated with increased mortality., Conclusions: IE rates have decreased in the current HAART era. IDUs and those with advanced immunosuppression are more likely to develop IE. In addition, there is significant morbidity and 1-year mortality in HIV-infected patients with IE, indicating the need for more aggressive follow-up, especially in those over 40 years of age. Future studies investigating the utility of IE prophylaxis in HIV patients with a history of IE may be warranted.

Background: Intracranial mycotic aneurysms, although rare neurovascular pathology, represented a neurosurgical challenge that required careful stepwise decision making. Different approaches for their management were used. We present our experience with 4 patients treated in terms of indications and efficacy of different treatment modalities., Methods: Four patients with infective endocarditis and 5 intracranial mycotic aneurysms were treated during the last 5 years. All of the patients were men; their ages ranged between 29 and 62 years (mean, 47.3 years). Distal MCA was the commonest site (3 patients) of aneurysm, 1 was located at the distal PCA, whereas the remaining aneurysm was at the distal ACA. Angiographic studies were done in 2 patients because of neurologic signs and for screening in 2 patients with documented endocarditis., Results: One patient was treated conservatively because of his moribund general condition; 1 patient was treated with direct surgical clipping; 1 patient was treated with surgical trapping and resection of the aneurysm without revascularization; and the remaining patient, harboring 2 distal mycotic aneurysms, was treated with selective embolization for his PCA aneurysm and endovascular trapping for the distal ACA aneurysm. Follow-up angiographic results showed stable occlusion of the aneurysms. No periprocedural technical complications were reported, and none of the patients, including the patient with medical treatment only, has ever experienced new neurologic events after definitive treatment., Conclusions: Prolonged courses of antibiotics are recommended for all patients with mycotic aneurysms. Selective endovascular embolization or trapping with soft and ultrasoft electrolytically detachable coils seems to be an effective technique that should be considered for treatment of dynamic unruptured mycotic aneurysms, with conventional surgical repair restricted for ruptured aneurysms with associated hematoma and high intracranial pressure.

Brucella endocarditis is a zoonosis transmitted by contaminated dairy products. Endocarditis is a rare complication of brucellosis and mainly the aortic valve is infected. We present the case of a female patient with prosthetic mitral valve endocarditis associated with QT prolongation and torsades de pointes. Transesophageal echocardiography revealed vegetation on both anterior and posterior mitral annulus. She was seropositive with Brucella agglutination titers of up to 1/320. The QT interval was markedly prolonged upon admission (QTc 530 ms). She experienced torsades de pointes several times. She underwent reoperation under an appropriate antibiotic regimen. She continued on triple antibiotic therapy for 12 months. She is now well and free of symptoms.

Background: Infective endocarditis is a diagnostic and therapeutic challenge that ultimately requires surgical intervention in 20% of all cases. Early determinants of morbidity and mortality in this high risk population are not well described., Methods: The aim of this study was to determine preoperative clinical, microbiological, electrocardiographic, and echocardiographic variables that predicted the need for permanent pacemaker implantation and in-hospital death in a surgical cohort of patients with active infective endocarditis., Results: We identified 91 patients (61 males and 30 females, mean age 58 +/- 16 years) who underwent surgical intervention for active culture-positive infective endocarditis as defined by the Duke criteria. Native valve infective endocarditis was present in 78 (85.7%) and prosthetic valve endocarditis in 13 (14.3%) of cases. The aortic valve was infected in 61 (67.0%), the mitral in 35 (38.5%), and multiple valves in 8 patients (8.8%). The most common indication for surgical intervention was intractable heart failure. Twenty-two patients (24.2%) required pacemakers, while there were 14 (15.4%) in-hospital deaths. In age-adjusted and gender-adjusted analyses, the presence of left bundle branch block on preoperative electrocardiogram (ECG) and presence of depressed left ventricular systolic function (ejection fraction [EF] < 50%) predicted the need for a permanent pacemaker implantation, while the presence of depressed left ventricular function predicted in-hospital mortality., Conclusions: Preoperative ECG findings of left bundle branch block and reduced left ventricular function may allow for early risk stratification of this high risk population.

Background: The causes of aortic regurgitation (AR) severe enough to warrant aortic valve replacement (AVR) have received little attention in the last 20 years., Methods and Results: We analyzed the causes of pure AR in 268 patients > 20 years of age having isolated AVR at Baylor University Medical Center from 1993 to 2005 that was unassociated with mitral stenosis, mitral valve replacement, or a previous operation involving a cardiac valve or ascending aorta. In 122 patients (46%), the AR resulted from a problem with the aortic valve: congenital malformation unassociated with infective endocarditis, 66 patients (54%); infective endocarditis, 46 patients (38%; 15 with bicuspid valves); probable rheumatic heart disease, 8 patients (6%); and miscellaneous, 2 patients (2%). In the other 146 patients (54%), the AR was the consequence of a condition affecting the ascending aorta: dissection, 28 patients (19%); the Marfan syndrome or its forme fruste variety, 15 patients (10%); aortitis, 12 patients (8%), and in the remaining 91 patients (62%), the cause of the AR was not determined. This latter group was the oldest (mean age 66 years), 83 (91%) had hypertension, 26 (29%) had small calcific deposits in the valve cusps, and 46 (51%) had simultaneous coronary artery bypass grafting., Conclusions: The causes of pure AR severe enough to warrant isolated AVR are diverse. The most common category in this study was "cause unclear."

In recent years, the frequency of serious cardiovascular infections such as endocarditis has increased, particularly in association with nosocomially acquired antibiotic-resistant pathogens. Growing evidence suggests a crucial role for the interaction of bacteria with human platelets in the pathogenesis of cardiovascular infections. Here, we review the nature of the interactions between platelets and bacteria, and the role of these interactions in the pathogenesis of endocarditis and other cardiovascular diseases.

Background: The clinical manifestations of Q fever endocarditis are protean in nature. Mixed cryoglobulinemia type II is rarely a facet of the presenting clinical manifestations of Q fever endocarditis., Case Presentation: We report a case of a 65-year-old pensioner with such an association and review the literature. As transesophageal echocardiograms are usually normal and blood cultures are usually negative in Q fever endocarditis, many of the manifestations (fever, rash, glomerulonephritis/evidence of renal disease, low serum C4 complement component, presence of mixed type II cryoglobulin, constitutional symptoms as arthralgias and fatigue) can be attributed to Mixed cryoglobulinemia type II per se. The use of Classic Duke Endocarditis Service criteria does not always suffice for the diagnosis of Q fever., Conclusion: The application of the modified criteria proposed by Fournier et al for the improvement of the diagnosis of Q fever endocarditis will help to reach the diagnosis earlier and thus reduce the high mortality of the disease. We would like to stress the importance of ruling out the diagnosis of Q fever endocarditis in cases of mixed type II cryoglobulinemia.

Body piercing in young adults is on the rise in western countries and also in Korea. It is usually practised by non-medical persons, and therefore frequently entails local adverse events. Serious complications, such as septic arthritis or infective endocarditis, are occasionally reported, but infective endocarditis in patients with normal cardiac valve is rare. We experienced a case of acute S. aureus endocarditis after ear piercing. Thereafter we studied the status and complications of body piercing in college students of Korea based on a questionnaire survey, and revealed that the rate of ear piercing is high (96.5%) and 61.3% of the pierced persons experience local complications.

Infective endocarditis in association with spondylodiscitis is rarely observed. It is sometimes difficult to distinguish between rheumatologic diseases and infective endocarditis. We reported a 61-year-old male with Streptococcus viridans endocarditis suffering from low-back pain as initial symptom. Infective endocarditis was diagnosed according to Duke Criteria. L4-5 spondylodiscitis was revealed on the lumbar magnetic resonance imaging. He responded to antibiotic treatment. Infective endocarditis should be considered in patients with fever and low-back pain due to spondylodiscitis.

Introduction: Infective endocarditis (IE) is an ongoing challenge in terms of excess morbidity and mortality. Neurologic complications occur in 20-40% of patients, and the brain is the main location of IE extracardiac complications., Aim: To analyse clinical characteristics of the neurologic complications found in patients with IE, focused on the diagnostic and prognostic aspects., Patients and Methods: We studied retrospectively the cases of patients with IE admitted to the Hospital de Valme and Hospital de la Merced between 1998 and 2003. Laterly, patients with and without neurologic manifestations were compared. Sixty episodes of IE were evaluated., Results: Neurological complications occurred in 12 patients (20%). The most frequent neurologic manifestation was unilateral hemi paresis, which occurred in seven cases (58.3%), three cases with acute confusional state (25%) and two patients developed meningitis (16.6%). Brain infarction was the most common lesion found in neuroimaging, in 6 patients (50%), followed by 2 cases (16.6%) of brain hemorrhage, and without significant findings in the cases left. Cases with neurologic complications had significantly higher mortality (p < 0.001) and higher frequency of negative blood culture (p < 0.001)., Conclusions: Neurologic complications of IE are frequent during the evolution of the disease, and they still constitute a significant problem in clinical practice because they often are not accurately diagnosed and significantly increase patients' mortality.

This study sought to determine the antimicrobial susceptibility of Staphylcoccus aureus and viridans group streptococci strains collected from the forearm skin and saliva of 30 patients at high risk of endocarditis. Agar susceptibility tests of antibiotics routinely utilized in dentistry were used to verify antimicrobial resistance of bacterial strains. Of the Staphylcoccus aureus strains, 50% were resistant to ampicillin, 53.3% to amoxicillin, 60.0% to penicillin G, 13.3% to amoxicillin/clavulanate, 20.0% to azithromycin, 27.6% to clarithromycin, 23.3% to erythromycin, 3.3% to cefazolin, and 6.7% to clindamycin. Regarding streptococci, 16.7% of the strains were resistant to ampicillin, 16.7% to amoxicillin, 23.3% to azithromycin, 23.3% to clarithromycin, 30.0% to erythromycin, 13.3% to cefazolin, 26.7% to clindamycin, 16.7% to penicillin G, and 3.3% to amoxicillin/clavulanate. Pathogens associated with bacterial endocarditis exhibited elevated resistance rates against the antibiotics used for prophylaxis in dentistry.

Enterococcal prosthetic valve infective endocarditis (PVE) is an incompletely understood disease. In the present study, patients with enterococcal PVE were compared to patients with enterococcal native valve endocarditis (NVE) and other types of PVE to determine differences in basic clinical characteristics and outcomes using a large multicenter, international database of patients with definite endocarditis. Forty-five of 159 (29%) cases of definite enterococcal endocarditis were PVE. Patients with enterococcal PVE were demographically similar to patients with enterococcal NVE but had more intracardiac abscesses (20% vs. 6%; p=0.009), fewer valve vegetations (51% vs. 79%; p<0.001), and fewer cases of new valvular regurgitation (12% vs. 45%; p=0.01). Patients with either enterococcal PVE or NVE were elderly (median age, 73 vs. 69; p=0.06). Rates of in-hospital mortality, surgical intervention, heart failure, peripheral embolization, and stroke were similar in both groups. Patients with enterococcal PVE were also demographically similar to patients with other types of PVE, but mortality may be lower (14% vs. 26%; p=0.08). Notably, 93% of patients with enterococcal PVE came from European centers, as compared with only 79% of patients with enterococcal NVE (p=0.03). Thus, patients with enterococcal PVE have higher rates of myocardial abscess formation and lower rates of new regurgitation compared to patients with enterococcal NVE, but there are no differences between the groups with regard to surgical or mortality rates. In contrast, though patients with enterococcal PVE and patients with other types of PVE share similar characteristics, mortality is higher in the latter group. Importantly, the prevalence of enterococcal PVE was higher in the European centers in this study.

Objectives: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens., Design: Cohort study., Methods: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133)., Results: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality., Conclusions: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Background: Although a high number of patients with congenital heart disease (CHD) undergo surgical palliation or definite correction up to adolescence, adult congenital heart disease (ACHD) may remain a potential lifelong risk factor for infective endocarditis (IE) in patients growing up with congenital heart disease (GUCH)., Methods: In a retrospective case study of a tertiary care center long-term clinical course and complications of patients with IE and GUCH were analysed., Results: Data of 52 patients with CHD, who fulfilled the Saiman criteria for infective endocarditis and were treated between April 1986 and March 2001, were identified: Risk factors for infective endocarditis were previous cardiovascular operation (51.9%), use of foreign material (38.5%), dental or other surgical procedures without recommended antibiotic prophylaxis (25.0%), or cardiac catheterization (5.8%). Staphylococcal (38.9%) or streptococcal species (35.2%) were cultivated in most cases as causative microorganisms. Complications were: recurrence of IE (7.7%), septic embolisms (30.8%) leading to central nervous complications (7.7%), embolism of pulmonary arteries (7.7%), renal arteries (1.9%), arteries of the extremities (9.6%), or infarction of spleen (1.9%). Other cardiac (23.1%) or extracardiac (13.5%) complications were frequent. The need of re-operations during or after IE was high (67.3%). The hospital mortality was 1.9%, late mortality was 7.7%., Conclusions: Patients with IE and CHD show a broad clinical spectrum of cardiac and extracardiac complications. They may lead to a complicative short- and long-term course with the potential risk of death and a high number of re-operation. Efforts have to be made to improve long-term outcome of patients with ACHD by an interdisciplinary cooperation.

The jet lesions of valvular regurgitation or intracardiac shunts have been hypothesized to play an important role in the pathogenesis of endocarditis for many years. We describe a case of mitral valve endocarditis that involved the left atrium along the path of a jet lesion. This resulted in atrial endocarditis and pericarditis, both of which complicated her presentation and hospital course. Using transesophageal echocardiography, we were able to directly visualize the path and full extent of infection prior to surgery. Special attention should be focused upon the path of eccentric jets in order to fully define the extent of endocarditis.

Haemophilus species are an infrequent cause of subacute bacterial endocarditis. Of the Haemophilus species causing endocarditis, H. aphrophilus and H. parainfluenzae are more frequent causes of subacute bacterial endocarditis than H. influenzae. H. parainfluenzae requires growth factor V (nicotinamide adenine dinucleotide) and grows very slowly on routine culture media. H. parainfluenzae is a rare cause of "culture negative" endocarditis because it is a slow-growing organism. We present a case of a 42-year-old intravenous drug abuser with H. parainfluenzae mitral prosthetic valve endocarditis. To the best of our knowledge, this is the first case of mitral prosthetic valve endocarditis caused by H. parainfluenzae in an intravenous drug abuser.

Aims: We aimed to compare the clinical and echocardiographic correlates of chordal rupture in patients with rheumatic mitral valve disease and floppy mitral valve., Methods and Results: The study group comprised of 224 patients who underwent transthoracic and transesophageal echocardiography because of the severe mitral regurgitation. Chordal rupture was detected in 58 (25.9%) out of the 224 patients, in 33 out of the 83 (39.7%) patients with floppy mitral valve, and in 25 out of the 141 (17.7%) patients with rheumatic mitral valve disease. Chordal rupture was more frequently associated with anterior leaflet (80%) in patients with rheumatic mitral valve disease, and posterior leaflet (72.7%) in patients with floppy mitral valve (p<0.05). Univariate correlates of chordal rupture were age, male sex, posterior mitral leaflet thickening and chordal elongation in patients with floppy mitral valve (p<0.05), and chordal shortening (p<0.0001) and infective endocarditis involving mitral anterior leaflet (p<0.05) in rheumatic group. Independent predictors of chordal rupture were age (>50 years), posterior mitral leaflet thickness (> or =0.45cm), and male sex (p<0.05) in patients with floppy mitral valve while infective endocarditis involving mitral anterior leaflet (p<0.05) in patients with rheumatic mitral valve disease. Patients with chordal rupture due to floppy mitral valve had an older age (p<0.0001), a male dominance, longer mitral leaflets and chordae, and a larger mitral annulus circumference (p<0.05) as compared to those with rheumatic chordal rupture. Despite the comparable severity of mitral regurgitation and left atrial diameters between the two groups of chordal rupture (p>0.05), functional class and pulmonary artery systolic pressure were higher, and atrial fibrillation, acute deterioration, infective endocarditis, mitral leaflet rupture and need for mitral valve surgery in the 3 months were more frequent in rheumatic chordal rupture subgroup (p<0.05)., Conclusion: Chordal rupture seems to be more frequently associated with anterior mitral leaflet in rheumatic mitral valve disease, whereas it was the posterior leaflet in floppy mitral valve. Chordal rupture was related to male sex, older age, posterior leaflet thickening, and chordal elongation in patients with floppy mitral valve. However, infective endocarditis, acute deterioration, and need for early mitral surgery were more frequent in patients with rheumatic chordal rupture.

Objective: Mortality in active infective endocarditis (AIE) is substantial and reinfection can strongly influence outcome. Assessment of factors influencing mortality is important. We studied 108 (33%) patients suffering from root abscess out of a total of 327 AIE patients admitted to the Deutsches Herzzentrum Berlin for surgical treatment between 1996 and 2003. Among them were 53 (25.5% of all patients) who were diagnosed as having secondary infective mitral valve disease (SMVD). Mean age was 53+/-14.2 years; there were 37 men and 16 women., Methods: Risk factors were assessed on the basis of clinical, hemodynamic, echocardiographic and surgical information. Mean follow-up was 325+/-251 days with complete echocardiographic examination performed in patients with double valve surgery. The differences between groups were analyzed using Student's t-test. Multivariate analysis for the whole group suffering from abscess was performed to identify independent factors influencing mortality., Results: In 19 (35.8%) patients suffering from SMVD mitral valve reconstruction was undertaken and mitral valve replacement was performed in 34 (64.2%) patients. There were 27 patients treated with a Shelhigh prosthesis: 18 with double valve replacement (both Shelhigh) and nine with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral reconstruction in 10 and a stented mitral prosthesis in seven. In nine cases two stented valve prostheses were used. The calculated mean Doppler gradient for homografts and Shelhigh in aortic position was 12 (+/-5.7) and 15 (+/-4.6), respectively (NS). The following predisposing factors for mortality were assessed: severe damage of aortic annulus (OR 4.65, CI 1.22-17.1, P=0.0159); septic shock (OR 3.44, CI 0.85-13.9, P=0.07) and poor ejection fraction (<40%), and dilated LV., Conclusions: Excessive mortality reaching 29% was noted in patients suffering from AIE with aortic ring abscess and SMVD requiring double valve surgery. Double valve surgery with semi-stented Dacron-free valve prostheses is associated with a low rate of reinfection and good function of the implants. The most potent independent risk factors for death were septic shock and severe aortic root destruction.

Pacemaker infection with Mycobacterium fortuitum has not been reported previously. We describe a case of pacemaker generator pocket infection and intravascular lead endocarditis due to Mycobacterium fortuitum. The entire pacing system was removed and the patient was treated successfully with a multidrug regimen for a total of 6 months.

Botryomycosis is a rare bacterial infection of the skin and, rarely, viscera that is characterized by the formation of characteristic hyaline grains. We encountered a patient with Erysipelothrix rhusiopathiae endocarditis who developed visceral botryomycosis. He was a 54-year-old black man who presented in sepsis with a history of progressive weakness and severe weight loss. He died 10 hours after admission. At autopsy, endocarditis was identified, along with infarcts of the spleen and kidneys. Microscopically, visceral botryomycosis was seen. With these bacteria, an animal source is usually identified, although one was not found in this man. Erysipelothrix rhusiopathiae is an organism that is becoming identified in a range of infections in humans, the manifestations and pathophysiology of which are still being discovered.

Therapeutic options for invasive Staphylococcus aureus infections have become limited due to rising antimicrobial resistance, making relevant animal model testing of new candidate agents more crucial than ever. In the present studies, a rat model of aortic infective endocarditis (IE) caused by a bioluminescently engineered, biofilm-positive S. aureus strain was used to evaluate real-time antibiotic efficacy directly. This strain was vancomycin and cefazolin susceptible but gentamicin resistant. Bioluminescence was detected and quantified daily in antibiotic-treated and control animals with IE, using a highly sensitive in vivo imaging system (IVIS). Persistent and increasing cardiac bioluminescent signals (BLS) were observed in untreated animals. Three days of vancomycin therapy caused significant reductions in both cardiac BLS (>10-fold versus control) and S. aureus densities in cardiac vegetations (P < 0.005 versus control). However, 3 days after discontinuation of vancomycin therapy, a greater than threefold increase in cardiac BLS was observed, indicating relapsing IE (which was confirmed by quantitative culture). Cefazolin resulted in modest decreases in cardiac BLS and bacterial densities. These microbiologic and cardiac BLS differences during therapy correlated with a longer time-above-MIC for vancomycin (>12 h) than for cefazolin ( approximately 4 h). Gentamicin caused neither a reduction in cardiac S. aureus densities nor a reduction in BLS. There were significant correlations between cardiac BLS and S. aureus densities in vegetations in all treatment groups. These data suggest that bioluminescent imaging provides a substantial advance in the real-time monitoring of the efficacy of therapy of invasive S. aureus infections in live animals.

Infective endocarditis (IE) remains a disease associated with high morbidity and mortality rates. In this pilot study, the role of troponin I in IE was assessed. Myocardial involvement distal to the site of infection in IE has been previously described. Elevated troponin was demonstrated in 11 of 15 patients diagnosed with the condition. Patients diagnosed with staphylococcal endocarditis were more likely to have elevated troponin (3 of 3 patients). Patients with elevated troponin I were not more likely to need valve replacement. Troponin I levels did not predict perivalvular extension. It is hypothesized that elevated troponin I is a reflection of myocardial involvement.

Eleven isolates of Enterococcus faecalis causing endocarditis were screened for possible virulence factors with PCR and phenotypic assays. The gene coding for the enterococcal surface protein (esp) was detected in one isolate only, and haemolysin was produced by two isolates. Aggregation substance, biofilm formation and gelatinase were present in seven, nine and eight isolates, respectively. Predisposing factors, particularly hospitalisation and multiple antibiotic therapy, appeared to be more relevant to the development of enterococcal endocarditis following bloodstream infections than the pattern of virulence factors.

Endocarditis due to Streptococcus pneumoniae is unusual in children, accounting for 3%-7% of all cases of childhood endocarditis. The US Pediatric Multicenter Pneumococcal Surveillance Group has prospectively identified patients with invasive disease at 8 children's hospitals. During the period of 1 September 1993 through 28 February 2003, a total of 11 children with pneumococcal endocarditis were seen. Seven (64%) were 3-36 months old; 8 (73%) were boys. Ten (91%) had preexisting structural heart disease; 5 had undergone previous heart surgery. Concomitant sites of infection were noted in 6 patients (55%), including 3 patients with meningitis. One patient (9%) died during hospitalization, and 5 others (45%) experienced serious complications. Only 2 patients remained hospitalized for their entire course of parenteral antibiotic therapy. Eight of 10 pneumococcal isolates tested were vaccine or vaccine-related serotypes included in the currently licensed 7-valent conjugated pneumococcal vaccine. Pneumococcal endocarditis in children is unusual but often has serious complications.

Objectives: Infective endocarditis is common and data regarding its pattern and outcome from developing countries is sparse. We therefore examined the spectrum, demographics and clinical features of infective endocarditis and sought to determine the factors affecting its clinical outcome., Patients and Methods: Over a five-year period at our university hospital in Karachi, Pakistan, we identified 66 patients with infective endocarditis and compared their clinicoepidemiologic features and outcomes to subjects in the West., Results: The male:female ratio was 2:1; overall median age was 24 years (35.5 years for men and 13.5 years for women) (p < 0.001). Median duration of symptoms before presentation was 20.5 days. Major predisposing cardiac abnormalities included congenital (50%) and rheumatic (23%) lesions, and a history of heart surgery (17%). Causative organisms and valvular sites of infection were similar to those seen in developed countries. Blood culture-negative infective endocarditis was found in 48% of cases. Renal failure was more frequent among culture-positive patients (p = 0.055). Risk factors for mortality included neurologic (p = 0.003) and embolic (p = 0.02) complications, renal (p = 0.03) and left ventricular failure (p = 0.002), and a history of cardiac surgery (p = 0.026). Overall mortality was 27%., Conclusions: Patients with infective endocarditis in Pakistan exhibit significant differences compared to their counterparts in the West, including younger age at presentation, incidence of predisposing cardiac conditions, and gender differences reflecting sociocultural bias. Neurologic and embolic complications, renal failure and heart failure predict a worse outcome.

The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade. There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year. Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months. Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia. IE occurs in approximately 2% to 6% of patients receiving HD. The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

Hospital-acquired infective endocarditis (IE) is a growing health-care problem. Hospital-acquired IE, according to the commonly used definition, is IE manifesting > or =72 h after admission to the hospital or within several weeks after a hospital-based invasive procedure. To assess the validity of this definition, we evaluated 87 episodes of IE, with special attention to recent hospitalizations. The incidence rate of IE in the 6-month period after discharge from the hospital was 27 cases per 100,000 person-years, compared with 1.1 cases per 100,000 person-years in a population with no recent hospitalizations. Furthermore, episodes of IE manifesting during this 6-month period were notable for a high proportion of typically hospital-acquired pathogens (26% vs. 0%; P=.001) and a low proportion of viridans streptococci (0% vs. 36%; P<.001), compared with community-acquired episodes that did not involve recent hospitalization. We conclude that characteristics of hospital-acquired IE extend to episodes arising within 6 months after discharge from the hospital and suggest that the definition of hospital-acquired IE be broadened to include these episodes.

Background: Inflammation-induced procoagulant changes and alterations in platelet activity appear to play an important role in thromboembolic complications of infective endocarditis (IE)., Hypothesis: The aim of this study was to investigate systemic coagulation activity, fibrinolytic capacity, and platelet activation in patients with IE with and without embolic events by measuring the plasma levels of prothrombin fragment 1+2 (PF1+2), thrombin-antithrombin III complex (TAT), plasminogen activator inhibitor-1 (PAI-1), beta-thromboglobulin (beta-TG), and platelet factor 4 (PF4), respectively., Methods: The study included 76 consecutive patients (female = 55, male = 21, mean age 26 years, range 8-64 years) with definite IE according to the Duke criteria; of these, 13 (17.1%) had embolic events., Results: Plasma concentrations of PF1+2 (3.2 +/- 1.3 vs. 1.7 +/- 0.7 and 1.4 +/- 0.7 nmol/l, p < 0.001, respectively) and TAT (7.3 +/- 1.5 vs. 2.9 +/- 1.2 and 2.2 +/- 1.1 ng/ml, p < 0.001, respectively) were elevated in patients with embolic events compared with patients without embolic events and control subjects. Similarly, patients with embolic events had increased plasma levels of beta-TG (63.3 +/- 10.9 vs. 33.1 +/- 11.6 and 19.1 +/- 10.6 ng/ml, p < 0.001, respectively) and PF4 (106.0 +/- 28.7 vs. 50.3 +/- 16.7 and 43.0 +/- 15.8 ng/ml, p < 0.001, respectively) compared with those without embolic events and the control group. Embolic patients also had higher PAI-1 levels than nonembolic patients and healthy subjects (14.4 +/- 6.4 vs. 8.6 +/- 5.9 and 5.4 +/- 4.3 ng/ml, p = 0.002, respectively)., Conclusion: Patients with IE and with subsequent thromboembolism have increased systemic coagulation activation, enhanced platelet activity/damage, and impaired fibrinolysis. The resulting imbalance produces a sustained hypercoagulable state, which contributes to the increased risk of thromboembolic events in this particular group.

We report the results of a prospective, multicenter trial assessing intravenous and oral clinafloxacin treatment for infective endocarditis. Sixty-six patients constituted the final study population. Among the 53 patients with native valve infection, Staphylococcus aureus and Streptococcus viridans were the most common pathogens. Twelve patients with native valve infection required surgery, at which time all valve tissue culture results were negative. The overall success rate for native valve infection was 87%. Single valves were involved in 11 of 13 patients with prosthetic valve endocarditis (PVE), and multiple valves were involved in 2 cases. Enterococcus faecalis was the most common pathogen, causing 4 of the PVE cases. The overall success rate for treatment of PVE was 69%. Patients with PVE who did not respond to treatment presented with complications that predict poor prognosis. Clinafloxacin may be effective for both native and PVE, but further studies are indicated.

Among the bacteria of the HACEK group, Actinobacillus actinomycetemcomitans is the organism involved most commonly in infective endocarditis. However, the epidemiological and clinical features specifically associated with this species have not been evaluated adequately. Three patients with infective endocarditis caused by A. actinomycetemcomitans seen at the Hospital La Timone (Marseille, France) between 1994 and 2001 are reported. Of 99 cases in the literature, 75% of patients had previous heart disease before infective endocarditis, the portal of entry of which was usually the oral cavity. Among the total of 102 cases, 27 had prosthetic valves. Intermittent fever was observed in all cases, and weight loss and peripheral signs of endocarditis were noteworthy in this study. Anaemia and microscopic haematuria were frequently noted. The disease is insidious, with a mean duration of symptoms of 13 weeks before diagnosis, as confirmed by blood cultures incubated for > 5 days. The aortic valve is most commonly involved, and echocardiographic findings were non-specific. Complications occurred in 63% of patients, with emboli being the most common. The surgery rate was 23.5%. The overall mortality rate was 18%. Of the cases, 76.5% were cured with antibiotics alone, including a simple third-generation cephalosporin or a combination of ampicillin and an aminoglycoside. An antibiotic therapy duration of at least 4 weeks is recommended. Surgical therapy is usually required for haemodynamic reasons. Prophylaxis of A. actinomycetemcomitans endocarditis relies on antibiotic therapy for all cardiac patients at risk before dental procedures. Among 17 patients undergoing dental manipulations, only eight received amoxycillin before the procedure, demonstrating that prophylaxis is far from being systematically prescribed. In conclusion, A. actinomycetemcomitans endocarditis should be highly suspected in patients with previous cardiac disease and for whom symptoms have evolved over a number of weeks or even months.

We describe a rare case of Enterococcus avium endocarditis in a patient with an ovarian malignancy, and review 2 previously reported cases. We contend that Enterococcus avium bacteremia and endocarditis may be associated with gastrointestinal pathology.

Operations were performed on 183 patients with infective endocarditis and injury of the valve apparatus of the heart. Duration of the disease was from 5 weeks to 9 years. Insufficiency of circulation of the III-IV functional class was noted in 92% of the patients. High activity of the infective process observed in 30% of the patients by the moment of operation did not influence the results of surgical treatment. Postoperative lethality was 7.6%.