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Infections, Complications and Management of Endocarditis

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (20 June 2022) | Viewed by 12927

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Prof. Dr. Pascal Lim

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Cardiology Department, Henri Mondor University Hospital, AP-HP, Creteil, France
Interests: endocarditis; structural heart disease; cardiogenic shock; cardiac imaging
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Dr. Raphaël Lepeule

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Department of Infectious Diseases, Henri-Mondor University Hospital, AP-HP, 94000 Creteil, France
Interests: infectious disease; antibiotic; endocarditis
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Dear Colleagues,

Endocarditis is a rare disease, and the outcome remains poor despite improvement in diagnosis and treatment strategies. Expert endocarditis centers and endocarditis teams have reduced endocarditis mortality by improving diagnosis and surgical timing. However, the epidemiological and clinical patient characteristics are changing rapidly because of an aging population and the widespread development and implantation of percutaneous cardiac devices. In this setting, clinicians need specific studies addressing optimal diagnosis and therapeutic strategies. The sensitivity of the Duke’s criteria to diagnose endocarditis related to intracardiac prosthesis or devices has been improved with the use of cardiac CT and PET CT, but the price to pay is a reduction in specificity. Multimodality imaging with or without a merging approach should be investigated to counterbalance this decrease in specificity. Standardization of imaging criteria using parametric imaging is also needed to simplify the interpretation, reduce inter- and intra-observer bias and improve the reproducibility. This is a key point because cardiac surgery is mainly based on imaging findings, which remain partly subjective. New microbiological techniques should also be investigated, particularly the potential utility of metagenomic sequencing for improving etiologic diagnosis of blood culture-negative or due to fastidious bacteria endocarditis. Importantly, more investigation is needed to define the role of adaptive antibiotic regimen to prevent renal and neurological toxicity in the aging population. Studies should both address the efficiency of suppressive antibiotherapy regimen since a larger proportion of patients may be treated medically but also clearly define the place of cardiac surgery.

Prof. Dr. Pascal Lim
Dr. Raphaël Lepeule
Guest Editors

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Keywords

Endocarditis
Structural heart disease
Cardiac surgery
Antibiotic strategy

Related Special Issue

Infections, Complications and Management of Endocarditis: Part II in Journal of Clinical Medicine (2 articles)

Published Papers (6 papers)

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Research

10 pages, 1446 KiB

Open AccessArticle

Vasoplegic Syndrome after Cardiac Surgery for Infective Endocarditis

by Pascal Lim, Margaux Le Maistre, Lucas Benoudiba Campanini, Quentin De Roux, Nicolas Mongardon, Valentin Landon, Hassina Bouguerra, David Aouate, Paul-Louis Woerther, Fihman Vincent, Adrien Galy, Vania Tacher, Sébastien Galien, Pierre-Vladimir Ennezat, Antonio Fiore, Thierry Folliguet, Raphaelle Huguet, Armand Mekontso-Dessap, Bernard Iung and Raphael Lepeule

J. Clin. Med. 2022, 11(19), 5523; https://doi.org/10.3390/jcm11195523 - 21 Sep 2022

Cited by 2 | Viewed by 1380

Abstract

Purpose: Post-operative vasoplegic syndrome is a dreaded complication in infective endocarditis (IE). Methods and Results: This retrospective study included 166 consecutive patients referred to cardiac surgery for non-shocked IE. Post-operative vasoplegic syndrome was defined as a persistent hypotension (mean blood pressure < 65 mmHg) refractory to fluid loading and cardiac output restoration. Cardiac surgery was performed 7 (5–12) days after the beginning of antibiotic treatment, 4 (1–9) days after negative blood culture and in 72.3% patients with adapted anti-biotherapy. Timing of cardiac surgery was based on ESC guidelines and operating room availability. Most patients required valve replacement (80%) and cardiopulmonary bypass (CPB) duration was 106 (95–184) min. Multivalvular surgery was performed in 43 patients, 32 had tricuspid valve surgery. Post-operative vasoplegic syndrome was reported in 53/166 patients (31.9%, 95% confidence interval of 24.8–39.0%) of the whole population; only 15.1% (n = 8) of vasoplegic patients had a post-operative documented infection (6 positive blood cultures) and no difference was reported between vasoplegic and non-vasoplegic patients for valve culture and the timing of cardiac surgery. Of the 23 (13.8%) in hospital-deaths, 87.0% (n = 20) occurred in the vasoplegic group and the main causes of death were multiorgan failure (n = 17) and neurological complications (n = 3). Variables independently associated with vasoplegic syndrome were CPB duration (1.82 (1.16–2.88) per tertile) and NTproBNP level (2.11 (1.35–3.30) per tertile). Conclusions: Post-operative vasoplegic syndrome is frequent and is the main cause of death after IE cardiac surgery. Our data suggested that the mechanism of vasoplegic syndrome was more related to inflammatory cardiovascular injury rather than the consequence of ongoing bacteremia. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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10 pages, 715 KiB

Open AccessArticle

Multivalvular Endocarditis: A Rare Condition with Poor Prognosis

by Sara Álvarez-Zaballos, Victor González-Ramallo, Eduard Quintana, Patricia Muñoz, Sofía de la Villa-Martínez, M. Carmen Fariñas, Francisco Arnáiz-de las Revillas, Arístides de Alarcón, M. Ángeles Rodríguez-Esteban, José M. Miró, Miguel Angel Goenaga, Josune Goikoetxea-Agirre, Elisa García-Vázquez, Lucía Boix-Palop, Manuel Martínez-Sellés and on behalf of GAMES

J. Clin. Med. 2022, 11(16), 4736; https://doi.org/10.3390/jcm11164736 - 13 Aug 2022

Cited by 8 | Viewed by 1884

Abstract

Background. Infective endocarditis (IE) is a severe condition. Our aim was to describe the profile and prognosis of patients with multivalvular infective endocarditis (MIE) and compare them to single-valve IE (SIE). Methods. We used a retrospective analysis of the Spanish IE Registry (2008–2020). Results. From 4064 definite cases of valvular IE, 577 (14.2%) had MIE. In patients with MIE, the most common locations were mitral (552, 95.7%) and aortic (550, 95.3%), with mitral-aortic involvement present in 507 patients (87.9%). The most common etiologies were S. viridans (192, 33.3%) and S. aureus (113, 19.6%). MIE involved only native valves in 450 patients (78.0%). Compared with patients with SIE, patients with MIE had a similar age (69 vs. 67 years, respectively, p = 0.27) and similar baseline characteristics, but were more frequently men (67.1% vs. 72.9%, p = 0.005) and had a higher incidence of intracardiac complications (36.2% vs. 50.4%, p < 0.001), heart failure (42.7% vs. 52.9%, p < 0.001), surgical indication (67.7 vs. 85.1%, p < 0.001), surgery (46.3% vs. 56.3%), and in-hospital mortality (26.9% vs. 34.3%, p < 0.001). MIE was an independent predictor of in-hospital mortality (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1–1.7, p = 0.004) but did not have an independent association with 1-year mortality (OR 1.1, 95% CI 0.9–1.4, p = 0.43). Conclusions. About one-seventh of the valvular IE patients had MIE, mainly due to mitral-aortic involvement. MIE is associated with a poor in-hospital prognosis. An early diagnosis and treatment of IE might avoid its spread to a second valve. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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12 pages, 2980 KiB

Open AccessArticle

Risk Factors for Mortality in Cardiac Implantable Electronic Device (CIED) Infections: A Systematic Review and Meta-Analysis

by Jinghao Nicholas Ngiam, Tze Sian Liong, Meng Ying Sim, Nicholas W. S. Chew, Ching-Hui Sia, Siew Pang Chan, Toon Wei Lim, Tiong-Cheng Yeo, Paul Anantharajah Tambyah, Poay Huan Loh, Kian Keong Poh and William K. F. Kong

J. Clin. Med. 2022, 11(11), 3063; https://doi.org/10.3390/jcm11113063 (registering DOI) - 29 May 2022

Cited by 10 | Viewed by 2644

Abstract

Background: Infections following cardiac implantable electronic device (CIED) implantation can require surgical device removal and often results in significant cost, morbidity, and potentially mortality. We aimed to systemically review the literature and identify risk factors associated with mortality following CIED infection. Methods: Electronic searches (up to June 2021) were performed on PubMed and Scopus. Twelve studies (10 retrospective, 2 prospective cohort studies) were included for analysis. Meta-analysis was conducted with the restricted maximum likelihood method, with mortality as the outcome. The overall mortality was 13.7% (438/1398) following CIED infection. Results: On meta-analysis, the male sex (OR 0.77, 95%CI 0.57–1.01, I² = 2.2%) appeared to have lower odds for mortality, while diabetes mellitus appeared to be associated with higher mortality (OR 1.47, 95%CI 0.67–3.26, I² = 81.4%), although these trends did not reach statistical significance. Staphylococcus aureus as the causative organism (OR 2.71, 95%CI 1.76–4.19, I² = 0.0%), presence of heart failure (OR 1.92, 95%CI 1.42–4.19, I² = 0.0%) and embolic phenomena (OR 4.00, 95%CI 1.67–9.56, I² = 69.8%) were associated with higher mortality. Surgical removal of CIED was associated with lower mortality compared with conservative management with antibiotics alone (OR 0.22, 95%CI 0.09–0.50, I² = 62.8%). Conclusion: We identified important risk factors associated with mortality in CIED infections, including Staphyloccocus aureus as the causative organism, and the presence of complications, such as heart failure and embolic phenomena. Surgery, where possible, was associated with better outcomes. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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12 pages, 581 KiB

Open AccessArticle

Unreliability of Clinical Prediction Rules to Exclude without Echocardiography Infective Endocarditis in Staphylococcus aureus Bacteremia

by Jorge Calderón-Parra, Itziar Diego-Yagüe, Beatriz Santamarina-Alcantud, Susana Mingo-Santos, Alberto Mora-Vargas, José Manuel Vázquez-Comendador, Ana Fernández-Cruz, Elena Muñez-Rubio, Andrea Gutiérrez-Villanueva, Isabel Sánchez-Romero and Antonio Ramos-Martínez

J. Clin. Med. 2022, 11(6), 1502; https://doi.org/10.3390/jcm11061502 - 9 Mar 2022

Cited by 5 | Viewed by 1986

Abstract

Background: It is unclear whether the use of clinical prediction rules is sufficient to rule out infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB) without an echocardiogram evaluation, either transthoracic (TTE) and/or transesophageal (TEE). Our primary purpose was to test the usefulness of PREDICT, POSITIVE, and VIRSTA scores to rule out IE without echocardiography. Our secondary purpose was to evaluate whether not performing an echocardiogram evaluation is associated with higher mortality. Methods: We conducted a unicentric retrospective cohort including all patients with a first SAB episode from January 2015 to December 2020. IE was defined according to modified Duke criteria. We predefined threshold cutoff points to consider that IE was ruled out by means of the mentioned scores. To assess 30-day mortality, we used a multivariable regression model considering performing an echocardiogram as covariate. Results: Out of 404 patients, IE was diagnosed in 50 (12.4%). Prevalence of IE within patients with negative PREDICT, POSITIVE, and VIRSTA scores was: 3.6% (95% CI 0.1–6.9%), 4.9% (95% CI 2.2–7.7%), and 2.2% (95% CI 0.2–4.3%), respectively. Patients with negative VIRSTA and negative TTE had an IE prevalence of 0.9% (95% CI 0–2.8%). Performing an echocardiogram was independently associated with lower 30-day mortality (OR 0.24 95% CI 0.10–0.54, p = 0.001). Conclusion: PREDICT and POSITIVE scores were not sufficient to rule out IE without TEE. In patients with negative VIRSTA score, it was doubtful if IE could be discarded with a negative TTE. Not performing an echocardiogram was associated with worse outcomes, which might be related to presence of occult IE. Further studies are needed to assess the usefulness of clinical prediction rules in avoiding echocardiographic evaluation in SAB patients. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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11 pages, 562 KiB

Open AccessArticle

Impact of an In-Hospital Endocarditis Team and a State-Wide Endocarditis Network on Perioperative Outcomes

by Mahmoud Diab, Marcus Franz, Stefan Hagel, Albrecht Guenther, Antonio Struve, Rita Musleh, Anika Penzel, Christoph Sponholz, Thomas Lehmann, Henning Kuehn, Karim Ibrahim, Marcus Jahnecke, Holger Sigusch, Henning Ebelt, Gloria Faerber, Otto W. Witte, Bettina Loeffler, Michael Bauer, Mathias W. Pletz, P. Christian Schulze and Torsten Doenst Show full author list Hide full author list

J. Clin. Med. 2021, 10(20), 4734; https://doi.org/10.3390/jcm10204734 - 15 Oct 2021

Cited by 10 | Viewed by 2018

Abstract

Background: Infective endocarditis (IE) requires multidisciplinary management. We established an endocarditis team within our hospital in 2011 and a state-wide endocarditis network with referring hospitals in 2015. We aimed to investigate their impact on perioperative outcomes. Methods: We retrospectively analyzed data from patients operated on for IE in our center between 01/2007 and 03/2018. To investigate the impact of the endocarditis network on referral latency and pre-operative complications we divided patients into two eras: before (n = 409) and after (n = 221) 01/2015. To investigate the impact of the endocarditis team on post-operative outcomes we conducted multivariate binary logistic regression analyses for the whole population. Kaplan–Meier estimates of 5-year survival were reported. Results: In the second era, after establishing the endocarditis network, the median time from symptoms to referral was halved (7 days (interquartile range: 2–19) vs. 15 days (interquartile range: 6–35)), and pre-operative endocarditis-related complications were reduced, i.e., stroke (14% vs. 27%, p < 0.001), heart failure (45% vs. 69%, p < 0.001), cardiac abscesses (24% vs. 34%, p = 0.018), and acute requirement of hemodialysis (8% vs. 14%, p = 0.026). In both eras, a lack of recommendations from the endocarditis team was an independent predictor for in-hospital mortality (adjusted odds ratio: 2.12, 95% CI: 1.27–3.53, p = 0.004) and post-operative stroke (adjusted odds ratio: 2.23, 95% CI: 1.12–4.39, p = 0.02), and was associated with worse 5-year survival (59% vs. 40%, log-rank < 0.001). Conclusion: The establishment of an endocarditis network led to the earlier referral of patients with fewer pre-operative endocarditis-related complications. Adhering to endocarditis team recommendations was an independent predictor for lower post-operative stroke and in-hospital mortality, and was associated with better 5-year survival. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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10 pages, 487 KiB

Open AccessArticle

Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism—The Risk of Intermediate Deterioration

by Alexey Dashkevich, Georg Bratkov, Yupeng Li, Dominik Joskowiak, Sven Peterss, Gerd Juchem, Christian Hagl and Maximilian Luehr

J. Clin. Med. 2021, 10(10), 2136; https://doi.org/10.3390/jcm10102136 - 15 May 2021

Cited by 9 | Viewed by 2108

Abstract

Cerebral embolism due to infective endocarditis (IE) is associated with significant morbidity and mortality. The optimal time-interval between symptomatic stroke and cardiac surgery remains unclear. This study aimed to analyze the patients’ outcomes and define the potential risk factors with regard to surgical timing for IE patients with preoperative symptomatic cerebral embolism (CE). A total of 119 IE patients with CE were identified and analyzed with regard to operative timing: early (1–7 days), intermediate (8–21 days), and late (>22 days). The preoperative patient data, comorbidities and previous cardiac surgical procedures were analyzed to identify potential predictors and independent risk factors for in-hospital mortality using univariate and multivariate regression analysis. Actuarial survival was estimated by the Kaplan-Meier method. In-hospital mortality for the entire study cohort was 15.1% (n = 18), and in comparison, between groups was found to be highest in the intermediate surgical group (25.7%). Univariate analysis identified preoperative mechanical ventilation dependent respiratory insufficiency (p = 0.006), preoperative renal insufficiency (p = 0.019), age (p = 0.002), large vegetations (p = 0.018) as well as intermediate (p = 0.026), and late (p = 0.041) surgery as predictors of in-hospital mortality. The presence of large vegetations (>8 mm) (p = 0.019) and increased age (p = 0.037)—but not operative timing—were identified as independent risk factors for in-hospital mortality. In the presence of large vegetations (>8 mm), cardiac surgery should be performed early and independently from the entity of cerebral embolic stroke. Postponing surgery to achieve clinical stabilization and better postoperative outcomes of IE patients with CE is reasonable, however, worsening of the disease process with deterioration and resulting heart failure during the first 3 weeks after CE results in a significantly higher in-hospital mortality and inferior long-term survival. Full article

(This article belongs to the Special Issue Infections, Complications and Management of Endocarditis)

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