Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Lucy Q Zhang ◽  
Sung Cho ◽  
Robert Marquardt ◽  
Prateek Thatikunta ◽  
M. Shazam Hussain ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Valve Replacement ◽  
Hemorrhagic Stroke ◽  
Neurological Complication ◽  
Neurological Complications ◽  
Early Surgery ◽  
Optimal Timing ◽  
Native Valve ◽  
Cerebral Angiogram ◽  
Duke Criteria

Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke. Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as >14 days. Neurological complication is defined as delirium >72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke. Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p<0.05), but pre-operative stroke on imaging was not. Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.

scholarly journals PERDARAHAN INTRASEREBRAL SEBAGAI KOMPLIKASI NEUROLOGI EMBOLI SEPTIK PADA ENDOKARDITIS INFEKTIF: SEBUAH LAPORAN KASUS

2020 ◽  
Vol 36 (4) ◽  
Author(s):  
Mohammad Kurniawan ◽  
Salim Harris ◽  
Al Rasyid ◽  
Taufik Mesiano ◽  
Rakhmad Hidayat ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Intracerebral Hemorrhage ◽  
American Heart Association ◽  
American Heart ◽  
Neurological Complication ◽  
Vascular Occlusion ◽  
Heart Association ◽  
Neurological Complications ◽  
Septic Embolism ◽  
Duke Criteria

      INTRACEREBRAL HEMORRHAGE AS A NEUROLOGICAL COMPLICATION OF SEPTIC EMBOLISM IN INFECTIVE ENDOCARDITIS: A CASE REPORTABSTRACTInfective endocarditis (IE) is a life-threatening disease. The incidence of IE in developing countries is reported at 1.7-6.2 per 100,000 individuals per year. IE is also known as a potential condition for embolization, especially septic embolism to the brain. Septic embolism results in various neurological complications and manifestations due to vascular occlusion, aneurysm formation and rupture of the aneurysm. We report a case of 34-year-old male with definitive IE based on Duke criteria who experienced neurological complications of intracerebral bleeding. Patient was given pharmacological treatment according to the guidelines of the American Heart Association (AHA)with improvement in clinical symptoms.Keywords: Infective endocarditis, intracerebral hemorrhage, septic embolismABSTRAKEndokarditis infektif (EI) merupakan penyakit yang mengancam nyawa, walaupun angka kejadiannya kecil, yaitu 1,7-6,2 per 100.000 individu per tahun di negara berkembang. EI juga sangat potensial menyebabkan embolisasi, khususnya emboli septik ke otak. Emboli ini mengakibatkan manifestasi gangguan neurologis yang disebabkan karena oklusi pembuluh pembentukan dan ruptur aneurisma. Dilaporkan kasus seorang laki-laki 34 tahun dengan EI definitif berdasarkan kriteria Duke yang mengalami komplikasi neurologis perdarahan intraserebral. Pasien ditatalaksana sesuai panduan American Heart Association (AHA) dengan perbaikan gejala klinis.Kata kunci: Endokarditis infektif, emboli septik, perdarahan intrakranial  

Abstract 84: Ischemic and Hemorrhagic Stroke in Infective Endocarditis: Features, Predictors and Trends Over Three Decades

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mehmet A Topcuoglu ◽  
Oguzhan Kursun ◽  
Ferdinando S Buonanno ◽  
Eric M Isselbacher ◽  
Rocio M Hurtado ◽  
...  
Keyword(s):  
Renal Failure ◽  
Ischemic Stroke ◽  
Infective Endocarditis ◽  
Hemorrhagic Stroke ◽  
Anterior Circulation ◽  
Native Valve ◽  
Stroke Subtypes ◽  
Home Discharge ◽  
Duke Criteria ◽  
Stroke Group

Background: Stroke is a major complication of infective endocarditis (IE). The features and predictors of ischemic and hemorrhagic stroke subtypes are unknown. Methods and Results: In this retrospective study (1980-2011) we used original Duke criteria to diagnose IE in 1149 episodes (1081 patients; 81% definite, 80% native valve). Neuro complications occurred in 28% including infarcts (17.6%), ICH (4.6%), meningitis (4%), brain/spinal abscess (8%), and seizures (2%). Ischemic stroke was the isolated presenting symptom in 11%; its most frequent presentations were total/partial anterior-circulation syndrome (47%) and embolic encephalopathy (21%). On DWI, infarcts were disseminated small (45%) or multi-sized (31%), single (16%), or territorial (9%). Disseminated infarcts were associated with poor outcome (p=0.026). Post-ischemic hemorrhage occurred in 6.4%. Primary ICH was evident on admission in 55% including 36 parenchymal (92% lobar), 13 SAH (69% convexal) and 4 SDH. As compared to the non-stroke group (n=885), the ischemic (n=202) and hemorrhagic stroke (n=53) groups had higher rates of complications (e.g., meningitis, seizures, sepsis, renal failure), longer LOS, higher mortality, and lower rates of home discharge (all p<0.05). Both stroke groups had higher rates of S. viridans and Group B strep infections and more valvular vegetations; the ischemic stroke group had more intracardiac thrombi, and the hemorrhagic stroke group had more mechanical valve infection (all p<0.05). Heparin use was associated with a higher rate of new infarcts (12% vs. 5%, p=0.027) but not ICH (2.4% vs. 1.4%, p=0.6). Overall mortality (14.6%) was higher in both stroke groups, however both groups had similar neurological mortality. Mitral valve involvement, sepsis, and strep infections were independent predictors of both ischemic and hemorrhagic stroke. Age, renal failure, heart failure, sepsis, and Staph aureus endocarditis were independent predictors of non-home discharge. Over three decades the LOS decreased, ischemic stroke rates increased, but there was no change in ICH or mortality rates. Conclusion: Endocarditis-related ischemic and hemorrhagic stroke subtypes have overlapping risk factors, predictors, clinical phenotypes, and effects on outcome.

scholarly journals Corynebacterium jeikeium native valve infective endocarditis case report: a confirmed microbiological and pathological diagnosis from heart valvular tissue

2020 ◽  
Author(s):  
Wentzel Bruce Dowling ◽  
Johan Koen
Keyword(s):  
Infective Endocarditis ◽  
Aortic Valve ◽  
Penicillin G ◽  
Peripheral Vascular ◽  
Native Valve ◽  
Valve Tissue ◽  
Case Summary ◽  
Duke Criteria ◽  
G Prior ◽  
Initial Blood

Abstract Background The Modified Duke criteria is an important structured schematic for the diagnosis of infective endocarditis (IE). Corynebacterium jeikeium is a rare cause of IE that is often resistant to standard IE anti-microbials. We present a case of C. jeikeium IE, fulfilling the Modified Duke pathological criteria. Case summary A 50-year-old male presented with left leg peripheral vascular disease with septic changes requiring amputation. Routine echocardiography post-amputation demonstrated severe aortic valve regurgitation with vegetations that required valve replacement. Two initial blood cultures from a single venepuncture showed Streptococcus mitis which was treated with penicillin G prior to surgery. Subsequent aortic valve tissue cultured C. jeikeium with suggestive IE histological valvular changes and was successfully treated on a prolonged course of vancomycin. Discussion This is the first C. jeikeium IE case diagnosed on heart valvular tissue culture and highlights the importance for the fulfilment of the Modified Duke criteria in diagnosing left-sided IE. Mixed infection IE is rare, and this case possibly represents an unmasking of resistant C. jeikeium IE following initial treatment of penicillin G.

Abstract WP335: Intracranial Mycotic Aneurysms in Infective Endocarditis: Incidence, Predictors and Outcome

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mehmet A Topcuoglu ◽  
Oguzhan Kursun ◽  
Ferdinando S Buonanno ◽  
Aneesh B Singhal
Keyword(s):  
Infective Endocarditis ◽  
Mitral Regurgitation ◽  
Multivariable Analysis ◽  
Native Valve ◽  
Duke Criteria ◽  
Mycotic Aneurysms ◽  
Mean Size ◽  
Pre Treatment ◽  
Cardiac Valve Disease

Introduction: Intracranial mycotic aneurysms (IMA) are rare but serious complications of infective endocarditis (IE). Methods and Results: In this retrospective study (1980-2011) we used original Duke criteria to diagnose IE in 1149 episodes (1081 patients; 81% definite, 80% native valve). Neuro complications occurred in 28%, stroke in 22% (202 infarcts, 53 hemorrhages) and 1% had TIA/TMB. N=33 IMA were detected in 23 (2%) patients. IMA were detected in 8% with focal neuro deficits, 13% with seizures, and 3% with encephalopathy. IMA-related symptoms were present in 22 of 23 cases: headache 48%, seizure 13%, altered sensorium 35% and focal deficits 61%. IMA were detected in 0/885 without stroke, 5.4% with infarcts and 22.6% with hemorrhages (p<0.001); the latter included 9/36 (25%) with ICH, 3/13 (23%) with SAH, and 0/4 with SDH. Of the 23 IMA patients 61% had hemorrhage, 30% had SAH and 57% had infarcts. IMAs were detected by DSA in 21/166 (12.7%). The mean size was 3.6±2.4 mm; 30% multiple; 61% located in distal segments; and 67% in MCA branches. On MRI, 31 had any SAH and 45 had any ICH; IMA detected in 6/9 with diffuse SAH, 2/22 with convexal SAH, 11/45 with ICH, and 11/202 with infarcts. Patients with IMA had higher rates of women, hypertension, known cardiac valve disease, mitral regurgitation, mitral vegetation and S.viridians infection (all p<0.05). On multivariable analysis, mitral regurgitation with vegetation (OR 5.9, 95% CI 2.5-14.0, p<0.001) was the only independent predictor of IMA. Clipping was performed in 8 (all pre-2000); endovascular treatment in 7 (all post-1997); 2 died pre- treatment; 1 detected on autopsy; 1 no follow-up available, and 4 regressed/disappeared with antibiotics. Patients with and without IMA showed no difference in rates of in-hospital mortality (22% v. 19%, p=0.93), and length of stay (32d v. 24d, p=0.28). IMA rates did not decrease during the study period (2.2% in 784 episodes 1980-2000 vs. 1.6% of 365 episodes 2001-2011, p=0.653). Conclusion: IMA are invariably heralded by neurological symptoms and stroke (especially hemorrhages) on brain imaging. Mitral IE has the highest risk for IMA. IMAs can resolve with antibiotics however studies are needed to determine the efficacy of different treatment approaches.

scholarly journals Early surgery for native valve infective endocarditis

Critical Care ◽  
2013 ◽  
Vol 17 (1) ◽  
Author(s):  
Khursheed Haider ◽  
Michael R Pinsky
Keyword(s):  
Infective Endocarditis ◽  
Early Surgery ◽  
Native Valve

Clinical and pathogen features of infective endocarditis:A retrospective study of 111 episodes in a teaching hospital in southwest China

2019 ◽  
Author(s):  
Yuanfang Wang ◽  
Mei Kang ◽  
Ya Liu ◽  
Siyin Wu ◽  
Weili Zhang ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Heart Disease ◽  
Infective Endocarditis ◽  
Laboratory Data ◽  
Clinical Manifestations ◽  
Resistance Rate ◽  
Native Valve ◽  
Duke Criteria ◽  
Preventive Medication ◽  
History Of

Abstract Background Infective endocarditis (IE) is a health-threaten infectious disease. Diverse and complicated etiology and causative microorganisms make IE difficult to diagnose and treat. As we know, current investigations of clinical and pathogen features of IE in West china are scarce. In this study, we aimed to investigate the epidemiology and pathogen characteristic of IE in our region. Methods A retrospective analysis of clinical and laboratory data was performed from all blood culture positive IE patients between 2012 to 2017 in Westchina Hospital of Sichuan University。The diagnosis is traditionally based on the modified Duke criteria. Results The mean age of the patient cohort was 40.7±21.5 years (ranging from 2-78); 73 cases (65.2%) were males and 39 cases (34.8%) were females. Of the 111 cases, 100 were native valve endocarditis (NVE) while 11 were prosthetic valve endocarditis (PVE), 87 cases (78.4%) were left-heart infection. Congenital heart disease (28.6%) and rheumatic heart disease (11.6%) were most common history of heart disease. Primary clinical manifestations were fever (87.5%) and heart murmur (78.6%).Streptococci spp (20.7%) was the most common organism, followed by Staphylococcus spp(17.9%). Streptococcus viridians showed no resistance to penicillin, erythromycin and clindamycin resistance rate were 47.4% and 40%. Benzocillin resistance rate of staphylococcus aureus to was 26.3%. Vancomycin or linezolid resistance staphylococcus aureus were not found. 75 patients died while 36 patients survived at last. With respect to risk factors, history of heart disease was the only prognostic risk factor (OR: 0.239, 95%CI 0.08-0.68) Conclusions Epidemiological and clinical characteristics of infective endocarditis are various and complex, distribution of pathogen is regional difference. Our research of infective endocarditis with bloodstream infection verified regional characteristics of infective endocarditis. The variations we observed in the study will be of important value to clinical preventive medication in our region.

Prosthetic valve endocarditis

ESC CardioMed ◽  
2018 ◽  
pp. 1720-1723
Author(s):  
José A. San Román ◽  
Javier López
Keyword(s):  
Computed Tomography ◽  
Infective Endocarditis ◽  
Antibiotic Treatment ◽  
Prosthetic Valve ◽  
Photon Emission ◽  
Clinical Manifestations ◽  
Prosthetic Valve Endocarditis ◽  
Native Valve ◽  
Native Valve Endocarditis ◽  
Duke Criteria

Prosthetic valve endocarditis (PVE) complicates the clinical course of 1–6% of patients with prosthetic valves and it is one of the types of infective endocarditis with the worst prognosis. In early-onset PVE (that occurs within the first year after surgery), the microbiological profile is dominated by staphylococci. In late-onset PVE, the microorganisms are similar to native valve endocarditis. Clinical manifestations are very variable and depend on the causative microorganism. The diagnosis is established with the modified Duke criteria although they yield lower diagnostic accuracy than in native valve endocarditis. Transoesophageal echocardiography is the main imaging technique in everyday clinical practice in PVE as the sensitivity is higher than transthoracic echocardiography. The findings of other techniques, as cardiac computed tomography (CT), positron emission tomography/CT, or single-photon emission computed tomography/CT have been recently recognized as new major diagnostic criteria and can be very useful in cases with a high level of clinical suspicion and negative echocardiography. Empirical antibiotic treatment should cover the most frequent microorganisms, especially staphylococci. Once the microbiological diagnosis is made, the antibiotic treatment is similar to native valve infective endocarditis, except for the addition of rifampicin in staphylococcal PVE and a longer length (up to 6 weeks) of the treatment. Surgical indications are also similar to native valve endocarditis, heart failure being the most common and embolic prevention the most debatable. Prognosis is bad, and during the follow-up, a team experienced with endocarditis is needed. Patients with a history of PVE should receive antibiotic prophylaxis if they undergo invasive dental manipulations.

scholarly journals Addition of Rifampin to Standard Therapy for Treatment of Native Valve Infective Endocarditis Caused by Staphylococcus aureus

2008 ◽  
Vol 52 (7) ◽  
pp. 2463-2467 ◽  
Author(s):  
David J. Riedel ◽  
Elizabeth Weekes ◽  
Graeme N. Forrest
Keyword(s):  
Staphylococcus Aureus ◽  
Infective Endocarditis ◽  
Drug Interactions ◽  
Standard Therapy ◽  
Cohort Analysis ◽  
Urban Hospital ◽  
Hepatitis C Infection ◽  
Native Valve ◽  
Duke Criteria ◽  
The Impact

ABSTRACT Staphylococcus aureus is a common cause of native valve infective endocarditis (IE). Rifampin is often added to traditional therapy for the management of serious S. aureus infections. There are no large, prospective studies documenting the safety and efficacy of adjunctive therapy with rifampin for treatment of native valve S. aureus IE. We reviewed all cases of definite native valve S. aureus IE confirmed by modified Duke criteria in a large urban hospital between 1 January 2004 and 31 December 2005. A retrospective cohort analysis was used to assess the impact of the addition of rifampin to standard therapy. There were 42 cases of S. aureus IE treated with the addition of rifampin and 42 controls. Cases received a median of 20 days of rifampin (range, 14 to 48 days). Rifampin-resistant S. aureus isolates developed in nine cases who received rifampin before clearance of bacteremia (56%), while significant hepatic transaminase elevations also occurred in nine cases, all of whom had hepatitis C infection. Unrecognized significant drug-drug interactions with rifampin occurred frequently (52%). Cases were more likely to have a longer duration of bacteremia (5.2 versus 2.1 days; P < 0.001) and were less likely to survive (79% versus 95%; P = 0.048) than controls. Our results suggest that the potential for hepatotoxicity, drug-drug interactions, and the emergence of resistant S. aureus isolates warrants a careful risk-benefit assessment before adding rifampin to standard antibiotic treatment of native valve S. aureus IE until further clinical studies are performed.

scholarly journals A structured approach to native mitral valve infective endocarditis: Is repair better than replacement?

2020 ◽  
Vol 58 (3) ◽  
pp. 544-550
Author(s):  
Rufin J Defauw ◽  
Anton Tomšič ◽  
Thomas J van Brakel ◽  
Nina Ajmone Marsan ◽  
Robert J M Klautz ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Mitral Valve ◽  
Valve Replacement ◽  
Complex Disease ◽  
Patch Repair ◽  
Early Surgery ◽  
Valve Repair ◽  
Post Surgery ◽  
Late Morbidity ◽  
Structured Approach

Abstract OBJECTIVES Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients. METHODS Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and ‘patch’ repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed. RESULTS In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504–2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002–6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52). CONCLUSIONS Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.

scholarly journals Survival benefits and optimal timing for surgical intervention for infective endocarditis

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
H L Li ◽  
Y K Tse ◽  
S Y Yu ◽  
M Z Wu ◽  
Q W Ren ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Propensity Score ◽  
Lower Risk ◽  
Surgical Intervention ◽  
Public Institution ◽  
Early Surgery ◽  
Causative Organism ◽  
Optimal Timing ◽  
Risk Of Death ◽  
Doubly Robust Estimation

Abstract Background Surgery is often indicated in patients with infective endocarditis (IE), but the survival benefits of surgical intervention have not been validated in large-scale studies. Although previous studies appeared to support early surgical intervention, the optimal timing of intervention remains uncertain. Purpose We aim to evaluate the benefits of surgery and identify the optimal timing of surgical intervention for patients with IE. Methods From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. Patients were divided into those who received surgical intervention within 1 year of IE (surgical cohort) and those who did not (control cohort). The two cohorts were then compared using inverse probability weighting of the covariate balancing propensity score, which included demographics, comorbidities, and causative organism as covariates. Outcomes of interest include, at 1 year, all-cause death, and the development of complications. A Cox proportional hazards model was used to evaluate the association between surgical intervention and death, with “doubly-robust estimation” used to minimise the effect of confounders. For complications, a Fine-Gray model was used to account for competing risk. The surgical cohort was subdivided into early (≤7 days of hospitalisation) or late surgical intervention; a similar propensity score analytic approach was used to evaluate the effects of early vs. late intervention, with those who died within the 7 days excluded to ensure a fair comparison. Results A total of 5,657 patients (age 59.9±18.3 years, 37.2% females) were included, of which 930 (16.4%) received surgical intervention in 1 year. Overall, the surgical cohort had a 45% risk reduction in all-cause death (hazard ratio [HR] 0.55, 95% CI [0.46 to 0.65], P&lt;0.001) (Figure). This association remained consistent in subgroup analysis stratified by age, sex, and causative organisms (Table 1). The surgical cohort also had a lower risk of complications, including acute kidney injury (HR 0.61, 95% CI 0.43 to 0.87, P=0.006), systemic embolism (HR 0.35 [0.23 to 0.55], P&lt;0.001), ischaemic stroke (HR 0.37 [0.24 to 0.55], P&lt;0.001), cardiac dysrhythmia (HR 0.79 [0.66 to 0.95], P=0.011), and pneumonia (HR 0.36 [0.26 to 0.49], P&lt;0.001). In the surgical cohort, compared to those who had early surgery (N=181), those with delayed surgery had a lower risk of all-cause death (HR 0.58 [0.34 to 0.99], P=0.045) (Figure) and complications (Table 2) at 1 year. In those who had early surgery, patients who received ultra-early surgery (≤3 days of hospitalisation, N=104) did not have a significantly different risk of death (HR 1.19 [0.47 to 3.34], P=0.654). Conclusions Surgical intervention significantly reduced the risk of death and complications in patients with infective endocarditis. Delayed surgical intervention appeared to be more protective. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

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