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International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

Intravenous drug use is a predisposing condition for infective endocarditis (IE). We report the clinical features of IE, taken from the Italian Registry of IE, in people who inject drugs (PWIDs). The registry prospectively collected epidemiological, clinical, in-hospital, and follow-up data on patients with IE from 17 Italian centers. A total of 677 patients were enrolled, and 61 (9%) were intravenous drug users (IDUs). Most PWIDs were male (78.6%), and aged between 41 and 50 years old (50%). The most frequent comorbidities were HIV (34.4%) and chronic liver disease (32%). Predisposing factors for IE were present in 6.5% of the patients, and 10% had minor valvular abnormalities. IE had occurred previously in 16.4% of the patients, and 50% of them had undergone heart surgery. Overall mortality was 9.8% in IDUs and 20% in patients with recurrent IE. IE in PWIDs mostly affected the native valves (90%). The echocardiographic diagnosis of IE was based on the detection of vegetation in 91.82% of cases. Staphylococcus aureus was the main microorganism isolated (70%) from blood cultures. Thirty patients (49%) underwent heart surgery: thirteen had aortic valves, eleven had mitral valves, and six had tricuspid valve interventions. IE in PWIDs was relatively common, and patients with native valve right-sided IE had a better prognosis, with a low rate of surgical interventions.

Patent foramen ovale (PFO) and cryptogenic stroke (CS) both have a high prevalence. The optimal treatment to reduce stroke recurrence after CS remains controversial. Results from clinical trials, meta-analyses, and position papers, support percutaneous PFO device closure and medical therapy compared to medical therapy alone. However, the procedure may be associated with cardiac complications including an increased incidence of new atrial fibrillation. The benefit/risk balance should be determined on a case-by-case basis with the greatest benefit of PFO closure in patients with atrial septal aneurysm and PFO with large shunts. Future studies should address unsolved questions such as the choice of medical therapy in patients not undergoing closure, the duration of antiplatelet therapy, and the role of PFO closure in patients over 60 years old.

The present study aims at assessing the distribution and extension of the coralligenous cliffs in Tuscany and describing the structure and the patterns of spatial variability. The mapping of seabed was obtained through Multibeam echosounder data coupled with video images. Coralligenous cliffs were sampled by SCUBA divers in 11 sectors of rocky costs following the STAR procedure. Coralligenous cliffs were present in all study sites, with a total length of about 62.5 km and a total surface of 0.47 km2. The linear extension of the habitat may be estimated about the 20% of Tuscany rocky coast.

This paper aims at collating and reviewing all data collected using the ESCA (Ecological Status of Coralligenous Assemblages) index from 2009 to 2018 during different local applications, in order to evaluate at large spatial scale its effectiveness and temporal variability. To this scope, the large-scale response of ESCA to anthropogenic disturbance was tested comparing ESCA values calculated at 42 sites of the Western Mediterranean Sea with the anthropization index. Moreover, the sensitivity of ESCA to punctual human disturbance and the robustness of the index across the natural space and time variability were evaluated. The large spatial scale study showed significant correlation between ESCA and the anthropization index, while very low correlation was detected when descriptors of ESCA (i.e., sensitivity levels, α-diversity, and β-diversity) were considered separately. The three impact evaluation studies highlighted significantly lower values of the ESCA index in disturbed conditions than in the control ones. The coastal monitoring study confirmed the robustness of the index which showed a high ecological quality of coralligenous reefs in reference conditions compared to more anthropized sites, and this pattern was maintained throughout the ten years study period. Application of the ESCA index to different situations tested positively its sensibility to different levels and type of human disturbance and its stability with respect to regional spatio-temporal variability. This confirm the reliability of the ESCA index already tested on the local and annual scale, thus broadening its range of application and validating it on a wider space–time scale.

The aim of the study was to evaluate the effectiveness of the application of multiple environmental descriptors through an asymmetrical sampling design to detect possible impacts related to the Costa Concordia event on the coastal marine environment. The Costa Concordia shipwreck occurred on a submerged rocky reef in the north-western Mediterranean Sea and the wreck was removed 2 years later. To achieve the proposed objective two main coastal ecosystems, the seagrass Posidonia oceanica and coralligenous assemblages were studied using two ecological indices, PREI and ESCA, respectively. Both indices show a lower ecological quality in the disturbed sites compared with the control ones. Differences between the disturbed and control sites observed in both studied ecosystems would seem to indicate an increase of turbidity around the shipwreck as the most plausible cause of impact. The concurrent use of different ecological indices and asymmetrical sampling designs allowed detection of differences in ecological quality of the disturbed sites compared with the controls. This approach may represent an interesting tool to be employed in impact evaluation studies.

The ESCA (Ecological Status of Coralligenous Assemblages) index was developed to assess the ecological quality of coralligenous habitat using macroalgae as a biological indicator. The aim of this study was to evaluate the response to human-induced pressures of macroalgae and sessile macro-invertebrates shaping the coralligenous habitat and to integrate their sensitivity into the ESCA index. Coralligenous assemblages were sampled at 15 locations of the NW Mediterranean Sea classified into three groups: i) marine protected areas; ii) low urbanized locations; and iii) highly urbanized locations. A sensitivity level value was assigned to each taxon/group on the basis of its abundance in each environmental condition, the data available in the literature and the results of an expert judgement survey. The index that includes the totality of the assemblages (named ESCA-TA), calculated using both macroalgae and sessile macro-invertebrates, detected the levels of human pressure more precisely than the index calculated with only macroalgae or with only invertebrates. The potential for assessing the ecological quality of marine coastal areas was thus increased with the ESCA-TA index thanks to the use of a higher variety of descriptors., El índice ESCA (Estado Ecológico de las Comunidades Coralígenas) ha sido desarrollado para determinar el estado ecológico de los hábitats coralígenos utilizando macro-algas como indicador biológico. El objetivo de este estudio fue evaluar la respuesta, ante presiones antropogénicas, de macro-algas y macro-invertebrados sésiles moldeadores de la comunidad coralígena y su sensibilidad al índice ESCA. Se muestrearon comunidades coralígenas en 15 localizaciones del Mediterráneo Nord-Occidental clasificadas en 3 grupos: i) áreas marinas protegidas; ii) poco urbanizadas; iii) muy urbanizadas. Un valor de Nivel de Sensibilidad fue asignado a cada taxón/grupo en base a su abundancia en cada condición medioambiental, a información bibliográfica disponible y a los resultados de juicios por parte de expertos. El índice que integra la totalidad de las comunidades (llamado ESCA-TA), calculado usando tanto macro-algas como macro-invertebrados sésiles, detectó los diferentes niveles de presión humana de manera más precisa que el índice calculado solo con macro-algas o solo con invertebrados. El potencial para determinar el estado ecológico de las áreas marinas protegidas se incrementó con el índice ESCA-TA gracias al uso de una mayor variedad de descriptores.

The study aimed at contributing to the development of methods to assessing the effects of human disturbance on coralligenous reefs. The effects of the presence of a fish farm on coralligenous reefs were evaluated using the STAR (STAndaRdized coralligenous evaluation procedure) sampling procedure. An asymmetrical sampling design was used to compare the aquaculture site with two reference sites in areas unaffected by human pressure. The response of different ecological indices (ESCA, Ecological Status of Coralligenous Assemblages; ISLA, Integrated Sensitivity Level of coralligenous Assemblages; COARSE, COralligenous Assessment by Reef Scape Estimate) and descriptors (α-diversity, β-diversity and Sensitivity Level) of this kind of disturbance was compared. Results indicate that coralligenous reefs are vulnerable to aquaculture fish cages, and differences in the structure of coralligenous assemblages between the disturbed and the reference sites were mostly due to the decrease in β-diversity. On the contrary, no significant differences in the number of taxa/groups were highlighted. Encrusting Corallinales, erect Rhodophyta, Dictyotales, Fucales and Halimeda tuna were more abundant in reference sites than in disturbed site, while Peyssonnelia spp. and algal turfs had the opposite trend. Conversely, no significant differences between conditions were found in the abundance of sessile invertebrates. The study supports the suitability of the STAR approach to be employed in impact evaluation assessments, such as in monitoring programs. The present study is a first attempt to combine three different ecological indices (ESCA, ISLA and COARSE) within a unified approach, in order to assess the status of coralligenous reefs subjected to a moderate human-induced disturbance. The inconsistent response of the different indices highlights the advantage of applying different indices and descriptors to evaluate the variable human pressures on natural systems.

The 2015 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis recommend the use of a multidisciplinary team in the care of patients with infective endocarditis. A standardized collaborative approach should be implemented in centres with immediate access to different imaging techniques, cardiac surgery and health professionals from several specialties. This position paper has been produced by the Task Force for Management of Infective Endocarditis of Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) with the aim of providing recommendations for the implementation of the Endocarditis Team within the Italian hospital network. On the basis of the Italian hospital network with many cardiology facilities encompassing a total of 405 intensive cardiac care units (ICCUs) across the country, 224 (3.68 per million inhabitants) of which have on-site 24-h PCI capability, but with relatively few centres equipped with cardiac surgery and nuclear medicine, in the present article, the SIECVI Task Force for Management of Infective Endocarditis develops the idea of a network where 'functional' reference centres act as a link with the periphery and with 'structural' reference centres. A number of minimum characteristics are provided for these 'functional' reference centres. Outcome and cost analysis of implementing an Endocarditis Team with functional referral is expected to be derived from ongoing Italian and European registries.

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

Background AtrioVentricular (AV) and InterVentricular (VV) delay optimization can improve ventricular function in Cardiac Resynchronization Therapy (CRT) and is usually performed by means of echocardiography. St Jude Medical has developed an automated algorhythm which calculates the optimal AV and VV delays (QuickOpt™) based on Intracardiac ElectroGrams, (IEGM), within 2 min. So far, the efficacy of the algorhythm has been tested acutely with standard lead position at right ventricular (RV) apex. Aim of this project is to evaluate the algorhythm performance in the mid- and long-term with RV lead located in mid-septum. Methods AV and VV delays optimization data were collected in 13 centers using both echocardiographic and QuickOpt™ guidance in CRTD implanted patients provided with this algorhythm. Measurements of the aortic Velocity Time Integral (aVTI) were performed with both methods in a random order at pre-discharge, 6-month and 12-month follow-up. Results Fifty-three patients were studied (46 males; age 68 ± 10y; EF 28 ± 7%). Maximum aVTI obtained by echocardiography at different AV delays, were compared with aVTI acquired at AV delays suggested by QuickOpt. The AV Pearson correlations were 0.96 at pre-discharge, 0.95 and 0,98 at 6- and 12- month follow-up respectively. After programming optimal AV, the same approach was used to compare echocardiographic aVTI with aVTI corresponding to the VV values provided by QuickOpt. The VV Pearson Correlation were 0,92 at pre-discharge, 0,88 and 0.90 at 6-month and 12- month follow-up respectively. Conclusions IEGM-based optimization provides comparable results with echocardiographic method (maximum aVTI) used as reference with mid-septum RV lead location.

Coralligenous reefs are considered as one of the most important benthic ecosystems in the Mediterranean Sea in terms of biodiversity, ecosystem functioning, and aesthetic value. Bryozoans deserve special attention within the coralligenous framework fauna: they are among the most common animals, showing high diversity values and playing different functional roles. Distribution, spatial variability, and demographic features of five erect bryozoan taxa Adeonella sp., Myriapora truncata, Pentapora fascialis, Reteporella sp., and Smittina cervicornis were studied in the central Tyrrhenian Sea. Abundance, size, and relationship with other taxa/morphological groups of benthic organisms were studied in coralligenous reefs between 35 and 40 m depth. High density of colonies was reported especially in association to gorgonians and algae dominated assemblages. Size distributions of the five bryozoans were characterized by small colonies; only two species (P. fascialis and S. cervicornis) showed colonies larger than 50 cm2. Structure of coralligenous assemblages and disturbances outlined different ecological requirements of the five studied taxa. Results provide baseline information for monitoring trajectories of change of these organisms in the coralligenous ecosystem. To date, this work represents the first study exploring ecology and distribution patterns of common erect bryozoans in the Mediterranean Sea.

Introduction The epidemiology of infective endocarditis (IE) is changing due to a number of factors, including aging and health related comorbidities and medical procedures. The aim of this study is to describe the main clinical, epidemiologic and etiologic changes of IE from a large database in Italy. Methods We prospectively collected episodes of IE in 17 Italian centers from July 2007 to December 2010. Results We enrolled 677 patients with definite IE, of which 24% health-care associated. Patients were male (73%) with a median age of 62years (IQR: 49–74) and 61% had several comorbidities. One hundred and twenty-eight (19%) patients had prosthetic left side IE, 391 (58%) native left side IE, 94 (14%) device-related IE and 54 (8%) right side IE. A predisposing cardiopathy was present in 50%, while odontoiatric and non odontoiatric procedures were reported in 5% and 21% of patients respectively. Symptoms were usually atypical and precocious. The prevalent etiology was represented by Staphylococcus aureus (27%) followed by coagulase-negative staphylococci (CNS, 21%), Streptococcus viridans (15%) and enterococci (14%). CNS and enterococci were relatively more frequent in patients with intravascular devices and prosthesis and S. viridans in left native valve. Diagnosis was made by transthoracic and transesophageal echocardiography in 62% and 94% of cases, respectively. The in-hospital mortality was 14% and 1-year mortality was 21%. Conclusion The epidemiology is changing in Italy, where IE more often affects older patients with comorbidities and intravascular devices, with an acute onset and including a high frequency of enterococci. There were few preceding odontoiatric procedures.

Objectives Observational studies on early surgery in infective endocarditis have conflicting results. This study aims to compare the treatment strategies for early surgery (within 2 weeks of diagnosis) and late surgery/medical therapy in terms of survival among patients with the left-sided infective endocarditis. Methods This study included patients with the left-sided infective endocarditis registered between 2006 and 2010 in the Italian Registry of Infective Endocarditis (RIEI). A Cox proportional hazards model was used to estimate the effect of these treatment strategies on overall survival and included sociodemographic and clinical characteristics associated with treatment, risk factors for mortality and early surgery as a time-dependent covariate to avoid indication and immortal time biases. Results Among the 502 patients included, 184 (36.7%) underwent early surgery. Of the remaining 318 patients, 138 underwent late surgery. The early surgery group had fewer patients with comorbidities and with enterococcus as the causative microorganism, but this group had more complicated cardiac conditions. No difference in mortality risk was estimated between the treatment groups including early surgery as time-dependent variables (adjusted hazard ratio = 0.95, 95% confidence interval 0.55-1.63), while a distorted and overestimated beneficial effect of surgery was estimated considering surgery as a non-time-dependent variable (adjusted hazard ratio 0.41, 95% confidence interval 0.25-0.70). Conclusions Our study did not confirm a better overall survival in patients undergoing early surgery. However, even with the use of statistical techniques to control biases, we could not draw definitive conclusions that early surgery is not beneficial. Our results need to be assessed by randomized trials before any changes in clinical practice can be recommended.

Coralligenous habitat is one of the most important and sensitive habitats of the Mediterranean Sea and several different sampling procedures are currently used in the ecological investigations of coralligenous assemblages. This study aimed to assess the efficacy of different methods in detecting anthropogenic impacts on coralligenous habitat. In particular, the choice of sampling methods, the level of taxonomic resolution, the sampling area, the number of replicates and the spatial scales for detecting possible impacts were evaluated. Results showed that photographic samples larger than 1800 cm2, numbers of replicates larger than 10, the use of taxa and morphological groups as assemblage descriptors, and sampling designs with a high replication at small spatial scales are a valid methodological procedure in impact evaluation studies based on coralligenous assemblages. El hábitat coralígeno es uno de los más importantes y sensibles del mar Mediterráneo y actualmente se pueden aplicar varios métodos de muestreo en las investigaciones ecológicas de las comunidades macroalgales coralígenas. El objetivo del presente estudio es evaluar la efectividad de los diferentes procedimientos para detectar el impacto antrópico sobre el hábitat de coralígeno. Se evaluaron en particular la elección de los métodos de muestreo, el nivel de resolución a la que los taxones tienen que ser identificados, la superficie de muestreo, el número de repeticiones y las escalas espaciales adecuadas para la investigación de los posibles impactos. Los resultados indican que muestras fotográficas de 1800 cm2, un número de repeticiones mayor que 10, el uso de taxones y grupos morfológicos como descriptores y diseños de muestreo con una alta replicación asociada a pequeñas escalas espaciales pueden representar elementos metodológicos válidos en los estudios de evaluación de impacto basados en las comunidades coralígenas.

This paper presents a new biotic index (ESCA, Ecological Status of Coralligenous Assemblages), based on analyses of in situ records of coralligenous macroalgal assemblages in the Mediterranean Sea. The ESCA index was developed on the basis of previous impact evaluation studies carried out by traditional destructive methods. It was validated on an independent dataset collected during a 3-year study carried out at five localities in the north-western Mediterranean, and tested on a gradient of anthropogenic stressors. Assemblage descriptors selected as metrics of the ESCA index were: (a) presence/absence and abundance of sensitive taxa/groups (expressed as sensitivity level of assemblages, SL), (b) diversity of assemblages (expressed as α-diversity) and (c) heterogeneity of assemblages (expressed as β-diversity). The three metrics were combined to give a final value for the multimetric ecological index, Ecological Quality Ratio, calculated as the ratio between the measured values and the value obtained in th...

International audience; Echocardiography is essential for the diagnosis and management of ă infective endocarditis (IE). However, the reproducibility for the ă echocardiographic assessment of variables relevant to IE is unknown. ă Objectives of this study were: (1) To define the reproducibility for IE ă echocardiographic variables and (2) to describe a methodology for ă assessing quality in an observational cohort containing site-interpreted ă data. IE reproducibility was assessed on a subset of echocardiograms ă from subjects enrolled in the International Collaboration on ă Endocarditis registry. Specific echocardiographic case report forms were ă used. Intra-observer agreement was assessed from six site readers on ten ă randomly selected echocardiograms. Inter-observer agreement between ă sites and an echocardiography core laboratory was assessed on a separate ă random sample of 110 echocardiograms. Agreement was determined using ă intraclass correlation (ICC), coverage probability (CP), and limits of ă agreement for continuous variables and kappa statistics ă (kappa(weighted)) and CP for categorical variables. Intra-observer ă agreement for LVEF was excellent [ICC = 0.93 +/- 0.1 and all pairwise ă differences for LVEF (CP) were within 10 %]. For IE categorical ă echocardiographic variables, intra-observer agreement was best for ă aortic abscess (kappa(weighted) = 1.0, CP = 1.0 for all readers). ă Highest inter-observer agreement for IE categorical echocardiographic ă variables was obtained for vegetation location (kappa(weighted) = 0.95; ă 95 % CI 0.92-0.99) and lowest agreement was found for vegetation ă mobility (kappa(weighted) = 0.69; 95 % CI 0.62-0.86). Moderate to ă excellent intra- and inter-observer agreement is observed for ă echocardiographic variables in the diagnostic assessment of IE. A ă pragmatic approach for determining echocardiographic data ă reproducibility in a large, multicentre, site interpreted observational ă cohort is feasible.

Background Host factors and complications have been associated with higher mortality in infective endocarditis ( IE ). We sought to develop and validate a model of clinical characteristics to predict 6‐month mortality in IE . Methods and Results Using a large multinational prospective registry of definite IE (International Collaboration on Endocarditis [ ICE ]–Prospective Cohort Study [ PCS ], 2000–2006, n=4049), a model to predict 6‐month survival was developed by Cox proportional hazards modeling with inverse probability weighting for surgery treatment and was internally validated by the bootstrapping method. This model was externally validated in an independent prospective registry ( ICE ‐ PLUS , 2008–2012, n=1197). The 6‐month mortality was 971 of 4049 (24.0%) in the ICE ‐ PCS cohort and 342 of 1197 (28.6%) in the ICE ‐ PLUS cohort. Surgery during the index hospitalization was performed in 48.1% and 54.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE , causative organism, left‐sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6‐month mortality, and surgery was associated with a lower risk of mortality (Harrell's C statistic 0.715). In the validation model, these variables had similar hazard ratios (Harrell's C statistic 0.682), with a similar, independent benefit of surgery (hazard ratio 0.74, 95% CI 0.62–0.89). A simplified risk model was developed by weight adjustment of these variables. Conclusions Six‐month mortality after IE is ≈25% and is predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality but is performed less frequently in the highest risk patients. A simplified risk model may be used to identify specific risk subgroups in IE .

The cause of acute and recurrent pericarditis is often a major concern for the clinicians in clinical practice. Several possible causes of pericarditis can be listed, as the pericardium may be involved in a large number of systemic disorders or may be diseased, as an isolated process. The reported diagnostic yield of extensive laboratory evaluation and pericardiocentesis is low in the absence of cardiac tamponade or suspected neoplastic, tuberculous, and purulent pericarditis. Patients with pericarditis can be safely managed on an outpatient basis without a thorough diagnostic evaluation unless a specific cause is suspected or the patient has high-risk features, or both. A targeted aetiological search should be directed to the most common cause on the basis of the clinical background, epidemiological issues or specific presentations. In developed countries the clinicians should rule out neoplastic, tuberculous, and purulent pericarditis, as well as pericarditis related to a systemic disease.

In the last 30 years, major improvements have been made in understanding the pathogenesis, diagnosis and treatment of infective endocarditis. Nevertheless, mortality still remains high, close to 30-40% at 1 year, and its reduction remains the main challenge. Moreover, important epidemiological changes have been recorded. Social changes in Western countries have led to an increase in the mean length of life, and thus in degenerative valvular diseases, whereas rheumatic heart disease has almost disappeared. Increasing medicalization has led to a rise in complications and diseases related to longer hospital stay, surgical therapies and other invasive interventions. At the same time, there is an increase in immunosuppressive therapies, diseases such as cancer, diabetes mellitus and renal insufficiency that may enhance the disease. Further knowledge is needed for specific subgroups to improve both treatment and prognosis. Nevertheless, randomized trials are lacking to guide the management of the disease, and the role and indications of antibiotic prophylaxis are still the subject of debate. International multicenter studies are providing new important findings based on the experience of tertiary centers; these results may reflect referral biases. The proposal of an Italian national registry on infective endocarditis (RIEI) will overcome these limitations and provide a wide picture of the national presentation of the disease. The aim of the registry is to improve the management of infective endocarditis, through a better understanding of demographic, clinical, therapeutic and prognostic features of the disease in the real world. The background, rationale, aims and expected results of the registry are reviewed.

We report a difficult case of a 45-year-old woman with refractory recurrent pericarditis, who was treated with several different medical therapies, pericardial window, and pericardiectomy. This case suggests that more invasive diagnostic and therapeutic choices, such as pericardial window and pericardiectomy, should be carefully considered for possible side-effects and the risk of promoting further recurrences. Non-steroidal anti-inflammatory drugs and colchicine are first-choice drugs, whereas corticosteroids should be considered only in patients with a frequent crisis unresponsive to non-steroidal anti-inflammatory drugs, and by using proper dosage and a careful slow tapering. Patience and appropriate medical therapy are the keys to successful management. In true refractory cases, combination therapy with two or three drugs such as non-steroidal anti-inflammatory drugs, colchicine and corticosteroid may be considered before applying other more complex and less safe treatments. Immunosuppressive drugs and steroid sparing agents might be used, but it should be acknowledged that only weak evidence-based data support their use.

Background— The clinical search for indicators of poor prognosis of acute pericarditis may be useful for clinical triage of patients at high risk of specific causal conditions or complications. The aim of the present article is to assess the relationship between clinical features at presentation and specific causes or complications. Methods and Results— A total of 453 patients aged 17 to 90 years (mean age 52±18 years, 245 men) with acute pericarditis (post–myocardial infarction pericarditis was excluded) were prospectively evaluated from January 1996 to August 2004. A specific cause was found in 76 of 453 patients (16.8%): autoimmune in 33 patients (7.3%), neoplastic in 23 patients (5.1%), tuberculous in 17 patients (3.8%), and purulent in 3 patients (0.7%). In multivariable analysis, women (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.03 to 2.70; P =0.036) and patients with fever >38°C (HR 3.56, 95% CI 1.82 to 6.95; P P =0.002), large effusion or tamponade (HR 2.15, 95% CI 1.09 to 4.23; P =0.026), and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 2.50, 95% CI 1.28 to 4.91; P =0.008) were at increased risk of specific causal conditions. After a mean follow-up of 31 months, complications were detected in 95 patients (21.0%): recurrences in 83 patients (18.3%), tamponade in 14 patients (3.1%), and constriction in 7 patients (1.5%). In multivariable analysis, women (HR 1.65, 95% CI 1.08 to 2.52; P =0.020) and patients with large effusion or tamponade (HR 2.51, 95% CI 1.37 to 4.61; P =0.003) and failure of aspirin or of nonsteroidal anti-inflammatory drugs (HR 5.50, 95% CI 3.56 to 8.51; P Conclusions— Specific clinical features (fever >38°C, subacute course, large effusion or tamponade, and aspirin or NSAID failure) may be useful to identify higher risk of specific causal conditions and complications.

Patterns of spatial and temporal variability of coastal fish assemblages were compared between areas subjected to different levels of protection at two different depths using a visual census technique. A no take reserve was compared with recreational fishing areas around a small Mediterranean island at 5 m and 20 m depth. Univariate and multivariate statistical techniques were used to test the hypothesis that protection could have different effects at different depths. A total of 56 species were identified during the survey. The most represented families were Sparidae and Labridae. Results showed an interaction between depth and levels of protection that was not persistent across the study period. This result was consistent for the whole fish assemblage and for the target species; most species showed higher abundance in protected areas at 20 m depth.

Intravenous drug users (IVDUs) are at increased risk of infective endocarditis. Moreover, HIV infection is common in IVDUs, with a reported prevalence of 40-90%. The clinical features of IVDUs with infective endocarditis and HIV infection may be peculiar. Few data have been reported on the diagnostic accuracy of Duke criteria in IVDUs with or without HIV infection, and a comparison of these two populations is lacking.The present study aimed to compare prospectively the clinical features of patients with infective endocarditis with or without HIV infection and to evaluate the diagnostic accuracy of Duke criteria in these patients. The study population consisted of 201 consecutive adult IVDUs with a suspected infective endocarditis (102 patients with HIV infection and 99 patients without HIV infection).Infective endocarditis was the final diagnosis in 40 of 102 patients (38.2%) with HIV infection and in 55 of 99 HIV-negative patients (55.6%). Despite similar baseline features, longer vegetations were recorded in infective endocarditis without HIV infection (23.7 +/- 7.1 mm versus 13.6 +/- 6.8 mm; P = 0.001). Patients with infective endocarditis and HIV infection had a higher total mortality at 2 months (respectively 12.5% versus 1.8%; P = 0.09); almost all the deaths were recorded in patients with AIDS or a CD4 cell count below 200 per microl, and no deaths were recorded in patients with HIV infection and a CD4 cell count500 per microl.Despite no identical clinical features, Duke criteria had a similar sensitivity, specificity and diagnostic accuracy in IVDUs with and without HIV infection.

The ESCA (Ecological Status of Coralligenous Assemblages) index was recently developed to evaluate the ecological quality of coralligenous habitat. The study aims to improve the first index proposal through testing response to different sources of anthropogenic pressures and optimizing the sampling effort. ESCA was calculated on 14 sites and tested against a gradient of human pressures. Moreover, the main scales of spatial variability of assemblages were evaluated and values of index obtained with different sampling designs were compared. Results showed that studied sites resulted in high, good or moderate ecological status, according to an increasing gradient of the anthropization level. Values of ESCA index obtained with different methods have been compared and photographic method provides EQR values lower than destructive method. Spatial variability of assemblages was higher at large and small scales than at intermediate ones. Two locations for each study site and 20 replicated samples for each location may be consider the best sampling combination providing reliable values of ESCA index for the evaluation of ecological quality of coralligenous assemblages.

Background— Staphylococcus aureus left-sided native valve infective endocarditis (LNVIE) has higher complication and mortality rates compared with endocarditis from other pathogens. Whether echocardiographic variables can predict prognosis in S aureus LNVIE is unknown. Methods and Results— Consecutive patients with LNVIE, enrolled between January 2000 and September 2006, in the International Collaboration on Endocarditis were identified. Subjects without S aureus IE were matched to those with S aureus IE by the propensity of having S aureus . Survival differences were determined using log-rank significance tests. Independent echocardiographic predictors of mortality were identified using Cox-proportional hazards models that included inverse probability of treatment weighting and surgery as a time-dependent covariate. Of 727 subjects with LNVIE and 1-year follow-up, 202 had S aureus IE. One-year survival rates were significantly lower for patients with S aureus IE overall (57% S aureus IE versus 80% non- S aureus IE; P S aureus IE versus 68% non- S aureus IE; P P P =0.004) were the only independent echocardiographic predictors of in-hospital mortality in S aureus LNVIE. Valve perforation (hazard ratio, 2.16; 95% confidence interval, 1.21–3.68; P =0.006) and intracardiac abscess (hazard ratio, 2.25; 95% confidence interval, 1.26–3.78; P =0.004) were the only independent predictors of 1-year mortality. Conclusions— S aureus is an independent predictor of 1-year mortality in subjects with LNVIE. In S aureus LNVIE, intracardiac abscess and left ventricular ejection fraction

Objectives We sought to investigate the safety and efficacy of a protocol for acute pericarditis triage and outpatient management of low-risk cases. Background Acute pericarditis has generally a brief and benign course after empiric treatment by non-steroidal anti-inflammatory drugs, and routine hospitalization of most patients may be unnecessary. Methods From January 1996 to December 2001, all consecutive cases of acute pericarditis were evaluated on a day-hospital basis. Patients without clinical poor prognostic predictors (fever >38°C, subacute onset, immunodepression, trauma, oral anticoagulant therapy, myopericarditis, severe pericardial effusion, cardiac tamponade) were considered low-risk cases and assigned to outpatient treatment with high-dose oral aspirin. Patients with poor prognostic predictors or aspirin failure were hospitalized for etiology search and treatment. A clinical and echocardiographic follow-up was performed at 48 to 72 h, 7 to 10 days, 1 month, 6 months, and 1 year. Results Two hundred fifty-four out of 300 (84.7%) patients were selected as low-risk cases. Outpatient treatment was efficacious in 221 out of 254 (87%) cases. Thirty-three out of 254 patients were hospitalized because of aspirin failure. Patients treated on an out-of-hospital basis had no serious complications after a mean follow-up of 38 months (no cases of cardiac tamponade). A higher frequency of recurrences and constriction was recorded in aspirin-resistant cases than in aspirin responders (60.6% vs. 10.4% for recurrences and 9.1% vs. 0.5% for constriction, respectively; all p Conclusions A protocol for acute pericarditis triage and outpatient therapy of low-risk cases is safe and efficacious and may reduce management costs.

ObjectivesThis study was designed to investigate the prognostic value of cardiac troponin I (cTnI) in viral or idiopathic pericarditis.BackgroundIdiopathic acute pericarditis has been recently reported as a possible cause of nonischemic release of cTnI. The prognostic value of this observation remains unknown.MethodsWe enrolled 118 consecutive cases (age 49.2 ± 18.4 years; 61 men) within 24 h of symptoms onset. A highly sensitive enzymoimmunofluorometric method was used to measure cTnI (acute myocardial infarction [AMI] threshold was 1.5 ng/ml).ResultsA cTnI rise was detectable in 38 patients (32.2%). The following characteristics were more frequently associated with a positive cTnI test: younger age (p < 0.001), male gender (p = 0.007), ST-segment elevation (p < 0.001), and pericardial effusion (p = 0.007) at presentation. An increase beyond AMI threshold was present in nine cases (7.6%), with an associated creatine kinase-MB elevation, a release pattern similar to AMI, and echocardiographic diffuse or localized abnormal left ventricular wall motion without detectable coronary artery disease. After a mean follow-up of 24 months a similar rate of complications was found in patients with a positive or a negative cTnI test (recurrent pericarditis: 18.4 vs. 18.8%; constrictive pericarditis: 0 vs. 1.3%, for all p = NS; no cases of cardiac tamponade or residual left ventricular dysfunction were detected).ConclusionsIn viral or idiopathic acute pericarditis cTnI elevation is frequently observed and commonly associated with young age, male gender, ST-segment elevation, and pericardial effusion at presentation. cTnI increase is roughly related to the extent of myocardial inflammatory involvement and, unlike acute coronary syndromes, is not a negative prognostic marker.

International audience; Background - The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods - Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results - EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions - In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE.

Objective The purpose of this study was to determine the sensitivity and specificity of new criteria proposed by Duke University for case definition of infective endocarditis as compared to the previously accepted Von Reyn criteria. Patients A total of 143 consecutive suspected cases of infective endocarditis in 137 febrile patients were included. Of these, 69 had infective endocarditis, pathologically proven in 28, but with only a clinical diagnosis in 41. In the remaining 74 cases, the diagnosis of-infective endocarditis was rejected after a follow-up of at least 3 months. Results The sensitivity of Duke's criteria was significantly higher, both when patients with possible infective endocarditis were considered as true-positive (definition 1; 100% vs 69%, P

This work presents the development of an inexpensive measurement technique based on miniature microphones for the measurement of pressure fluctuations in a wide frequency range, starting from infrasound up to several kilohertz. Special emphasis has been put on achieving accurate calibration of the system at very low frequencies and good agreement with reference measurements have been achieved at frequencies as low as 1 Hz, therefore opening new low-budget research possibilities in many fields of fluid mechanics. The measurement technique proposed is specially indicated when the number of simultaneous pressure measurements is high since the sensors used are inexpensive, contrarily to common research equipment. One particular area in which this technique results useful is bluff-body aerodynamics. As an example of the potential of the technique, the structural response of a finite-square cylinder immersed in a turbulent flow is studied.

We present the case of a 46 year-old male, HCV infected, treated with corrective surgery for tetralogy of Fallot (TOF) immediately after percutaneous closure of the Blalock Taussig shunt. Four months later, the patient had infective endocarditis by Staphylococcus capitis localised on the right side of the patch, treated by oxacillin and gentamycin. The particularity of our report is the unusual location of the acute endocarditis and the bacterium involved: the pulmonary valve is much more likely to be involved in endocarditis in TOF patients and the patch endocarditis has rarely been reported. Moreover, Staphylococcus capitis has never been reported as a cause of acute endocarditis in corrected TOF patients. We believe that antibiotic therapy should be instituted as soon as possible even though an aggressive surgical treatment is mandatory to achieve complete recovery, mainly when clinical condition and inflammation markers do not improve.

One-hundred-and-fifty-five consecutive symptom-free patients underwent maximal treadmill exercise testing, rest and stress radionuclide angiography at least two months after an uncomplicated acute myocardial infarction; of these, 90 underwent coronary angiography. All patients were followed-up for a mean of 32 +/- 13 months regarding the prediction of hard (death and reinfarction) and soft (angina and coronary surgery) coronary events. The specificity, sensitivity, positive and negative predictive value of exercise stress test were 47%, 76% and 41% for any coronary events; none of the patients who incurred a hard coronary event showed ischemia during electrocardiographic exercise tests. Sensitivity, specificity and positive predictive value for failure to increase the ejection fraction of at least 5% were 60%, 45% and 30% for any coronary event and 25%, 49% and 2% for any hard coronary event. The presence of multivessel disease at coronary angiography showed a sensitivity of 62% for any coronary event and of 67% for hard coronary events; specificities were 66% and 57%, and predictive values were 52% and 10%, respectively. It is concluded that electrocardiographic exercise testing, radionuclide angiography and coronary angiography are not helpful two months after an episode of uncomplicated myocardial infarction in order to identify patients who will suffer a new coronary event.

This paper contributes to the knowledge of macroalgal coralligenous systems. The species composition of coralligenous assemblages of Tuscany's coasts and islands (north-western Mediterranean Sea) was examined and different aspects of alpha and beta diversity were evaluated. The encrusting layer of coralligenous habitat in the study areas mostly comprised the Corallinales Mesophyllum alternans. A total of 187 epiphytic macroalgal species was observed, among them 29 Ochrophyta, 14 Chlorophyta and 144 Rhodophyta. In the studied area, coralligenous assemblages show a similar structure across large scales, as 41species were common to all the studied locations. Multivariate analysis showed that locations along continental coasts were distinct from islands. Vertical and horizontal substrata were distinct on islands, but not in coastal locations. The studied assemblages showed a high diversity, especially in relation to the smaller spatial scales examined.

International audience; Referral bias occurs because of the clustering of patients at tertiary care centers. This may result in the distortion of observed clinical manifestations of rare diseases. This analysis evaluates the effect of referral bias on the epidemiology of infective endocarditis (IE) in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). This is a prospective multicenter cohort study comparing transferred and non-transferred patients with IE. Factors independently associated with transfer status were evaluated using multivariable logistic regression. A total of 2,760 patients were included in the analysis, of which 1,164 (42.2%) were transferred from other medical centers. Transferred patients more often underwent surgery for IE (odds ratio [OR] = 2.5; 95% confidence interval [CI] 1.9-3.2). They were also more likely to have complications such as stroke (OR = 1.5; 95% CI 1.3-1.9), heart failure (OR = 1.4; 95% CI 1.1-1.6), and new valvular regurgitation (OR = 1.3; 95% CI 1.1-1.6). The in-hospital mortality rates were similar in both groups. Patients with IE who require surgery and suffer complications are referred to tertiary hospitals more frequently than patients with an uncomplicated course. Hospital transfer has no obvious effect on the in-hospital mortality. Referral bias should be taken into consideration when describing the clinical spectrum of IE.

Background Antibiotic prophylaxis of patients believed to be at a risk of developing infective endocarditis has been recently revisited with limited indications compared with the previous body of knowledge in use by the medical community. As a consequence, most of the healthcare specialists in cardiology and infectious diseases have doubts related to the enormous change that has been proposed. In this study, we report the results of an Italian consensus of experts in cardiology and infectious diseases, with the aim to offer a national document that illustrates the reasons for such a change through the review of the basis of infective endocarditis prophylaxis, the historical background, and the reasons for the change, providing practical conclusions and illustrating grey areas. Methods The main guidelines published on the topic of antibiotic prophylaxis for infective endocarditis were discussed as well as the risk of anaphylaxis. Overall, the group agreed that the evidence for prophylaxis is weak and limited to few case-control studies, expert opinion, clinical experience, and descriptive studies. Results The 'downgrading' of the indications for prophylaxis is mainly due to a cultural change and a more critical attitude towards available published data. Although the group acknowledge the critical view of the previously published guidelines, it seems to be more practical to consider the issue of prophylaxis without the evidence required by guidelines but rather as a consensus document based on the available data. Conclusion Contemporary guidelines on infective endocarditis prophylaxis challenge previous recommendations based on a low level of evidence. The main recommendation of the study group is to underline that prophylaxis may often be based on adequate education without the administration of antibiotics, which only remains suggested, following the usual practice, in patients with heart diseases, when the risk of a complicated prognosis following infective endocarditis may be anticipated. .

Background— Corticosteroid use is widespread in recurrent pericarditis, even if rarely indicated, and high doses (eg, prednisone 1.0 to 1.5 mg · kg −1 · d −1 ) are generally recommended, although only weak evidence supports their use with possible severe side effects. The aim of this work was to compare side effects, recurrences and other complications, and hospitalizations of a low- versus high-dose regimen of prednisone for recurrent pericarditis. Methods and Results— A retrospective review of all cases of recurrent pericarditis treated with corticosteroids according to different regimens from January 1996 to June 2004 was performed in 2 Italian referral centers. One hundred patients with recurrent pericarditis (mean age, 50.1±15.8 years; 57 females) were included in the study; 49 patients (mean age, 47.5±16.0; 25 females) were treated with low doses of prednisone (0.2 to 0.5 mg · kg −1 · d −1 ), and 51 patients (mean age, 52.6±15.3; 32 females) were treated with prednisone 1.0 mg · kg −1 · d −1 . Baseline demographic and clinical characteristics were well balanced across the groups. Each initial dose was maintained for 4 weeks and then slowly tapered. After adjustment for potential confounders (age, female gender, nonidiopathic origin), only high doses of prednisone were associated with severe side effects, recurrences, and hospitalizations (hazard ratio, 3.61; 95% confidence interval, 1.96 to 6.63; P Conclusions— Use of higher doses of prednisone (1.0 mg · kg −1 · d −1 ) for recurrent pericarditis is associated with more side effects, recurrences, and hospitalizations. Lower doses of prednisone should be considered when corticosteroids are needed to treat pericarditis.

Colchicine appears to be safe and effective in the treatment and prevention of recurrent pericarditis after failure of conventional therapies in case reports and non-randomized observational studies without control groups. On this basis, colchicine has been proposed as a therapeutic choice in the 2004 guidelines of the European Society of Cardiology. However, the exact number of responders is unknown, and no randomized placebo-controlled trial is available to guide the management of recurrent pericarditis. Moreover, some authors recommend the use of the drug at the first recurrence, whereas others propose to consider the drug only after failure of conventional therapies for the second or subsequent recurrence.The CORP trial will enroll 120 patients in a prospective, randomized, double-blind, multicentre investigation of colchicine compared with placebo in patients with a first episode of recurrent pericarditis. In the CORP-2 trial, 240 patients will be enrolled in a prospective, randomized, double-blind, multicentre investigation of colchicine compared with placebo in patients with two or more recurrences. In both trials, the primary efficacy end-point is the recurrence rate at 18 months, the secondary end-points are symptom persistence at 72 h, remission rate at 1 week, number of recurrences, time to recurrence, disease-related hospitalization, cardiac tamponade and constrictive pericarditis.The CORP and CORP-2 trials will be the first randomized placebo-controlled trials in this area. These trials will provide important evidence regarding the possible benefit of the early use of colchicine for the treatment and prevention of recurrent pericarditis.

Background Colchicine is safe and effective in the treatment and prevention of recurrent pericarditis after failure of conventional treatment. The recent guidelines of the European Society of Cardiology suggest that colchicine might be useful even in the treatment of the first episode. However, the use of the drug is not based on any strong evidence obtained from clinical trials, and no randomized placebo-controlled trial is available to guide the management of acute pericarditis. Study design The Investigation on Colchicine for Acute Pericarditis (ICAP) trial will enroll 240 patients in a prospective, randomized, double-blind, multicenter investigation of colchicine compared to placebo in patients with acute pericarditis. The primary efficacy end point is the recurrence rate at 18 months. The secondary end points are symptom persistence at 72 h, remission rate at 1 week, number of recurrences, time to first recurrence, disease-related hospitalization, cardiac tamponade, and constrictive pericarditis. Implications The ICAP trial will be the first randomized placebo-controlled trial in this area. This trial will provide important evidence regarding the possible benefit of the early use of colchicine in the treatment of acute pericarditis and the primary prevention of recurrences, the most troublesome and commonest complication of pericarditis.

To investigate the relative incidence, clinical presentation and prognosis of myopericarditis among patients with idiopathic or viral acute pericarditis.Prospective observational clinical cohort study.Two general hospitals from an urban area of 220 000 inhabitants.274 consecutive cases of idiopathic or viral acute pericarditis between January 2001 and June 2005.Relative prevalence of myopericarditis. Clinical features at presentation including echocardiographic data (ejection fraction (EF), wall motion score index (WMSI)) and follow-up data at 12 months including complications, results of echocardiography, electrocardiography and treadmill testing.Myopericarditis was recorded in 40/274 (14.6%) consecutive patients. At presentation, the following clinical features were independently associated with myopericarditis: arrhythmias (odds ratio (OR) = 17.6, 95% confidence interval (CI) 5.7 to 54.1; p0.001), male gender (OR = 6.4, 95% CI 2.3 to 18.4; p = 0.01), age40 years (OR = 6.1, 95% CI 2.2 to 16.9; p = 0.01), ST elevation (OR = 5.4, 95% CI 1.4 to 20.5; p = 0.013) and a recent febrile syndrome (OR = 2.8, 95% CI 1.1 to 7.7; p = 0.044). After 12 months' follow-up an increase of EF (basal EF 49.6 (5.1)% vs 12-month EF 59.1 (4.6)%; p0.001) and decrease of WMSI (basal WMSI 1.19 (0.27) vs 12-month WMSI 1.02 (0.09); p0.001) were recorded in patients with myopericarditis, with a normalisation of echocardiography, electrocardiography and treadmill testing in 98% of cases. Use of heparin or other anticoagulants (OR = 1.1, 95% CI 0.3 to 3.5; p = 0.918) and myopericarditis (OR = 2.3, 95% CI 0.7 to 7.6; p = 0.187) was not associated with an increased risk of cardiac tamponade or recurrences.Myopericarditis is relatively common and shows a benign evolution also in spontaneous cases not related to vaccination.

Background Embolic events to the central nervous system are a major cause of morbidity and mortality in patients with infective endocarditis (IE). The appropriate role of valvular surgery in reducing such embolic events is unclear. The purpose of this study was to determine the relationship between the initiation of antimicrobial therapy and the temporal incidence of stroke in patients with IE and to determine if this time course differs from that shown for embolic events in previous studies. Methods Prospective incidence cohort study involving 61 tertiary referral centers in 28 countries. Case report forms were analyzed from 1437 consecutive patients with left-sided endocarditis admitted directly to participating centers. Results The crude incidence of stroke in patients receiving appropriate antimicrobial therapy was 4.82/1000 patient days in the first week of therapy and fell to 1.71/1000 patient days in the second week. This rate continued to decline with further therapy. Stroke rates fell similarly regardless of the valve or organism involved. After 1 week of antimicrobial therapy, only 3.1% of the cohort experienced a stroke. Conclusions The risk of stroke in IE falls dramatically after the initiation of effective antimicrobial therapy. The falling risk of stroke in patients with IE as a whole precludes stroke prevention as the sole indication for valvular surgery after 1 week of therapy.