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Enterobacter species are Gram-negative, non-spore-forming, facultative anaerobes typically motile due to the presence of peritrichous flagella. E. cloacae, the species responsible for the majority of Enterobacter infections in humans, is part of the intestinal microbiota and may cause infection in patients that have previously received antimicrobial therapy or who have been admitted to the Intensive Care Unit. E. cloacae may cause several infections, such as pneumonia, urinary tract, skin and soft tissue and intravascular infections. Infective Endocarditis (IE) is a rare disease with notable morbidity and mortality. Even though IE is rarely caused by E. cloacae , these infections can be problematic due to the relative lack of experience in their management. The purpose of this study was to systematically review all published cases of IE by E. cloacae in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 14 th November 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by E. cloacae was performed. A total of 20 studies, containing data of 20 patients, were included. A prosthetic valve was present in 27.8%. Mitral valve was the commonest infected site, followed by aortic valve. Diagnosis was facilitated by transthoracic and transesophageal echocardiography in 38.5% each, while the diagnosis was set at autopsy in 10%. Fever, sepsis, shock and immunologic phenomena were the most common clinical presentations, followed by heart failure. Aminoglycosides, cephalosporins and carbapenems were the most common antimicrobials used. Clinical cure was noted in 75%, while overall mortality was 30%. Development of shock and treatment with the combination of piperacillin with tazobactam were associated with overall mortality.

This study aimed to systematically analyze all cases of infective endocarditis (IE) by Klebsiella species in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 27 th January 2021) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by Klebsiella species was performed. In this review, a total of 66 studies were included, providing data for 67 patients. A prosthetic valve was present in 16.4%, while the most common causative pathogen was K. pneumoniae followed by K. oxytoca . The aortic valve was the most commonly infected intracardiac site, followed by the mitral valve. The diagnosis was based on transthoracic echocardiography in 46.2%, while the diagnosis was set at autopsy in 9.2% of included patients. Blood cultures were positive in 93.8%. Fever and sepsis were the most frequent clinical presentations, followed by embolic phenomena, paravalvular abscess, and heart failure. Cephalosporins, aminoglycosides, and carbapenems were the most frequently used antimicrobials. Surgical treatment along with antimicrobials was performed in 37.3% of included patients. Clinical cure was noted in 80.3%, while the overall mortality was 19.4%. Infection at the aortic valve was independently associated with mortality by IE. This systematic review gives a comprehensive description of IE by Klebsiella and provides information on epidemiology, clinical manifestations, therapeutic strategies and their outcomes.

Infective endocarditis (IE) is a life-threatening disease, mostly caused by gram-positive cocci, needing a 4-6 weeks antibiotic course. Dalbavancin is a lipoglycopeptide active on gram-positive microorganisms, with a unique pharmacokinetic profile. We describe our experience with dalbavancin to complete the intravenous antibiotic regimen for difficult-to-treat IE cases due to gram-positive bacteria. We treated 10 severely ill patients, each presenting several comorbidities. Seven patients were microbiologically cured from IE, but two patients experienced IE relapse due to the same microrganism. Short-term mortality after dalbavancin was nil, but late mortality (within 1 year of hospital discharge) was 60%. No death was related to dalbavancin therapy. Treatment was generally well tolerated. Dalbavancin may be an option to complete IE treatment in selected cases, once blood culture clearance and improvement of clinical conditions under standard therapy is reached, allowing shortening of hospitalization.

A. baumannii - A. calcoaceticus complex infections are increasingly frequent, especially in intensive care units. Such infections are associated with a mortality that can be as high as 62%. On the other hand, infective endocarditis (IE) is an uncommon disease with notable morbidity and mortality. Even though IE is rarely caused by Acinetobacter species, these infections can be particularly problematic due to increasing antimicrobial resistance. The purpose of this study was to systemically review all published cases of IE by Acinetobacter species in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 25 April 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by Acinetobacter species was performed. A total of 35 studies, containing data of 37 patients, were included. A prosthetic valve was present in 40.5%, while the most common causative pathogen was A. baumannii - A. calcoaceticus complex, followed by A. lwoffii . Aortic valve was the commonest infected site, followed by mitral valve. Diagnosis was set with transthoracic echocardiography in 48.6%, while the diagnosis was set at autopsy in 20%. Fever and sepsis were the commonest clinical presentations, followed by heart failure and embolic phenomena. Aminoglycosides, cephalosporins and carbapenems were the commonest antimicrobials used. Clinical cure was noted in 70.3%, while overall mortality was 32.4%. Development of heart failure was independently associated with mortality by IE. This systematic review thoroughly describes IE by Acinetobacter and provides information on epidemiology, clinical presentation, treatment and outcomes.

It is recognised that infective endocarditis is frequently a challenging diagnosis to make, as it may present with a range of non-specific symptoms. A middle-aged man was admitted with an 8-day history of profuse non-bloody diarrhoea and vomiting. He had no medical history and no identifiable risk factors for infective endocarditis, and so this in combination with the patient's atypical symptoms presented a diagnostic challenge. The patient was eventually diagnosed with a Staphylococcus aureus right-sided infective endocarditis. This case report explores the events which led to this diagnosis and demonstrates a number of unique learning points. It also highlights the importance of maintaining an open mind and being prepared to revise an initial diagnosis in the face of medical uncertainty., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Surgical management of aortic valve endocarditis in high risk patients is controversial and the ideal treatment has not been found yet. We describe a selected series of eight patients treated with rapid-deployment aortic valve prosthesis as a therapeutic solution for minimizing the risks associated with annulus manipulation in case of severe aortic infective endocarditis., Methods: Eight consecutive patients (five men and three women) with a mean age of 74.3±7.2 years, mean logistic EuroSCORE II of 16.0%±0.1%, affected by aortic native (1 patient), or prosthetic valve endocarditis (7 patients), were treated with Edwards Intuity Elite implantation. Hemodynamic performance and infective data were collected pre-, intra-, and postoperatively with a mean follow-up of 2.7±0.7 years., Results: One case of in-hospital mortality was noted. None of the patients had any embolic or infective complication postoperatively. The cardiopulmonary bypass and aortic cross-clamp times were 148.4±41.6 and 90.5±25.3 min, respectively. The postoperative echocardiographic controls indicated a mean transvalvular gradient of 16.7±3.0 mmHg and one case of paravalvular leaks (2 +). Two patients underwent epigastric permanent pacemaker implantation. During the follow-up, seven patients were alive, with no evidence of symptoms or recurrences of endocarditis or embolic episodes. No new paravalvular leaks were noted, and the mean gradient on the valves was 12.4±3.4 mmHg., Conclusions: Rapid deployment aortic valve replacement in selected very high-risk patients affected by infective endocarditis could be a reasonable choice with acceptable results. However, further studies are needed to confirm these results.

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Invasive endocarditis of the aortic and mitral valves with involvement of the intervalvular fibrosa is a particular surgical challenge. We describe a technique for aortic and mitral valve replacement with concomitant reconstruction of the intervalvular fibrosa, utilizing a folded bovine pericardial patch (Commando operation).

Background: Infective endocarditis remains associated with substantial mortality and morbidity rates, and the presence of acute heart failure (AHF) compromises clinical results after valve surgery; however, little is known in cardiogenic shock (CGS) patients. This study evaluated the clinical results and risk of mortality in CGS patients after valve surgery.Methods and Results:This study enrolled 585 patients who underwent valve surgery for active endocarditis at 14 institutions between 2009 and 2017. Of these patients, 69 (12%) were in CGS, which was defined as systolic blood pressure <80 mmHg and severe pulmonary congestion, requiring mechanical ventilation and/or mechanical circulatory support, preoperatively. The predictors of CGS were analyzed, and clinical results of patients with non-CGS AHF (n=215) were evaluated and compared.Staphylococcus aureusinfection (odds ratio [OR] 2.19; P=0.044), double valve involvement (OR 3.37; P=0.003), and larger vegetation (OR 1.05; P=0.036) were risk factors for CGS. Hospital mortality occurred in 27 (13%) non-CGS AHF patients and in 15 (22%) CGS patients (P=0.079). Overall survival at 1 and 5 years in CGS patients was 76% and 69%, respectively, and there were no significant differences in overall survival compared with non-CGS AHF patients (P=1.000)., Conclusions: Clinical results after valve surgery in CGS patients remain challenging; however, mid-term results were equivalent to those of non-CGS AHF patients.

Background/purposes: Infective endocarditis (IE) is an important cause of morbidity and mortality in hemodialysis (HD) patients. Data on the differences in the microbiological features as well as clinical characteristics and outcomes of HD and non-HD patients with IE are limited., Methods: Medical records of patients (aged over 20 years) with IE were retrospectively reviewed from January 2008 to June 2017 in a tertiary care center in Northern Taiwan. Those with definite or possible IE were included in the study. The clinical characteristics, microbiological results, echocardiographic findings and outcomes of patients were analyzed., Results: Of the 183 patients with definite or possible IE, 47 had undergone HD and 136 had not. Advanced age (67.3 vs. 61.5 years, p = 0.027), more female gender (51.1% vs. 33.8%, p = 0.036), comorbidities (a high Charlson comorbidity index, 8.17 vs. 4.21, p < 0.001), diabetes mellitus (68.1% vs. 35.3%, p < 0.001), and hypertension (85.1% vs. 53.7%, p < 0.001) were commonly observed in HD patients than in non-HD patients. The yield rate of the blood cultures was higher in HD group than in non-HD group (89.4% vs. 72.8%, p = 0.02). The proportion of methicillin-resistant Staphylococcus aureus was significantly higher in HD group than in non-HD group (31.9% vs. 5.9%, p < 0.001). HD patients versus non-HD patients had higher cardiac complication rates (38.3% vs. 14%, p < 0.001)., Conclusion: Advanced age, sex (female), comorbidities, diabetes mellitus, and hypertension were more common in HD patients than in non-HD patients with IE. HD patients had higher proportion of methicillin-resistant S. aureus and cardiac complication rates than non-HD patients with IE. Culture-negative IE was more common in non-HD patients., (Copyright © 2018. Published by Elsevier B.V.)

The objective of this study was to evaluate the utility of transthoracic echocardiography (TTE) in children with structurally normal hearts suspected of having infective endocarditis (IE). We hypothesized that the diagnostic yield of TTE is minimal in low-risk patients with normal hearts. We performed a retrospective chart review of TTEs performed for concern for endocarditis at a pediatric tertiary care referral center in Portland, Oregon. Three hundred patients met inclusion criteria (< 21 years old, completed TTE for IE from 2005 to 2015, no history of congenital heart disease or endocarditis). We recorded findings that met the modified Duke criteria (MDC) including fever, positive blood culture, and vascular/immunologic findings; presence of a central line; whether or not patients were diagnosed with IE clinically; and if any changes to antibiotic regimens were made based on TTE. Ten patients (3%) had echocardiograms consistent with IE. When compared to the clinical diagnosis of IE, the positive predictive value (PPV) of one positive blood culture without other major/minor MDC was 0. Similarly, the PPV of two positive blood cultures without other major/minor criteria was 0.071. Patients should be evaluated using the MDC to assess the clinical probability of IE prior to performing a TTE. Patients with a low probability for IE should not undergo TTE as it has a low diagnostic yield and patients are unlikely to be diagnosed with disease.

Background:  We investigated differences in clinical presentation, microbiology, and short- and long-term results according to the affected valve in patients who underwent surgery for left-sided native valve infective endocarditis (IE)., Methods:  This was a single-center retrospective study of 117 patients with isolated mitral valve IE (group M) and 140 patients with isolated aortic valve IE (group A) who underwent surgery between 1998 and 2015., Results:  The mean age of patients in group M was 62 ± 14 years, whereas in group A the patients were 56 ± 14 years old ( p  = 0.001). There were 61 females (52% of patients) in group M and 31 females (22% of patients) in group A ( p  < 0.001). Abscesses were more common in group A than in group B. Staphylococcus aureus was more frequent in group M (47%, n  = 55) than in group A (21%, n  = 30; p  < 0.001). The length of time from symptom onset to surgery was longer in group A than in group M, but the time from diagnosis to surgery was shorter in group A than in group M. Ninety-day mortality was similar in group M and group A in patients operated within 48 hours after diagnosis, but in patients who were operated more than 48 hours after diagnosis the 90-day mortality was 15% in group M and 3% in group A ( p  = 0.006)., Conclusion:  There were considerable differences in preoperative characteristics, microbiology, timing of surgery, and outcomes between patients who underwent surgery for isolated aortic valve IE and those who were operated for isolated mitral valve IE., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction:  Surgical management for tricuspid valve (TV) endocarditis is usually TV repair or replacement. When repair is not feasible, and concerns for patient recidivism preclude TV replacement, tricuspid valvectomy without replacement is an option to alleviate symptoms and allow time for addiction management., Methods:  We reviewed our institution's experience with isolated tricuspid valvectomy for cases of intravenous drug use (IVDU)-associated endocarditis ( n  = 7) from 2009 to 2017., Results:  The decision for tricuspid valvectomy was based on each patient's comorbid condition and realization of active IVDU. This intervention resulted in 100% perioperative and mid-term survival with a mean follow-up of 25.4 months. One patient required a valve replacement in the long term only after appropriate substance abuse management was completed., Conclusion:  Cardiac surgeons increasingly encounter patients with active endocarditis who suffer from IVDU addiction. Drug addiction increases the risk for recurrent endocarditis and requires an effective management plan. Multidisciplinary endocarditis care teams may play a pivotal role in improving outcomes by better addressing addiction treatment., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

The only viable option in prosthetic valve endocarditis with extensive abscess of the aorto-mitral curtain is radical debridement and reconstruction of the intravalvular fibrous body. This report details a simplified intravalvular fibrous body reconstruction technique., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Right-sided infective endocarditis in non-intravenous drug abusers and non-immunocompromised patients is rare. The diagnosis is difficult as it can present as a respiratory illness leading to delays in diagnosis and development of complications, which can be fatal. The standard Duke criteria may not be adequate for diagnosis. We present a patient with isolated right-sided infective endocarditis mimicking right lower lobe non-resolving pneumonia who did not respond to antitubercular therapy., Competing Interests: None

Infective endocarditis is caused by a bacterial infection of the endocardial surface, and despite improvements in surgical interventions and antimicrobial therapy, mortality remains high. Recently published data suggest that intraoperative hemoadsorption therapy might represent a promising treatment option; however, randomized data still lack, and a comparative study on the intraoperative versus intraoperative plus postoperative use of CytoSorb has not yet been performed. We hypothesized that patients developing intraoperative renal failure benefit from additional postoperative CytoSorb treatment in terms of outcome. We examined the application of hemoadsorption therapy in 20 endocarditis patients separated into two groups: (1) sole intraoperative versus (2) intraoperative plus postoperative treatment, with regard to inflammatory and hemodynamic status, the postoperative course including development of complications, extent of extracorporeal organ support, and outcome. Despite an obviously more pronounced disease severity in the intraoperative plus postoperatively treated patients as evidenced by a higher initial European System for Cardiac Operative Risk Evaluation score, higher reoperation rate, longer cardiopulmonary bypass times, a worse inflammatory status, and perioperative development of acute renal failure, we observed a clear and comparable stabilization in hemodynamics and inflammatory parameters in both groups. More importantly and despite a higher rate of postoperative complications and a longer intensive care unit stay, patients from the intraoperative plus postoperative group showed an equal intensive care unit and 90-day survival compared to patients treated only intraoperatively. Our data suggest that postoperative continuation of hemoadsorption treatment might be beneficial in patients with endocarditis who develop perioperative renal failure in combination with severe hemodynamic instability and high-grade intraoperative findings.

Simultaneous left and right-sided native valve infective endocarditis (IE) is rare. Staphylococcus aureus was the predominant organism for bilateral IE. Shunt diseases are common risk factors of both-sided IE. Streptococcus anginosus (S. anginosus) is usually associated with pyogenic infections, but rarely a cause of IE. Here we present an extremely rare case of simultaneous left and right-sided native valve IE affecting the mitral and tricuspid valves caused by S. anginosus in an adult patient that has not been reported in the literature previously, particularly without the most frequent predisposing factors of IE. A 66-year-old man was admitted due to generalized fatigue, chills, malaise, and intermittent fevers for 1 year. A grade III-IV/VI systolic murmur at the mitral area and a III/VI systolic murmur at the tricuspid area were noted on physical examination. Laboratory evaluation revealed an elevated erythrocyte sedimentation rate and C-reactive protein level, and high fasting blood glucose. Blood culture was positive for S. anginosus. Echocardiography revealed vegetations in both sides of the heart: a large mitral valve vegetation with severe mitral regurgitation, as well as another vegetation on the tricuspid valve with moderate regurgitation. The case highlights a rare pathogen of both-sided IE, a rare presentation of S. anginosus infection, and several points worthy of note in echocardiography of IE.

Clinical Introduction: A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae . Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B-D and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313577.supp1Supplementary file 1 heartjnl;105/3/234/F1F1F1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography., Question: Which of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Diabetic foot infections are a common cause of morbidity and mortality in the United States, and successful treatment often requires an aggressive and prolonged approach. Recent work has elucidated the importance of appropriate therapy for a given severity of diabetic foot infection, and highlighted the ongoing risk such patients have for subsequent invasive life-threatening infection should diabetic foot ulcers fail to heal. The authors describe the case of a man with diabetes who had prolonged, delayed healing of a diabetic foot ulcer. The ulcer subsequently became infected by methicillin-resistant Staphylococcus aureus (MRSA). The infection was treated conservatively with oral therapy and minimal debridement. Several months later, he experienced MRSA bloodstream infection and complicating endocarditis. The case highlights the ongoing risk faced by patients when diabetic foot ulcers do not heal promptly, and emphasizes the need for aggressive therapy to promote rapid healing and eradication of MRSA.

Objectives: To assess the clinical characteristics, management, and outcomes of patients diagnosed with infective endocarditis (IE) after edge-to-edge mitral valve repair with the MitraClip device., Background: Transcatheter edge-to-edge mitral valve repair has emerged as an alternative to surgery in high-risk patients. However, few data exist on IE following transcatheter mitral procedures., Methods: Four electronic databases (PubMed, Google Scholar, Embase, and Cochrane Library) were searched for original published studies on IE after edge-to-edge transcatheter mitral valve repair from 2003 to 2017., Results: A total of 10 publications describing 12 patients with definitive IE (median age 76 years, 55% men) were found. The mean logistic EuroSCORE/EuroSCORE II were 41% and 45%, respectively. The IE episode occurred early (within 12 months post-procedure) in nine patients (75%; within the first month in five patients). Staphylococcus aureus was the most frequent (60%) causal microorganism, and severe mitral regurgitation was present in all cases but one. Surgical mitral valve replacement (SMVR) was performed in most (67%) patients, and the mortality associated with the IE episode was high (42%)., Conclusions: IE following transcatheter edge-to-edge mitral valve repair is a rare but life-threatening complication, usually necessitating SMVR despite the high-risk profile of the patients. These results highlight the importance of adequate preventive measures and a prompt diagnosis and treatment of this serious complication., (© 2018 Wiley Periodicals, Inc.)

Background: Patients with congenital cardiovascular disease involving the right ventricular outflow tract and with prosthetic valves in the heart are at high risk for developing infective endocarditis (IE). Recently, there has been concern about relatively high rates of IE after percutaneous pulmonary valve implantation (PPVI). Although there are factors specific to percutaneous valves that could plausibly contribute to the risk of IE, including procedural steps prior to implantation such as crimping the valved stent or mechanical forces during dilation, little is known about actual risk factors for this complication., Methods and Results: The purpose of this study was to assess the incidence rate of IE after PPVI in a single centre long-term experience. The cumulative follow-up time comprised 883.4 patient years for 226 transcatheter valves implanted in the pulmonic position. The annualized incidence rate of IE for all patients receiving valved stents in the RVOT was 1.9%. Freedom from IE 8 years after PPVI was estimated at 87%. The probability for valve removal because of IE was estimated after 8 years at 7%., Conclusion: In our experience, the incidence rate of IE after PPVI is acceptable and comparable to surgically implanted biological valves. Despite some IE events, freedom from reoperation was high and there was good performance of the valve in long-term follow-up., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Infective endocarditis (IE) is a life-threatening disease, caused by septic vegetations and inflammatory foci on the surface of the endothelium and the valves. Due to its complex and often indecisive presentation the mortality rate is still about 30%. Most frequently bacterial microorganisms entering the bloodstream are the underlying origin of the intracardiac infection. While the disease was primarily restricted to younger patients suffering from rheumatic heart streptococci infections, new at risk categories for Staphylococcus (S.) aureus infections arose over the last years. Rising patient age, increasing drug resistance, intensive treatment conditions such as renal hemodialysis, immunosuppression and long term indwelling central venous catheters but also the application of modern cardiac device implants and valve prosthesis have led to emerging incidences of S. aureus IE in health care settings and community. The aetiologic change has impact on the pathophysiology of IE, the clinical presentation and the overall patient management. Despite intensive research on appropriate in vitro and in vivo models of IE and gained knowledge about the fundamental mechanisms in the formation of bacterial vegetations and extracardiac complications, improved understanding of relevant bacterial virulence factors and triggered host immune responses is required to help developing novel antipathogenic treatment strategies and pathogen specific diagnostic markers. In this review, we summarize and discuss the two main areas affected by the changing patient demographics and provide first, recent knowledge about the pathogenic strategies of S. aureus in the induction of IE, including available experimental models of IE used to study host-pathogen interactions and diagnostic and therapeutic targets. In a second focus we present diagnostic (imaging) regimens for patients with S. aureus IE according to current guidelines as well as treatment strategies and surgical recommendations., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Background: Impaired cardiac function is the main predictor of poor outcome in infective endocarditis (IE). Global longitudinal strain (GLS) derived from two-dimensional strain echocardiography has proven superior in prediction of long-term outcome as compared to left ventricular ejection fraction (LVEF) in valvular disease and heart failure in general. Whether measurements of cardiac deformation can predict survival in patients with IE has not previously been investigated., Methods: The study included consecutive patients with Duke definite IE who underwent transthoracic and transesophageal echocardiography within 7 days. Clinical and echocardiographic markers associated with 1-year survival were identified using a Cox-proportional hazards model that included propensity adjustment for surgery. Reclassification statistics including receiver operating characteristic curves and net reclassification improvement were applied to LVEF and GLS, respectively., Results: A cohort of 190 patients met eligibility criteria. LVEF and GLS were both prognostic markers of mortality. Independent markers of 1-year mortality were S. aureus IE (HR:2.02; 95%CI 1.11-5.72, p = .022), diabetes (HR:2.05; 95%CI 1.12-3.75, p = .020), embolic stroke (HR:3.95; 95%CI 1.93-8.10, p < .001) and LVEF<45% (HR: 3.02; 95% CI 1.70-5.38, p < .001), GLS> -15.4% (HR:2.95; 95%CI 1.52-5.72, p < .001). Adding LVEF<45% to a model with known risk factors of IE did not significantly improve risk classification, whereas addition of GLS to the model resulted in significant increase (AUC = 0.763, p < .001)., Conclusions: When treatment was taken into account, LVEF<45% and GLS > -15.4% were both associated with adverse long-term outcome in left-sided IE. GLS >-15.4 % was significantly associated with 1-year mortality in the multivariate analysis. Further, GLS was superior to LVEF in risk prediction and risk discrimination of long-term outcome in patients with left-sided IE., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Persistent fever of unknown cause is only rarely of cardiac origin, but heart disease must be considered in the differential diagnosis. Aside from endocarditis, pericarditis and various other conditions may be responsible., Methods: This review is based on pertinent articles retrieved by a selective search in PubMed and Google Scholar employing the term "fever" in combination with "myocardial infarction," "pericarditis," "endocarditis," and "postcardiac injury," with additional consideration of current cardiological guidelines., Results: Endocarditis is associated with fever in 90% of cases, but 25-50% of patients also develop high body temperatures after acute myocardial infarction. In pericarditis, a temperature above 38°C indicates a poorer prognosis; if accompanied by other warning signs, it is an indication for hospitalization and pericardiocentesis. Fever can arise after cardiac surgical procedures as a manifestation of post - cardiotomy syndrome, a special type of perimyocarditis. There may be a latency period of up to 3 months., Conclusion: Fever can have both infectious and non-infectious cardiac causes. Its interpretation depends on the clinical context. The evidence base for treatment is sparse, and controlled trials are needed.

Rationale: Infective endocarditis (IE) is a life-threatening disease, mostly caused by gram-positive bacteria. Gram-negative bacteria were identified as a causative organism in relatively small number of cases. Although, antibiotic-resistant Escherichia coli is common cause of gram-negative endocarditis, AmpC beta-lactamase (BL)-harboring E coli is very rare cause of IE. Furthermore, emphysematous endocarditis is also a very rare manifestation of E coli infection., Patient Concerns: We report a case of 80-year-old female patient presenting with dizziness, fever, and altered mental status, who was finally diagnosed with emphysematous endocarditis caused by E coli harboring an AmpC BL gene., Diagnosis: Her chest computed tomography revealed air bubbles surrounding the annulus of a mitral valve and a transesophageal echocardiogram revealed a hyperechogenic mass fixed on the posteromedial side of the mitral annulus with 2 eccentric mitral regurgitation jets. Blood cultures grew E coli which harbored the DHA-type AmpC BL. The organism belonged to a B2 phylogenic group, and multilocus sequence typing analyses revealed that the strains were of ST-95., Interventions: She was treated with meropenem following the resistant profiles, and surgery was recommended by the healthcare professional, but denied by the patient's guardians. She was transferred to another hospital due to a refusal for further treatment., Lessons: Emphysematous endocarditis is an uncommon complication of E coli bacteremia. Certain phylogenetic groups may be associated with development of E coli endocarditis.

Background: Many patients with severe heart failure (HF) have an indication for baroreflex activation therapy (BAT) and an implantable cardioverter-defibrillator (ICD). Concerns about device-device interactions were addressed in a study with small sample size that concluded combined BAT and ICD therapy is safe. There are no published data, however, concerning device-device interactions between BAT and a subcutaneous ICD (S-ICD). Since BAT frequently interferes with surface electrocardiogram recordings, there are doubts about compatibility of BAT and S-ICD devices., Case Description: A 54-year-old male patient with dilated cardiomyopathy and severely reduced left ventricular ejection fraction received an S-ICD after recurrent systemic infections due to a diabetic foot syndrome, ultimately associated with infective endocarditis. Since medical HF therapy could not be further optimized and the patient presented with persistent cardiac decompensations, he was evaluated for BAT. Preoperatively, the barostim was epicutaneously placed on the patient's thorax with conductive gel in order to evaluate a possible interference with the S-ICD. Positioning of the barostim in loco typico did not affect the S-ICD's sensing in any vector. Only positioning of the carotis sinus lead directly upon the S-ICD lead, which is beyond clinical relevance, lead to missensing. Subsequently, BAT was implanted with successful perioperative testing of the S-ICD: there was accurate detection of ventricular fibrillation and immediate termination via first shock delivery under maximum barostim output., Conclusions: To our knowledge, there are no other reports in which a barostim was safely implanted in a patient with a preexisting S-ICD. Until data with large patient numbers are available, individual perioperative testing is highly recommended., (© 2017 Wiley Periodicals, Inc.)

Competing Interests: Competing interests: None declared.

Background  The aim of this study was to evaluate the perioperative characteristics and the short- and mid-term outcomes in patients undergoing tricuspid valve (TV) surgery for isolated TV endocarditis. Patients and Methods  A total of 56 patients with isolated TV endocarditis underwent TV surgery at a single center between June 1995 and February 2012. Mean age of patients was 53.8 ± 17.1 years, 39 (69.6%) being male. The mean left ventricular ejection fraction was 60.4 ± 13.6% and 13 (23.2%) patients had diabetes mellitus. Average logistic EuroSCORE was 19.4 ± 17.0%. Mean follow-up was 4.7 ± 3.8 years. Results  Microbiological investigations revealed positive blood cultures in 89.1% of patients and positive intraoperative swabs in 51.9%. The most common pathogen (42.9%) isolated was Staphylococcus aureus , followed by coagulase-negative staphylococcus (17.9%). Discussion  A history of intravenous drug abuse (IVDA) was recorded in 11 patients (19.6%), of which 8 patients additionally had hepatitis C. A total of 15 patients (26.8%) had a permanent pacemaker/implantable cardioverter-defibrillator in situ. TV replacement was performed in 22 patients (39.3%) and TV repair was performed in 34 patients (60.7%). Overall 30-day mortality was 12.5%. Five-year survival was 63.9 ± 7.2% (95% confidence interval [CI]: 64.0-137.5 months). Freedom from reoperation for recurrent TV endocarditis was 91.7 ± 4.0% (95% CI: 152.3-179.3 months) at 5 years. Conclusion  Blood culture is the most important tool to detect the causative pathogen causing IE of TV. The high risk of hepatitis C in patients with IVDA and IE of the TV should be mentioned., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Infectious endocarditis (IE), a complication that is both cardiac and infectious, occurs frequently and is associated with a heavy burden of morbidity and mortality in chronic hemodialysis patients (CHD). About 2-6% of chronic hemodialysis patients develop IE and the incidence is 50-60 times higher among CHD patients than in the general population. The left heart is the most frequent location of IE in CHD and the different published series report a prevalence of left valve involvement varying from 80% to 100%. Valvular and perivalvular abnormalities, alteration of the immune system, and bacteremia associated with repeated manipulation of the vascular access, particularly central venous catheters, comprise the main factors explaining the left heart IE in CHD patients. While left-sided IE develops in altered valves in a high-pressure system, right-sided IE on the contrary, generally develops in healthy valves in a low-pressure system. Right-sided IE is rare, with its incidence varying from 0% to 26% depending on the study, and the tricuspid valve is the main location. Might the massive influx of pathogenic and virulent germs via the central venous catheter to the right heart, with the tricuspid being the first contact valve, have a role in the physiopathology of IE in CHD, thus facilitating bacterial adhesion? While the physiopathology of left-sided IE entails multiple and convincing mechanisms, it is not the case for right-sided IE, for which the physiopathological mechanism is only partially understood and remains shrouded in mystery.

Endocarditis of a prosthetic heart valve is a life-threatening condition that is associated with high morbidity and mortality. Perivalvular extension in infective endocarditis includes complications such as periannular or intramyocardial abscesses, pseudoaneurysms and fistulae. The incidence of perivalvular extension ranges from 10 to 30% in native valve endocarditis and 30 to 55% in prosthetic aortic-valve endocarditis. Herein, we describe a case of a 66-year-old man who presented endocarditis of a prosthetic aortic valve complicated by infective pseudoaneurysm with localization next to the right coronary sinus of Valsalva. Moreover, we underscore the importance of the diagnostic imaging tools options and surgical timing.

The case is reported of a 55 year-old woman, with a previously known congenital septal defect, who was admitted to the emergency department with a diagnosis of meningoencephalitis, septic shock, and rapid clinical deterioration. Echocardiography revealed a vegetation occupying the right-side heart. Endocarditis affectation of the septal defect, aortic and tricuspid valves was noted and blood cultures were positive for Staphylococcus aureus. Urgent surgical treatment was performed whereby the ventricular septal defect was closed, a meticulous debridement of the affected area was conducted, and the aortic and tricuspid valves were replaced.

Infective Endocarditis (IE) is an endocardial infection usually caused by bacteria that affects not only the native heart valves but also, with increasing frequency intravascular implanted devices and congenital heart diseases. Despite medical advances, IE remains a life-threatening disease with substantial morbidity and mortality. In Africa, its diagnosis and treatment are still a major challenge in clinical practice. The objective of this work was to study the epidemiological, clinical features, diagnostic techniques currently used in medical practice and the range of micro-organisms that are responsible. This was a retrospective study done at Principal Hospital of Dakar. We include all patients who were admitted with clinical manifestations of definite or possible IE according to the extended DUKE criteria between January 1 st , 2005 and December 31 st , 2014. We collected and analyzed epidemiological, clinical, paraclinical and outcomes data of 42 patients. Hospital prevalence of IE was 0.078% (42/53711). The mean age was 27.5+/- 18 years with a sex ratio (M/F) of 0.55. IE were more common in patients with damaged or abnormal heart valves (78.6%) and in thoses with underlying structural defects (14.3%). The most common presenting symptoms were fever (90%) and cardiac murmurs (81%). Extracardiac clinical manifestations were very rare. The usual laboratory parameters of inflammation were elevated in 90% of patients. Blood cultures were negative in 50% of cases and positive in 21.4%. The main organism found was Staphylococcus aureus. Echocardiography found vegetations in 95.2% of cases, chamber enlargement in 73.8% and mitral regurgiation in 83.3%. Broad-spectrum penicillins including ampicillin and gentamycine were used for all patients. Major complications were heart failure (47.6%). Strokes and cerebral abcess (23.8%) and Vascular emboli 14.3%. Hospital mortality was 31%. IE remains a life-threatening disease with hight mortality despites improved techniques of diagnosis and modern antibiotics., Competing Interests: The authors declare no competing interests.

Congenital coronary artery fistulas (CAFs) are infrequent congenital coronary artery anomalies. Complications such as left-to-right shunt, congestive heart failure, myocardial infarction, pericardial effusion, aneurysm formation, rupture, hemopericardium, pulmonary hypertension, infective endocarditis (IE), syncope, stroke, and sudden death may occur with a variable low frequency. To describe the clinical characteristics of patients with CAFs complicated by IE. A search was conducted through PubMed using the terms "CAFs" and "IE." Papers with a full description of the fistula characteristics and detailed data regarding bacterial endocarditis were included for evaluation. In the overall group of reviewed subjects (n = 25, 9 females), the mean patient age was 42.5 years (range: 16 and 87). The right coronary artery (RCA) and left coronary artery (LCA) contributed equally to fistula formation. Terminations into the right heart side occurred in 19 (76%) fistulas. The majority of the fistulas (92%) were unilateral. The cultured microorganism was Streptococcus in 14 (56%) and Staphylococcus in 4 (16%) of the reviewed subjects. Echocardiographic single or multiple valvular regurgitation was found in 8 (32%) of the reviewed subjects. Small and large intracardiac vegetations were detected in 18 patients (72%). Antibiotic therapy was initiated in 20 (80%) subjects and 16 fistulas were treated surgically. During surgery, spontaneous closure of the fistula was observed in one patient. Percutaneous therapeutic embolization (PTE) was successfully performed in two subjects. CAFs complicated by IE may affect all age groups with a slight male preponderance. Unilateral fistulas, either arising from the right or left coronary artery, are predominant, draining mainly into the right heart side. It is emphasized that antibiotic prophylaxis is strongly advised for pediatric and adult patients with congenital CAFs., (© 2016 Wiley Periodicals, Inc.)

Mural endocarditis is a rare clinical entity with an extremely high mortality rate. It is usually predisposed by an underlying structural intracardiac abnormality. We present two cases of mural endocarditis occurring in the right atrium which were complicated by septic pulmonary embolism, one of which was predisposed by a jet lesion secondary to a coronary artery fistula. Both cases were successfully managed conservatively with excellent long-term outcomes., (Copyright © 2016 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.)

Introduction: To describe the clinical presentation, clinicopathological abnormalities and outcomes of a series of cats diagnosed with infective endocarditis (IE) at two tertiary care referral institutions., Animals: Thirteen client-owned cats presenting to the cardiology or emergency services of tertiary referral institutions with a diagnosis of endocarditis based on the modified Duke criteria., Materials and Methods: Retrospective case series. Medical records were reviewed to extract relevant data. In addition, cases that had cardiac tissue available were evaluated by polymerase chain reaction for the presence of Bartonella DNA., Results: Prevalence of feline IE was 0.007%. Cats with endocarditis tended to be older (median age: 9 years, range: 2-12 years) and no sex or breed was overrepresented. Commonly encountered clinical signs included respiratory distress (n = 5) and locomotor abnormalities of varying severity (n = 5). Echocardiographic examination detected valvular lesions consistent with endocarditis on the aortic (n = 8) or mitral (n = 5) valves. Nine cats were diagnosed with congestive heart failure at the time of endocarditis diagnosis. Overall, prognosis was grave with a median survival time of 31 days., Conclusions: In contrast to dogs, cats with IE typically present with clinical signs consistent with cardiac decompensation and locomotor abnormalities suggestive of either thromboembolic disease or inflammatory arthritis. Given the advanced state of disease when diagnosis typically occurs, prognosis is grave., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Enterococcus faecium is a common cause of nosocomial infections, of which infective endocarditis is associated with substantial mortality. In this study, we used a microarray-based transposon mapping (M-TraM) approach to evaluate a rat endocarditis model and identified a gene, originally annotated as "fruA" and renamed "bepA," putatively encoding a carbohydrate phosphotransferase system (PTS) permease (biofilm and endocarditis-associated permease A [BepA]), as important in infective endocarditis. This gene is highly enriched in E. faecium clinical isolates and absent in commensal isolates that are not associated with infection. Confirmation of the phenotype was established in a competition experiment of wild-type and a markerless bepA mutant in a rat endocarditis model. In addition, deletion of bepA impaired biofilm formation in vitro in the presence of 100% human serum and metabolism of β-methyl-D-glucoside. β-glucoside metabolism has been linked to the metabolism of glycosaminoglycans that are exposed on injured heart valves, where bacteria attach and form vegetations. Therefore, we propose that the PTS permease BepA is directly implicated in E. faecium pathogenesis., (© The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.)

Background: Despite a high burden of dialysis access-related bloodstream infections and an increasing incidence of endocarditis, few data are available addressing the risk of prosthetic valve endocarditis (PVE) in the dialysis population. We sought to assess the risk of PVE and death after valve replacement operations in patients receiving long-term dialysis., Methods: A matched retrospective cohort study was conducted comprising patients admitted for valve replacement operations at two university hospitals. Patients without dialysis were matched 1:1 with dialysis patients by valve(s) replaced, year of operation, and presence of active endocarditis as the indication for valve replacement. Patient characteristics were compared using χ(2) and t tests. The development of PVE was defined by use of the modified Duke criteria and analyzed with Cox proportional hazards regression., Results: Two hundred seventy-eight patients were included, with 139 in either cohort. The PVE risk per year of follow-up was 0.14 in the dialysis cohort and 0.03 in the nondialysis cohort. Dialysis remained a risk factor (adjusted hazard ratio 5.61 [95% confidence interval, 2.17 to 14.5], p = 0.0004) after age and race were controlled for. The 5-year survival rate was lower after valve replacement operation in the dialysis group (25.4%) than in the nondialysis group (75.9%, p < 0.001)., Conclusions: The risk of PVE and death after valve replacement operations in dialysis patients is substantial and significantly higher than in patients without dialysis. These findings highlight the importance of a careful preoperative risk-benefit assessment and underscore the need to prevent hemodialysis-related bloodstream infections., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aortic valve infective endocarditis (IE) can be complicated with severe aortic regurgitation (AR) jet-related lesions such as vegetations, pseudoaneurysms, aneurysms or perforations on the anterior mitral leaflet. Herein is reported the case of a 69-year-old male with culture-negative aortic valve endocarditis complicated with aortic valve perforations resulting in severe and eccentric AR and an AR jet-related ventricular septal defect (VSD). Neither transthoracic echocardiography (TTE) nor two-dimensional transesophageal echocardiography (2D-TEE) were unable to clearly discriminate an aorto-right ventricular fistula from a VSD. By contrast, three-dimensional TEE (3D-TEE) demonstrated multiple aortic valve vegetations, aortic valve perforations, severe AR, and an AR jet-related VSD. The 3D-TEE findings were confirmed at surgery, the aortic valve was replaced with a bioprosthetic valve, and the VSD was repaired with a pericardial patch. To the authors' knowledge, this is the first case of a VSD resulting from an AR jet lesion to be detected and characterized using 3D-TEE. The accurate preoperative diagnosis and characterization of the VSD with 3D-TEE contributed to successful surgery and the patient's short- and long-term survival. Video 1A: This four-chamber transthoracic echocardiography (TTE) view with color Doppler shows a color-Doppler jet traversing the basal interventricular septum (IVS) into the right ventricle, predominantly during systole. However, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. A mild to moderate degree of tricuspid regurgitation is also noted. Video 1B: Close-up view of the basal IVS demonstrates a color Doppler jet traversing the IVS, predominantly during systole and apparently originating in the left ventricular outflow tract side, as illustrated by a color Doppler acceleration zone. However, and as in Fig. 1A, the origin of the jet resulting from an aortic-right ventricular fistula cannot be determined. Video 1C: Color Doppler two-dimensional TEE view longitudinal to the aortic valve and aortic root, showing a predominantly systolic color Doppler jet originating in the left ventricular outflow tract and/or aorta and crossing the anterior and basal IVS defect into the right ventricle. Videos 1D: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1E: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D. Videos 1F: These three-dimensional TEE en-face left ventricular outflow tract views of the aortic valve and basal anterior IVS (Video 1D) and medial anterior close up (Video 1E) and lateral en-face (Video 1F) views of the LV outflow tract and IVS clearly define the anterior and basal location of the VSD with irregular borders and a residual mobile tissue fragment. Multiple aortic valve vegetations and a perforation are visible in Video 1D.