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Infective endocarditis (IE) marks an increasing morbidity and unchanged mortality despite advances in its diagnosis and treatment. In about 20% of IE cases are acute, with signs of sepsis and septic shock. Septic shock dramatically worsens prognosis and is an independent predictor of in – hospital death. Timely diagnosis and urgent surgical intervention can improve survival in these patients. We present a case of a 47-year-old man, with no history of past or concomitant diseases, who was admitted as an emergency to the Cardiology Intensive Care Unit, during the COVID-19 pandemic, with pronounced febrile-intoxication syndrome, shortness of breath, precordial discomfort and pain, cough, haemoptysis. From laboratory studies with a pronounced infl ammatory constellation, troponin I and D-dimers are also increased. This case shows the diffi culties in the diagnosis of acute IE, the specifi cs in the clinical course of the disease, as well as the importance of urgent surgical intervention to improve survival.

Any new pulmonary edema warrants an urgent rule out of acute cardiac dysfunction. Because sepsis protocols emphasize rapid stabilization and treatment over etiologic evaluation, some cases of endocarditis may be missed as sepsis with acute respiratory distress syndrome.

A 69-year-old woman with a history of mitral valve (MV) replacement was admitted for acute respiratory failure due to acute infective endocarditis complicated by cardiogenic shock, severe paravalvular mitral regurgitation (MR), severe degenerative mitral prosthetic valve stenosis, severe aortic

Structural valve degeneration, valve thrombosis, or acute infective endocarditis may affect the postprocedural outcome of transcatheter aortic valve implanted (TAVI) prostheses. Data of patients who required late surgical explant of TAVI prostheses were obtained from 8 European centers. There were 13 patients who underwent surgical treatment for TAVI prosthesis failure after original admission due to prosthetic infective endocarditis in 6 patients, structural valve degeneration in 4, and valve thrombosis in 3. Hospital mortality was 15%, and survival at the 2-year follow-up was 71%. Abstract word count: 80 (C) 2021 by The Society of Thoracic Surgeons

Infective endocarditis of the tricuspid valve is a known complication to intravenous drug use (IDU) and can lead to septic pulmonary embolism. This can be difficult to detect at a standard autopsy. The use of postmortem computed tomography (PMCT) is increasingly used as an important supplement to forensic autopsy. We herein present a case in which the PMCT of a 40-year-old woman with intravenous drug use (IDU) revealed multiple pulmonary infiltrates, which at the subsequent autopsy was shown to be septic pulmonary embolisms as a result of acute infective endocarditis of the tricuspid valve cusps. The endocarditis was macroscopically visible at autopsy, but the pulmonary embolisms were not. The PMCT images showed bipulmonary multiple scattered infiltrates, which were sampled and shown microscopically to be septic pulmonary embolisms. Using PMCT in this case allowed for a more targeted autopsy, and more accurate diagnosis and conclusions as to cause of death. This confirms the important role of PMCT as a complimentary examination method to autopsy.

Background: An accurate biomarker at hospital discharge is needed to identify patients with acute infective endocarditis (IE) who are at high risk of mortality. This prospective observational study evaluated the prognostic value of C-reactive protein (CRP).Methods: Patients with acute IE (n = 343) and hospitalized at 2 university-affiliated medical centers from January 2014 to December 2019 were enrolled. Patients were categorized as having low or high CRP (n = 217 and 126, respectively) at hospital discharge according to the optimal cutoff (CRP = 6.5 mg/L) determined via receiver-operating characteristic curve analysis. The primary endpoint was all-cause death, from hospital discharge to 1 year. The secondary endpoint was the cumulative rate of rehospitalization or paravalvular abscess at 1 year.Results: At the 12-month follow-up, the mortality rate of the high-CRP group (21.43%) was significantly higher than that of the low-CRP group (2.76%, log-rank P < 0.0001). The multivariate regression analysis indicated that the high-CRP group had a higher excess mortality hazard risk (HR = 4.182; 95% CI: 2.120, 5.211; P < 0.001). The cumulative 1-year incidence of paravalvular abscess of the high-CRP group (11.90%) was significantly higher than that of the low-CRP (5.07%; P = 0.022). The cumulative rate of heart rehospitalizations of the 2 groups were similar (18.25% cf. 14.29%, P = 0.273).Conclusion: For hospitalized patients with acute IE, a high CRP at discharge suggests a poor prognosis for 1-year mortality and paravalvular abscess.

Infective endocarditis is an uncommon disease, which most often affects elderly subjects at risk or with favorable factors. Its prognosis is guarded with complications or decompensating factors that are often formidable. We report the case of an acute endocarditis decompensated by acute alithiasic cholecystitis in a 52-year-old patient, with a history of diagnosed end-stage renal failure (GFR 7 ml/min according to the MDRD) for 4 weeks, of undetermined etiology, undergoing hemodialysis, followed for aortic disease for 6 years (IAO grade II, RAO loose). After 6 weeks, the evolution was favorable under adapted and early antibiotic treatment and associated hygiene measures including gastric rest. Infective endocarditis remains a serious pathology, due to its high morbi-mortality. The association of acute infective endocarditis and acute alithiasic cholecystitis is of reserved prognosis especially on a ground of immunodepression like the end-stage chronic renal failure. This association requires a rapid and efficient management., Highlights - Infectious endocarditis most often affects subjects at risk or with favorable factors - Alithiasis cholecystitis is an acute and necrotic inflammation of the gallbladder, in the absence of gallstones - It can be a decompensating factor of an infective endocarditis - The association of acute infective endocarditis and acute alithiasic cholecystitis is of reserved prognosis and requires a fast and effective management

Background: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry.Methods: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 +/- 16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival.Results: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs.Conclusions: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years. (C) 2019 Elsevier B.V. All rights reserved.

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Objectives Despite the controversy, the aortic homograft is supposedly the best option in acute infective endocarditis (AIE), due to its resistance to reinfection. However, the technical complexity and the risk of structural deterioration over time have limited its utilization. The aim of this study was to evaluate the long-term results of aortic homograft for the treatment of infective endocarditis in our institution with particular attention to predictors of survival and homograft reoperation. Methods The cohort includes 112 patients who underwent aortic valve replacement with an aortic homograft for AIE between January 1990 and December 2014. Results Fifteen patients (13.4%) died during the first 30 days after the operation. Two patients were lost to follow-up after discharge from the hospital; therefore, 95 patients were available for long-term analysis. The median duration of follow-up was 7.8 years (IQR 4.7-17.6). Five patients (5.3%) suffered a recurrence of infective endocarditis (1 relapse and 4 new episodes). Sixteen patients (16.8%) were reoperated for structural valve degeneration (SVD; n = 14, 87.5%) or for infection recurrence (n = 2, 12.5%). Freedom from homograft reoperation for infective endocarditis or structural homograft degeneration at 10 and 15 years postoperatively was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively. For patients requiring homograft reoperation, the median interval to reintervention was 11.6 years (IQR 8.3-14.5). Long-term survival was 63.6% (95% CI 52.4-72.8%) and 53.8% (95% CI 40.6-65.3%) at 10 and 15 years, respectively. Conclusions The use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to SVD is significant after one decade especially in young patients. The aortic homograft seems to be ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective process especially in early surgery.

Infective endocarditis (IE) can lead to antibody positive autoimmune vasculitis. Secondary vasculitis due to IE is a critical diagnosis as outcomes favor treating the vegetation. A 71 year old female with dual chamber AICD being treated for non-vegetative MSSA bacteremia presented with septic shock

Valve-in-valve implantation is an alternative to reoperation for patients with degenerated bioprostheses. This case report presents a 75-year-old woman presenting with worsening dyspnoea according New York Heart Association (NYHA) Class III after she had received a Sorin Perceval® S sutureless valve due to severe aortic valve stenosis 5 years ago. Echocardiography revealed a degenerated Perceval valve with severe valvular aortic regurgitation and stenosis. After exclusion of acute infective endocarditis, an Edwards SAPIEN 3 was implanted leading to an immediate haemodynamic improvement. A cerebral protection device caught a big embolized piece of material in the left carotid artery filter. The case demonstrates that not only suture-based stented and stentless bioprostheses can be treated by a valve-in-valve strategy, but it is also feasible to treat a failed sutureless Sorin Perceval using a balloon-expandable SAPIEN 3.

Involvement of the heart is infrequently seen in irritable bowel syndrome (IBD). We present a case of severe acute infective endocarditis diagnosed as ulcerative colitis in further workup.

International audience; AIMS: Indications for surgery in acute infective endocarditis (IE) are detailed in guidelines, but their application is not well known. We analysed the agreement between the patient's attending physicians and European Society of Cardiology guidelines regarding indications for surgery. We also assessed whether surgery was performed in patients who had an indication. METHODS AND RESULTS: From the 2008 prospective population-based French survey on IE, 303 patients with definite left-sided native IE were identified. For each case, we prospectively recorded (i) indication for surgery according to the attending physicians and (ii) indication for surgery according to guidelines. Surgery was indicated in 194 (65%) patients according to attending physicians and in 221 (73%) according to guidelines, while 139 (46%) underwent surgery. Agreement was moderate between attending physicians and guidelines (kappa 0.41-0.59) and between indication according to guidelines and the performance of surgery (kappa 0.38). Of the 90 (30%) patients not operated despite indication, contraindication to surgery was reported by the attending physicians in 42 (47%), and indication was not identified in 48 (53%). One-year survival was 76% in patients with indication and surgery performed (n = 131), 69% in patients without indication and no surgery (n = 74), 56% in patients with identified indication and contraindication to surgery (n = 42), and 60% in patients with no identified indication (n = 48; P = 0.059). CONCLUSION: Cardiac surgery during acute IE was recommended in almost three out of four patients, although fewer than half were actually operated. Indication was not acknowledged by the attending physicians in one out of six patients

This is a case of a 12-year-old boy who complained of unilateral leg pain for 1 month with associated low-grade fevers, weight loss, and joint pain. He was noted on examination to be small for age and had a significant heart murmur. He was subsequently diagnosed as having acute infective endocarditis with septic emboli to the leg causing microabscesses in the calf muscles and leg pain. This case also illustrates the important role of translation in the presence of a language barrier.

Acute intermittent porphyria (AIP) is a disorder of the heme biosynthesis pathway of a specific inherited enzymatic defect. Many different environmental factors such as drugs, calorie restriction, infection etc., often play a key role in triggering a porphiric acute attack. We describe a 50-year-old woman with AIP who underwent aortic valve replacement due to acute infective endocarditis and review the perioperative management of these patients.

Rational: Infective endocarditis caused by a foreign body of the upper digestive tract is rare. We report a rare case of Granulicatella adiacens and Candida albicans coinfection acute endocarditis combined with systematic embolization caused by a fish bone from the esophagus penetrating into the left atrium. Patient concern: A 42-year-old woman was admitted to our hospital because of fever, abdominal pain, headache, and right limb weakness. Diagnoses: Clinical examination indicated endocarditis and systemic embolisms secondary to a fish bone from the esophagus penetrating into the left atrium. The emergency surgery confirmed the diagnosis. Cultures of blood and vegetation show G adiacens and C albicans. Interventions: Antimicrobial therapy lasted 6 weeks after surgery. Outcomes: The patient was discharged with excellent condition7 weeks after hospitalization and was well when followed 6 months later. Lessons: The successful treatment of this patient combines quick diagnosis, timely surgery, and effective antimicrobial regimen. This rare possibility should be kept up in mind in acute infective endocarditis cases.

The mortality in acute infective endocarditis (IE) remains high. Data on results of early surgery are limited. The aim of our study was to determine whether early surgery is associated with reduced 6-month mortality in a large cohort of acute IE.310 consecutive patients examined by transthoracic and transoesophageal echocardiography (229 males; mean age: 60+/-15) with definite IE according to Duke criteria were prospectively enrolled. Early surgery was performed in 106 (34%) patients (37 mechanical prosthesis, 32 biological prosthesis, 19 valve repairs, 15 pace maker line extractions, three multiple valve replacements) with an operative mortality of 5,7%. The mean time between admission and early surgery was 12+/-9 days. Early surgery was performed more frequently in patients with heart failure (48% vs 33%, p=0.009), uncontrolled infection (40% vs 23%; p=0.002), abscess (35% vs 18%; p=0.001), neurological event (34% vs 20%; p=0.005), embolic event (50% vs 34%; p=0.006), severe regurgitation (60% vs 29%; p=0.001) and large vegetation (15 mm) (50% vs 23%; p0.001). In unadjusted analysis, early surgery was associated with lower 6-month mortality (24% vs 37%; p=0.045). After adjustment of variables associated with mortality and comorbidity index, early surgery was identified as an independent predictor of reduced 6-month mortality (HR=0.52; IC 95%=0.2-0.9; p=0.025).Early surgery performed in 34% of patients is independently associated with reduced mortality and should be considered in selected cases to improve outcome in acute IE.

Management of patients with systemic infections and concurrent need for acute pacing due to new-onset of hemodynamic relevant bradycardia such as at high grade AV-block is very difficult. Implantation of a permanent pacemaker is contraindicated in the case of ongoing sepsis. As a bridging therapy temporary pacing is needed in patients with life-threatening bradycardias. The complication rate of a temporary pacing like dislodgement of the pacing wire increases significantly in a time-dependent fashion. Therefore, in cases requiring long-term antibiotic treatment such as endocarditis, a different approach might be considered. We have treated two patients with acute infective endocarditis and new onset of hemodynamically relevant bradycardia with a temporary permanent active-fixation bipolar pacing lead connected to a second-hand disinfected pacemaker in VVI mode. In addition, we provide an overview of other published cases. The use of active-fixation permanent pacing leads connected to an externalized pacemaker for temporary pacing in patients requiring intermediate to long-term antibiotic treatment provides a safe and effective method for prolonged temporary pacing as a bridge to permanent pacing or recovery.

Aortic-left ventricular tunnel is a rare congenital cardiac anomaly, which always arises from the right coronary sinus and enters the left ventricle, occasionally the right ventricle and right atrium. However, aortic and left ventricular tunnel associated with infective endocarditis is rarely seen in literatures. Here, we present a case of aortic and left ventricular tunnel associated with infective endocarditis in a 47-year-old man.

a Department of Ultrasound, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen, China b Institute of Vascular Medicine, Institute of Innovative Medicine, Division of Cardiology and Heart Education and Research Training (HEART) Center, Li Ka Shing Institute of Health Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong c Department of Cardiovascular Surgery, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen Heart Center, Xiamen, China

Guidance on the proper diagnosis and treatment of acute infective endocarditis, particularly in intravenous drug users. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Gram-negative bacilli causing infective endocarditis (IE) is rare, even in intravenous drug users. This case report underscores several clinically important aspects of Delftia acidovorans IE: the organism's ability to cause rapid destruction of normal native valves and to cause embolic occlusion of large arteries and its resistance to all aminoglycosides.

The courses of two patients with pseudoaneurysm formation following aortic valve replacement using homografts are reported. Both patients had aortic valve replacement due to acute infective endocarditis with paravalvular abscess formation. The first case had an uneventful postoperative course; but on routine echocardiography, a pseudoaneurysm located at the left coronary commissure was found at one year follow-up. As the pseudoaneurysm was completely asymptomatic, the patient was followed up carefully at six months intervals. The second patient also had pseudoaneurysm formation postoperatively, but he presented one year after surgery with fever and elevated leucocyte count. He had surgical revision of the pseudoaneurysm because no other reason for an infection could be found. Four months later he presented again with infection signs and pseudoaneurysm formation. This time, the homograft was completely excised and another homograft was implanted. One year after the final operation, he is now free from re-infection. The two presented courses show that pseudoaneurysms complicating aortic valve replacement should be managed according to attendant circumstances and symptoms.

Acute infective endocarditis is a complex disease with changing epidemiology and a rapidly evolving knowledge base. To consistently achieve optimal outcomes in the management of infective endocarditis, the clinical team must have an understanding of the epidemiology, microbiology, and natural history of infective endocarditis, as well as a grasp of guiding principles of diagnosis and medical and surgical management. The focus of this review is acute infective endocarditis, though many studies of diagnosis and treatment do not differentiate between acute and subacute disease, and indeed many principles of diagnosis and management of infective endocarditis for acute and subacute disease are identical.

A Chiari's network, noted in approximately 2% of the general population, is a congenital remnant of the sinus venosum valve present in the right atrium. We report a case of a 67-year-old male who presented with acute infective endocarditis of the tricuspid valve due to coagulase-negative Staphylococci. Despite appropriate antimicrobial therapy for 2 weeks, the patient remained febrile with septic emboli to the pulmonary vasculature. Repeat transthoracic echocardiography (TTE) revealed persistent vegetations adherent to the tricuspid valve, extending onto the Chiari network, necessitating surgical intervention.

To the Editor: Despite advances in diagnosis and treatment, acute infective endocarditis remains a therapeutic challenge, with considerable morbidity and mortality. The therapeutic strategies for t...

A 40-year-old female presented with prolonged fever and new-onset seizures. On examination, she was found to have florid peripheral manifestations of infective endocarditis (IE), namely skin petechiae, subconjunctival hemorrhages, Janeway lesions, Osler nodes, and splinter hemorrhages. This helped in early, focused investigation and diagnosis of IE. Peripheral manifestations of subacute IE are rare in the current era of clinical practice owing to early diagnosis and treatment. We present a case where multiple peripheral signs were identified in the same patient.

A 72-year-old man with a 3-month history of fatigue and weight loss of 9 kg presented to hospital with a diffuse lower extremity rash. On examination, we found conjunctival petechiae, non-tender violaceous lesions on his palms and fingers, palpable purpura and petechiae over his legs and buttocks (figure, A), and a pansystolic murmur (grade III/VI) at the left lower sternal border, which radiated to the axilla. He had a normocytic anaemia and mild renal failure. While receiving a transfusion of red blood cells, he developed acute pulmonary oedema (figure, B) and was endotracheally intubated. We did a transthoracic echocardiography, which revealed a mobile mass on the posterior mitral valve leaflet and severe regurgitation. We treated the patient with intra-aortic balloon counter-pulsation and mitral valve replacement. Blood cultures subsequently grew Streptococcus oralis. He completed 6 weeks of antibiotic therapy and apart from residual renal insufficiency is recovering well.

Systemic embolization is common in infective endocarditis and is known to occur in 45-65% of cases. Coronary artery embolism has been seen in as many as 60% of cases at necropsy. However, it only rarely has been described as resulting in transmural myocardial infarction. In most cases, coronary embolism is inferred from circumstantial evidence. We present two patients with myocardial infarction in the setting of acute infective endocarditis. Current issues regarding the management of myocardial infarction in infective endocarditis are described in this article. We also describe the first documented case of Lactobacillus jensenii endocarditis leading to myocardial infarction. Possible factors, which may be instrumental in producing endocarditis with this organism, are also discussed.