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Future directions in infective endocarditis

Introduction The first descriptions of endocarditis appeared in the literature in the 1600s at a time when the anatomy and physiology of the heart was still incompletely characterized [ ]. Since that time, significant progress in medicine, including advances in imaging techniques, antimicrobial therapy, and surgical interventions, have ushered in a new era of management of patients with infective endocarditis (IE). This disease that once perplexed…

Multidisciplinary service delivery for the endocarditis patient

Introduction Infective endocarditis (IE) is a morbid disease that requires meticulous clinical assessment and risk stratification in the early stages of illness [ ]. Outcomes are impacted by multiple factors: patient characteristics, virulence of the infecting microorganism, severity of illness at presentation; including presence or absence of heart failure, embolic manifestations, the presence of cardiogenic and or septic shock, timing of presentation, diagnostic and therapeutic delays,…

Ethical controversies related to the care of an intravenous drug abuser with endocarditis

Introduction Infective endocarditis (IE) is a bacterial or fungal infection of the heart valves and lining that Jean François Fernel first mentioned nearly 500 years ago (1554). William Osler described the disease in detail in a series of lectures in 1885 [ ]. The clinical profile of endocarditis has undergone rapid and dramatic change in recent decades. Both microbiology and risk factors related to IE have…

Timing of surgical intervention following acute stroke from infective endocarditis

Introduction Neurologic sequelae are among the most common and devastating complications of infective endocarditis (IE) with an incidence varying between 10% and 75% [ ] and mortality ranging between 20% and 58% [ ]. In particular, mortality is higher in those with neurological complications than in those without [ , ], prompting careful attention to the management of patients with cerebral injuries. The spectrum of neurological…

Complex multivalve operations for infective endocarditis

Introduction Infective endocarditis (IE) has remained stable over time, however, the type of IE and rate of surgical intervention has changed. Patients are now more elderly, rheumatic heart disease is less common and invasive cardiac procedures with implantations are increasing. Moreover, intravenous substance abuse leading to IE is on the rise. In turn, the population requiring surgical intervention has increased in complexity [ , ]. About…

Surgery for aortic root abscess

Introduction Infective endocarditis can be associated with several clinical and anatomic complications. Among these is aortic root abscess. Aortic root abscess is defined by the presence of necrotic tissue in the aortic root, annulus, or as aortoventricular discontinuity. In this chapter, the presentation, diagnosis, and surgical management of endocarditis complicated by aortic root abscess will be discussed. Clinical presentation and diagnosis The definitive diagnosis of endocarditis…

Surgery for native aortic valve infective endocarditis

Introduction Heart valve infections are a quite uncommon pathology with an estimated annual incidence of 3–10 cases in 100,000 in a normal population. With a mortality standing between 15% and 30% (according to clinical circumstances and to the infective organism) [ , ], this pathology still remains a life-threatening disease that causes also significant morbidity. As a result of the enormous progress made in terms of…

Surgery for native mitral valve endocarditis

Epidemiology Infective endocarditis of a native valve is relatively rare with the incidence reported as roughly 2–10 cases per 100,000 person-years by several sources [ , ]. However, the burden of the disease remains large because of the high morbidity and mortality associated with it; patients with infective endocarditis have an ~20% in-hospital mortality rate and experience a variety of complications including stroke, embolization, and heart failure…

Surgery for right-sided infective endocarditis

Introduction Right-sided infective endocarditis (RSIE) most commonly occurs in the setting of intravenous drug use (IVDU) and has taken on increasing surgical significance as the opioid crisis has driven increased abuse of intravenous heroin [ , ]. Surgery for RSIE, which has historically received less attention than left-sided infective endocarditis (LSIE), poses unique challenges because of the high rate of recidivism and recurrent endocarditis in IVD…

Timing and indications for surgery

Overview of indications and timing for surgery The indications and timing of surgery for infective endocarditis (IE) is complex and nuanced. General considerations in deciding whether to operate and when to operate include the difference between left- and right-sided pathology, the impact of the pathology on patient's hemodynamic status, risk of thromboembolic complication, and the likelihood that source control requires invasive treatment. Therefore, response to antibiotics…

Outpatient follow-up and management of infective endocarditis

Funding and Acknowledgments JMM received a personal 80:20 research grant from Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, during 2017–19. AD received postdoctoral grants for his stay at the Hospital Clinic of Barcelona from the Lundbeck Foundation and the European Society of Cardiology. Financial disclosures: JMM has received consulting honoraria and/or research grants from Angelini, Contrafect, Cubist, Genentech, Gilead Sciences, Jansen, Lysovant; Medtronic,…

Endocarditis related to cardiovascular implantable devices

Introduction Cardiac implantable electronic devices (CIEDs), including the permanent pacemaker (PPM), implantable cardiac defibrillator (ICD), and cardiac resynchronization therapy (CRT) devices, provide life-saving intervention for a variety of clinically indicated cardiac conditions. However, their associated short-term and long-term outcomes are not without risk. One serious complication resulting in significant morbidity and mortality is device-related infection (CIED infection). The clinical presentation of CIED infection includes a spectrum…

Psychiatric considerations in patients with intravenous drug use and endocarditis

Introduction Opioid use disorder (OUD) with injection drug use has reached epidemic levels with endocarditis as a major potential medical complication increasing the risk of mortality. There has been an increase in the number of hospitalizations, particularly among patients who are younger, white non-Hispanic, and from rural areas [ ]. In one study, among hospitalized patients, 42% were uninsured or had Medicaid coverage, suggesting the high…

Neurologic complications of infective endocarditis

Introduction Despite modern advances in the diagnosis and management of infective endocarditis (IE), inpatient mortality rate for patients with IE remains high at 15%–20% [ ]. In IE patients with neurologic complications, mortality has been reported to be as high as 45% [ ]. In literature, the prevalence of neurologic complications in patients with left-sided IE ranges from 20% to 80% in literature as the definition of…

Postoperative care of the critically ill endocarditis patient

Introduction The postoperative course of patients with infective endocarditis is marked by relatively high mortality, with increased risk of severe complications leading to prolonged intensive care unit (ICU) and hospital lengths of stay. Nevertheless, over 90% of endocarditis patients who undergo surgery survive to hospital discharge, but with higher mortality rates among patients with prosthetic infections compared to native valve infections (13% vs. 5.6%) [ ].…

Preoperative care of the critically ill endocarditis patient

Introduction In-hospital mortality for patients with infective endocarditis (managed medically and/or surgically) remains high, ranging from 10% to 20% [ ]. At 6 months, nearly 30% of patients will have died, and at roughly 7 years, mortality will be over 50% [ , ]. Various factors increase mortality, including older age, the occurrence of neurologic or pulmonary complications, embolic events, and renal injury at the time…

Antimicrobial therapy in infective endocarditis

Introduction Incidence of infective endocarditis (IE) continues to increase, with an estimated 15 cases per 100,000 people in the United States in 2018. Gram-positive cocci are most frequently the source of infection, including streptococcus, staphylococcus, and enterococcus species. IE secondary to cardiac implanted devices, intravenous drug use (IVDU), and health-care exposures comprises an increasing number of cases. As a result, Staphylococcus aureus is the most common…

Prophylaxis and prevention of infective endocarditis

Infective endocarditis (IE) is a rare disease but with devastating consequences. In-hospital mortality rates of left-sided endocarditis are around 20%, and 5-year mortality rates are up to 40% despite the advances in diagnosis and treatment [ ]. High mortality and morbidity and difficulty in treatment mandate institution of effective preventive measures to lower the incidence of this life-threatening condition. Unfortunately, the low incidence of the disease…

Other imaging in the assessment of infective endocarditis

Introduction Current European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for the diagnosis and management of infective endocarditis (IE) require the association of an infective syndrome and confirmation of endocardial involvement to establish the diagnosis [ , ]. Although the “standard modified Duke criteria” are commonly used, these have a lower diagnostic yield in patients with prosthetic heart valves,…

Echocardiographic assessment of infectious endocarditis

Echocardiography is an essential imaging modality for the diagnosis and management of infective endocarditis. It is often the first imaging study ordered when endocarditis is suspected, and serial echocardiographic exams are commonly performed to follow course of illness and inform clinical decision-making. Early use of echocardiography is universally recommended when infectious endocarditis (IE) is suspected, and echocardiographic manifestations of IE are a cornerstone of establishing diagnosis.…