Infective Endocarditis in Patients on Chronic Hemodialysis.

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 < 0.001). Cardiac surgery was less frequently performed among HD patients (30.6% vs. 46.2%; p < 0.001), whereas relapses were higher (9.4% vs. 2.7%; p < 0.001). Risk factors for 6-month mortality included Charlson score (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 1.11 to 1.44; p = 0.001), CNS emboli and other emboli (HR: 3.11; 95% CI: 1.84 to 5.27; p < 0.001; and HR: 1.73; 95% CI: 1.02 to 2.93; p = 0.04, respectively), persistent bacteremia (HR: 1.79; 95% CI: 1.11 to 2.88; p = 0.02), and acute onset heart failure (HR: 2.37; 95% CI: 1.49 to 3.78; p < 0.001). CONCLUSIONS: HD-IE is a health care-associated infection chiefly caused by S. aureus, with increasing rates of enterococcal IE. Mortality and relapses are very high and significantly larger than in non-HD-IE patients, whereas cardiac surgery is less frequently performed.

Corynebacterium diphtheriae Native Aortic Valve Endocarditis in a Patient With Prosthetic Mitral Valve: A Rare Presentation.

Infective endocarditis due to non-toxigenic Corynebacterium diphtheriae is uncommon. We describe the case of a 42-year-old male with a history of mitral valve replacement with prosthetic valve for 4 years. He presented with fever, weight loss, dyspnea on exertion and orthopnea. The echocardiography demonstrated large vegetation attached on the left coronary cusp of the aortic valve with moderately severe aortic regurgitation but sparing of the prosthetic mitral valve. Three separate blood cultures grew Corynebacterium species. The patient underwent aortic valve replacement due to valvular dysfunction and congestive heart failure. C. diphtheriae DNA was detected by 16 S rDNA polymerase chain reaction (PCR) from the heart valve tissue. The patient recovered completely with combine antibiotics and surgical intervention. He was discharged from the hospital with good clinical outcome.

Echocardiographic Features in Bartonella Endocarditis: A Case Series.

Bartonella spp. are emerging pathogens that are reported as the cause of blood culture-negative endocarditis ( BCNE). However, echocardiographic features and assessment of this endocarditis remains unclear. Four patients with B. henselae endocarditis were identified. All patients had underlying cardiac conditions: rheumatic heart disease in three, congenital heart disease in one. Evidence of vegetations was found on the aortic valve in all patients with large, highly mobile vegetations and severely destroyed valves demonstrated by the transthoracic echocardiogram leading to severe aortic regurgitation and heart failure. The vegetations were found on both the aortic and the mitral valve in two patients. All patients had negative blood cultures and underwent urgent valves replacement due to heart failure with good clinical outcome. The diagnosis of B. henselae endocarditis is based mainly on clinical suspicion in BCNE, specific serologic testing and polymerase chain reaction (PCR) detection on excised valve tissue.

Slow loaded breathing training improves blood pressure, lung capacity and arm exercise endurance for older people with treated and stable isolated systolic hypertension.

BACKGROUND: Hypertension and reduced lung function are important features of aging. Slow loaded breathing training reduces resting blood pressure and the question is whether this can also improve lung function. METHODS: Thirty-two people (67 ±â€¯5 years, 16 male) with controlled isolated systolic hypertension undertook an eight weeks randomised controlled training trial with an inspiratory load of 25% maximum inspiratory pressure (MIP) at 6 breaths per minute (slow loaded breathing; SLB) or deep breathing control (CON). Outcome measures were resting blood pressure (BP) and heart rate; MIP; lung capacity; chest and abdominal expansion; arm cranking exercise endurance at 50% heart rate reserve. RESULTS: Home based measurement of resting systolic BP decreased by 20 mm Hg (15 to 25) (Mean and 95%CI) for SLB and by 5 mm Hg (1 to 7) for CON. Heart rate and diastolic BP also decreased significantly for SLB but not CON. MIP increased by 15.8 cm H2O (11.8 to 19.8) and slow vital capacity by 0.21 L (0.15 to 0.27) for SLB but not for CON. Chest and abdominal expansion increased by 2.3 cm (2.05 to 2.55) and 2.5 cm (2.15 to 2.85), respectively for SLB and by 0.5 cm (0.26 to 0.74) and 1.7 cm (1.32 to 2.08) for CON. Arm exercise time increased by 4.9 min (3.65 to 5.15) for SLB with no significant change for CON. CONCLUSION: Slow inspiratory muscle training is not only effective in reducing resting BP, even in older people with well controlled isolated systolic hypertension but also increases inspiratory muscle strength, lung capacity and arm exercise duration.

Validated Risk Score for Predicting 6-Month Mortality in Infective Endocarditis.

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.

Breathing Training for Older Patients with Controlled Isolated Systolic Hypertension.

INTRODUCTION: Isolated systolic hypertension (ISH) is very common but difficult to manage with conventional medication. We investigated whether slow breathing training, with and without an inspiratory load, could reduce the resting blood pressure of older well-managed ISH patients. METHODS: Thirty ISH patients (66 ± 4 yr) were randomized into loaded breathing (six breaths per min, 18 cm H2O), unloaded breathing (six breaths per min, no load), or control (normal breathing) groups. After a 2-wk run-in, loaded and unloaded groups trained at home for 30 min every day for 8 wk. Morning home blood pressure and heart rate were measured daily throughout the study. At the end of training, all participants reverted to normal breathing, and blood pressure and heart rate were recorded for a further 8 wk. RESULTS: Compared to the pretraining run-in period, systolic blood pressure was reduced by 18 ± 7 and 11 ± 4 mm Hg for loaded and unloaded groups, respectively (P < 0.001), the reduction being significantly larger for the loaded group (P < 0.05) after 8-wk training. There were no changes in the control group. After the end of training, systolic blood pressure remained below pretraining levels for a further 6 wk for the loaded group but for only 2 wk with the unloaded group. There was a small nonsignificant reduction in diastolic blood pressure with training, as there was for heart rate. Pulse pressures were reduced by 11 ± 5 and 5 ± 6 mm Hg for loaded and unloaded groups, respectively (P < 0.01). CONCLUSION: Slow breathing training, especially with an inspiratory load, is very effective in reducing resting systolic and pulse pressures and could be a valuable adjunct in the management of ISH.

First Case of Tricuspid Valve Endocarditis Caused by Gemella bergeri.

Gemella bergeri is a Gram-positive cocci species arranged in pairs and composes the normal flora of oral cavity, digestive and urinary tract. Several species of Gemella are known to cause endocarditis. Here, we report the first case in Thailand of G. bergeri endocarditis whose blood culture was negative using routine methods but was positive by PCR identification of bacteria in the affected valve. A 37-year-old male presented with prolonged fever, weight loss, and dyspnea on exertion. By transthoracic echocardiography, he was suspected of having infective endocarditis of the tricuspid valve. The patient underwent tricuspid valve repair and vegetectomy. Routine hospital blood cultures were negative but G. bergeri was identified by PCR/sequencing of the heart valve tissue.

Prospective comparison of infective endocarditis in Khon Kaen, Thailand and Rennes, France.

Prospectively collected, contemporary data are lacking on how the features of infective endocarditis (IE) vary according to region. We, therefore, compared IE in Rennes, France and Khon Kaen, Thailand. Fifty-eight patients with confirmed IE were enrolled at each site during 2011 and 2012 using a common protocol. Compared with French patients, Thais had a lower median age (47 versus 70 years old; P < 0.001) and reported more animal contact (86% versus 21%; P < 0.001). There were more zoonotic infections among Thai than France patients (6 and 1 cases; P = 0.017) and fewer staphylococcal infections (4 versus 15 cases; P = 0.011). Underlying rheumatic heart disease was more prevalent in Thai than in French patients (31% and 4%; P = 0.001), whereas prosthetic heart valves were less prevalent (9% and 35%; P = 0.001). Our data strengthen previous observations that IE in the tropics has distinctive demographic characteristics, risk factors, and etiologies and underscore the need for improved prevention and control strategies.

Echocardiographic features in Streptococcus agalactiae endocarditis: four cases report.

OBJECTIVE: Streptococcus agalactiae endocarditis is uncommon compared to other types of streptococcal endocarditis. The aim of this study was to describe the echocardiographic features of S. agalactiae endocarditis. MATERIAL AND METHOD: Between January 2010 and December 2012, 150 patients diagnosed with infective endocarditis by the modified Duke criteria treated at Srinagarind Hospital and Queen Sirikit Heart Center, Khon Kaen University were included. The transthoracic echocardiography (TTE) was performed on every patient. RESULTS: Four patients with S. agalactiae endocarditis were identified. The TTE features included one patient with a huge, highly mobile vegetation at the mitral position and patient presented with acute embolic stroke. Two patients with highly mobile vegetations at the aortic position and destroyed aortic cusps, both patients presented with congestive heart failure. One patient with vegetation at mechanical valve, mitral position and patient presented with congestive heart failure. All four patients underwent a combined medical and surgical therapy A correlation between the echocardiographic features and surgical findings in all but two patients, fewer abscesses were found by surgery. CONCLUSION: In the setting of acute endocarditis, the detection of large vegetation and severely destroyed valve by echocardiography is an argument in favor of S. agalactiae endocarditis and may warrant early surgical intervention.

Infective endocarditis in northeastern Thailand.

Despite rigorous diagnostic testing, the cause of infective endocarditis was identified for just 60 (45.5%) of 132 patients admitted to hospitals in Khon Kaen, Thailand, during January 2010-July 2012. Most pathogens identified were Viridans streptococci and zoonotic bacteria species, as found in other resource-limited countries where underlying rheumatic heart disease is common.

Postcaesarean open-heart surgery for Streptococcus sanguinis infective endocarditis.

A 33-week pregnant (gravida 3), 29-year-old woman was transferred for management of Streptococcus sanguinis infective endocarditis. A vegetation was present on the posterior leaflet of the mitral valve with moderate mitral regurgitation. On admission (day 1), the ultrasound examination revealed splenic abscesses and retarded intrauterine growth albeit with normal vessels. The fetal heart rate was 140 bpm. On day 11, the baby was delivered by Caesarean, and then the mother underwent tubal ligation followed by a mitral valve repair. The splenic abscess was treated with antibiotics. The woman was clinically stable and recovered uneventfully. This successful outcome was achieved by a strategic (optimal and sequential) timeline for selecting the mode of delivery and type of mitral valve correction.

Human Streptococcus suis Endocarditis: Echocardiographic Features and Clinical Outcome.

BACKGROUND: Human Streptococcus suis endocarditis occurs infrequently and continues to be a serious illness with high mortality. However, knowledge of the echocardiographic features and clinical outcome of this disease remains unclear. METHODS: One hundred and fourteen patients were identified in a prospective study, and hospitalized at Queen Sirikit Heart Center and Srinagarind Hospital, Khon Kaen University. Echocardiography was routinely performed in all patients. RESULTS: Between January 2010 and December 2011, three cases of S. suis endocarditis were diagnosed. All cases were male and aged 27-53 years. The most common risk factor for contracting S. suis infection was eating undercooked pork. Three patients presented with congestive heart failure. Transthoracic echocardiography demonstrated large, highly mobile vegetations and severe valvular damage. Aortic valve involvement was documented in two patients, and mitral valve involvement in one. One patient presented with embolic stroke and one with arterial occlusion. All patients underwent urgent valve replacement with a good clinical outcome. CONCLUSION: The echocardiographic features of S. suis endocarditis show destructive, extensive valvular damage and early embolization with a fulminant course, needing early surgical intervention with a good clinical outcome.

The first reported cases of Q fever endocarditis in Thailand.

We describe the first two reported cases of Q fever endocarditis in Thailand. Both patients were male, had pre-existing heart valve damage and had contact with cattle. Heightened awareness of Q fever could improve diagnosis and case management and stimulate efforts to identify risk factors and preventive measures.

The first reported case of Bartonella endocarditis in Thailand.

Bartonella species have been shown to cause acute, undifferentiated fever in Thailand. A study to identify causes of endocarditis that were blood culture-negative using routine methods led to the first reported case in Thailand of Bartonella endocarditis A 57 year-old male with underlying rheumatic heart disease presented with severe congestive heart failure and suspected infective endocarditis. The patient underwent aortic and mitral valve replacement. Routine hospital blood cultures were negative but B. henselae was identified by serology, PCR, immunohistochemistry and specific culture techniques.

An inspiratory load enhances the antihypertensive effects of home-based training with slow deep breathing: a randomised trial.

QUESTION: Can adding an inspiratory load enhance the antihypertensive effects of slow breathing training performed at home? DESIGN: Randomised trial with concealed allocation. PARTICIPANTS: Thirty patients with essential hypertension Stage I or II. INTERVENTION: Experimental groups performed slow deep breathing at home, either unloaded or breathing against a load of 20 cmH(2)O using a threshold-loaded breathing device. Participants trained for 30 min, twice daily for 8 weeks. A control group continued with normal activities. OUTCOME MEASURES: Resting blood pressure and heart rate were measured at home and in the laboratory before and after the training period. RESULTS: Compared to the control group, systolic and diastolic blood pressure decreased significantly with unloaded breathing by means of 13.5 mmHg (95% CI 11.3 to 15.7) and 7.0 mmHg (95% CI 5.5 to 8.5), [corrected] respectively (laboratory measures). With loaded breathing, the reductions were greater at 18.8 mmHg (95% CI 16.1 to 21.5) and 8.6 mmHg (95% CI 6.8 to 10.4), respectively. The improvement in systolic blood pressure was 5.3 mmHg (95% CI 1.0 to 9.6) greater than with loaded compared to unloaded [corrected] breathing. Heart rate declined by 8 beats/min (95% CI 6.5 to 10.3) with unloaded breathing, and 9 beats/min (95% CI 5.6 to 12.2) with loaded breathing. Very similar measures of blood pressure and heart rate were obtained by the patients at home. CONCLUSION: Home-based training with a simple device is well tolerated by patients and produces clinically valuable reductions in blood pressure. Adding an inspiratory load of 20 cmH(2)O enhanced the decrease in systolic blood pressure. TRIAL REGISTRATION: NCT007919689.

Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias.

BACKGROUND: The impact of early surgery on mortality in patients with native valve endocarditis (NVE) is unresolved. This study sought to evaluate valve surgery compared with medical therapy for NVE and to identify characteristics of patients who are most likely to benefit from early surgery. METHODS AND RESULTS: Using a prospective, multinational cohort of patients with definite NVE, the effect of early surgery on in-hospital mortality was assessed by propensity-based matching adjustment for survivor bias and by instrumental variable analysis. Patients were stratified by propensity quintile, paravalvular complications, valve perforation, systemic embolization, stroke, Staphylococcus aureus infection, and congestive heart failure. Of the 1552 patients with NVE, 720 (46%) underwent early surgery and 832 (54%) were treated with medical therapy. Compared with medical therapy, early surgery was associated with a significant reduction in mortality in the overall cohort (12.1% [87/720] versus 20.7% [172/832]) and after propensity-based matching and adjustment for survivor bias (absolute risk reduction [ARR] -5.9%, P<0.001). With a combined instrument, the instrumental-variable-adjusted ARR in mortality associated with early surgery was -11.2% (P<0.001). In subgroup analysis, surgery was found to confer a survival benefit compared with medical therapy among patients with a higher propensity for surgery (ARR -10.9% for quintiles 4 and 5, P=0.002) and those with paravalvular complications (ARR -17.3%, P<0.001), systemic embolization (ARR -12.9%, P=0.002), S aureus NVE (ARR -20.1%, P<0.001), and stroke (ARR -13%, P=0.02) but not those with valve perforation or congestive heart failure. CONCLUSIONS: Early surgery for NVE is associated with an in-hospital mortality benefit compared with medical therapy alone.

Reduced valve replacement surgery and complication rate in Staphylococcus aureus endocarditis patients receiving acetyl-salicylic acid.

OBJECTIVES: To assess the influence of acetyl-salicylic acid (ASA) on clinical outcomes in Staphylococcus aureus infective endocarditis (SA-IE). METHODS: The International Collaboration on Endocarditis - Prospective Cohort Study database was used in this observational study. Multivariable analysis of the SA-IE cohort compared outcomes in patients with and without ASA use, adjusting for other predictive variables, including: age, diabetes, hemodialysis, cancer, pacemaker, intracardiac defibrillator and methicillin resistance. RESULTS: Data were analysed from 670 patients, 132 of whom were taking ASA at the time of SA-IE diagnosis. On multivariable analysis, ASA usage was associated with a significantly decreased overall rate of acute valve replacement surgery (OR 0.58 [95% CI 0.35-0.97]; p<0.04), particularly where valvular regurgitation, congestive heart failure or periannular abscess was the indication for such surgery (OR 0.46 [0.25-0.86]; p<0.02). There was no reduction in the overall rates of clinically apparent embolism with prior ASA usage, and no increase in hemorrhagic strokes in ASA-treated patients. CONCLUSIONS: In this multinational prospective observational cohort, recent ASA usage was associated with a reduced occurrence of acute valve replacement surgery in SA-IE patients. Future investigations should focus on ASA's prophylactic and therapeutic use in high-risk and newly diagnosed patients with SA bacteremia and SA-IE, respectively.

Infective endocarditis in hypertrophic cardiomyopathy--mural and aortic valve vegetations: a case report.

Hypertrophic cardiomyopathy (HCM) is infrequently complicated by infective endocarditis (IE). The authors report the case of a 46-year-old woman developing IE in asymptomatic HCM. Blood cultures were positive for Streptococcus viridans. Echocardiography demonstrated: 1) a mobile (1.2 x 1 cm2) vegetation attached to the septal endocardium at the site of contact between the mitral valve leaflet and the hypertrophic septum; 2) two large (2.7 x 1.7 cm2 and 1.6 x 1.1 cm2) vegetations at NCC and RCC respectively of aortic valve, causing moderate valve regurgitation, and, 3) a mural (1 x 0.8 cm2) vegetation on the posterior wall of the left ventricle. On the third day of hospitalization, the patient underwent aortic valve replacement and removal of the vegetations. Antibiotics were continued for another four weeks. The patient recovered and follow-up was uneventful. Thus, chronic endocardial trauma of the septum, a common finding in HCM with outflow tract obstruction, may provide a fertile nidus for the development of vegetation, which in turn would play the major role in the pathogenesis of IE.

Effect of changes in diagnosis and management of active infective endocarditis on the clinical outcome at Srinagarind Hospital.

BACKGROUND: In recent years, diagnostic methods and treatment of infective endocarditis (IE) have been improved. It is not known whether the clinical outcome is any better. OBJECTIVE: To assess the effect of changes on the clinical outcomes of IE patients. MATERIAL AND METHOD: The authors performed a retrospective study comparing IE patients hospitalized at Srinagarind hospital during the period from 1/1/1990 to 31/12/2002. The authors classified the patients according to the period of diagnosed from 1990 to 1993 (n=57), 1994 to1997 (n=71), and 1998 to 2002 (n=72) cohorts. RESULTS: There were two hundred IE patients in the present study. Mean age and degenerative heart disease were increasing. Operative and in-hospital mortality were decreasing. Overall survival rate was 81% at the first year 60% at 5 years, 55% at 12 years in surgically treated patients, with 30-day mortality in 27.1% mostly from the 1990 to 1993 cohort. In medically treated IE, overall the survival rate was 37% in the first year, 32% at 5 years, 20% at 12 years, with 30-day mortality in 72.86% mostly in the 1990 to 1993 cohort. Early surgical intervention, improved long-term survival rates (hazard ratio 0.23; 95% CI 0.14-0.37), severe congestive heart failure (hazard ratio 1.87; 95% CI 1.17-2.99) and renal failure (hazard ratio 4.10; 95% CI 2.05-7.84) are the predictors of mortality by multivariate analysis. Survival rate from 1998 to 2002 cohort was 85%, 1994 to 1997 cohort was 54% and 1993 to 1990 cohort was 27% at 1-year (p < 0.001). CONCLUSION: The data indicated that the changing clinical outcome of this disease, reflected improvements in diagnostic method and treatment. Although IE remains a serious condition characterized by significant morbidity and mortality, the overall survival rate has significantly improved over time. The authors therefore, believe that early diagnosis and prompt treatment both medical or surgical interventions will improve the outcome of IE patients.

Infective endocarditis: prevalence, characteristics and mortality in Khon Kaen, 1990-1999.

OBJECTIVE: To update the prevalence, characteristics and mortality of infective endocarditis in a tertiary care hospital in Khon Kaen, Thailand. BACKGROUND: Numerous studies have shown that the prevalence and course of infective endocarditis remain unchanged inspite of the advance in treatment, diagnosis and of prophylactic recommendations. METHOD: The authors identified 160 patients from 1990-1999 with 86 per cent definite and 14 per cent possible endocarditis based on the Duke criteria. Data were collected from two tertiary care hospitals. RESULTS: The prevalence was 4 patients per 1,000 hospital admissions. The mean age of the 106 male and 54 female patients was 39+/-16 years. Twenty-four percent of the patients had no previously known heart disease. Native valve endocarditis was present in 95 per cent and prosthetic valve endocarditis was diagnosed in 5 per cent. Infective endocarditis was located on the aortic valve in 42 per cent, the mitral valve in 43 per cent, both mitral and aortic valves in 9 per cent and the tricuspid valve in 8 per cent. The infective organism was identified in only 62 per cent of cases. Streptococci was the most common in 43 per cent, followed by Staphylococci in 16 per cent. During the first month after admission, 45 per cent of the patients underwent surgery. In-hospital mortality was 25 per cent. CONCLUSION: Despite improved diagnostic techniques and aggressive surgical therapy, infective endocarditis remains a serious problem associated with a high mortality in Khon Kaen.