Infective endocarditis presentations during the COVID-19 pandemic: have they paid an untold toll?

Background: COVID-19 caused restrictions and re-allocation of medical resources among all healthcare services. During the peak of the pandemic, several unrelated-yet critical-conditions had silently taken their toll. Infective endocarditis (IE), owing to its non-specific clinical presentation, may have been largely mislabeled as COVID-19 in a number of cases. Results: This retrospective observational study reviewed all IE presentations at an IE unit in a university hospital during the peak of COVID-19. Patient characteristics, courses, and outcomes were compared with historical controls from our IE database published before the COVID era. We identified 30 IE cases [Group A] during the COVID-19 peak in our region (June 2021 to June 2022), with a 25% decrease compared to the usual annual rate. This is in contrast to the expected surge during the pandemic. Compared with group B (398 published IE cases from our database), group A had significantly longer symptoms-to-presentation intervals (60 [31-92] vs. 28 [14-72] days, p = 0.01). Male sex dominated both groups, but group A had significantly less pre-existing structural heart disease. Despite the more liberal use of empirical antibiotics in the COVID-era, group-A had lower rates of culture-negative IE. Compared to group B, group A demonstrated a better response to medical therapy, fewer arterial embolizations, fewer indications for surgery, and fewer overall complications, except for increased acute kidney injury. This can be explained by the abundant use of non-steroidal anti-inflammatory drugs. The data analysis strongly suggests that there might have been a natural selection or selection bias of IE patients with favorable profiles to survive the pandemic to the appropriate diagnosis. Conclusions: The diagnosis of IE and commencing the appropriate workup were significantly undermined during the COVID-19 pandemic. The inexplicable decline in IE referral rate and the favorable outcomes witnessed during the pandemic strongly suggest a referral bias and natural selection of those who survived the pandemic to the appropriate IE diagnosis.

Incremental value of P-wave indices for predicting left atrial dysfunction in patients with primary mitral regurgitation using speckle tracking echocardiography.

The correlation of P wave indices on surface ECG and phasic LA dysfunction in patients with significant primary mitral regurgitation (MR) due to the adverse LA adaptive structural and functional changes needs to be more studied. This study aims to investigate the diagnostic value of P wave indices to predict LA function assessed both by volumetric analysis using 3-dimensional (3D)echocardiography, and by strain analysis using speckle tracking echocardiography. (STE). The study included 107 subjects, we measured maximum P-duration (Pmax), P dispersion (PD), and V1 negative terminal force (V1-NTF) (negative duration x negative amplitude) on surface ECG. Both Basic and Dynamic LA volumes (LAV) during reservoir, conduit, and contractile phases were measured. The global LA strain and strain rate parameters were calculated By STE. LA ejection fraction (LAEF) and ejection force were also calculated.V1-NTF showed a significant positive correlation while P-max a significant negative correlation with global peak atrial longitudinal strain (GPALS) (r = 0.75; P < 0.001 and r = - 0.72; P < 0.001 respectively). Using ROC curve analysis, Pmax > 110 ms, 1-NTF ≥ 4 ms.mV and P notching > 40 ms had a sensitivity of 90%, 95% and 50% and a specificity of 87.4%, 94.3% and 100% respectively in predicting GPALS ≤ 30%. P notching > 40 ms was associated with severe LA dysfunction. ECG P wave indices represent a simple bedside tool that could have an incremental role in predicting LA dysfunction as well as size in patients with significant primary MR.

Beta-Hemolytic Streptococcal Infective Endocarditis: Characteristics and Outcomes From a Large, Multinational Cohort.

BACKGROUND: Beta-hemolytic streptococci (BHS) are an uncommon cause of infective endocarditis (IE). The aim of this study was to describe the clinical features and outcomes of patients with BHS IE in a large multinational cohort and compare them with patients with viridans streptococcal IE. METHODS: The International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) is a large multinational database that recruited patients with IE prospectively using a standardized data set. Sixty-four sites in 28 countries reported patients prospectively using a standard case report form developed by ICE collaborators. RESULTS: Among 1336 definite cases of streptococcal IE, 823 were caused by VGS and 147 by BHS. Patients with BHS IE had a lower prevalence of native valve (P < .005) and congenital heart disease predisposition (P = .002), but higher prevalence of implantable cardiac device predisposition (P < .005). Clinically, they were more likely to present acutely (P < .005) and with fever (P = .024). BHS IE was more likely to be complicated by stroke and other systemic emboli (P < .005). The overall in-hospital mortality of BHS IE was significantly higher than that of VGS IE (P = .001). In univariate analysis, variables associated with in-hospital mortality for BHS IE were age (odds ratio [OR], 1.044; P = .004), prosthetic valve IE (OR, 3.029; P = .022), congestive heart failure (OR, 2.513; P = .034), and stroke (OR, 3.198; P = .009). CONCLUSIONS: BHS IE is characterized by an acute presentation and higher rate of stroke, systemic emboli, and in-hospital mortality than VGS IE. Implantable cardiac devices as a predisposing factor were more often found in BHS IE compared with VGS IE.

Gender differences in clinical features and complications of infective endocarditis: 11-year experience of a single institute in Egypt.

BACKGROUND: No data exists about the gender differences among patients with infective endocarditis (IE) in Egypt. The objective was to study possible gender differences in clinical profiles and outcomes of patients in the IE registry of a tertiary care center over 11 years. RESULTS: The IE registry included 398 patients with a median age of 30 years (interquartile range, 15 years); 61.1% were males. Males were significantly older than females. Malignancy and recent culprit procedures were more common in females while chronic liver disease and intravenous drug abuse (IVDU) were more in males. IE on top of structurally normal hearts was significantly more in males (25.6% vs 13.6%, p = 0.005) while rheumatic valvular disease was more common in females (46.3% vs 29.9%, p = 0.001). There was no difference in the duration of illness before presentation to our institution. The overall complication rate was high but significantly higher in females. However, there were no significant differences in the major complications: mortality, fulminant sepsis, renal failure requiring dialysis, heart failure class III-IV, or major cerebrovascular emboli. CONCLUSION: In this registry, IE occurred predominantly in males. Females were significantly younger at presentation. History of recent culprit procedures was more common in females while IVDU was more common in males who had a higher incidence of IE on structurally normal hearts. The overall complication rate was higher in women. IE management and its outcomes were similar in both genders.

Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility.

BACKGROUND: Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years. RESULTS: The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007). CONCLUSION: This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.

Pericardial effusion in prosthetic and native valve infective endocarditis.

BACKGROUND: Pericardial effusion (PE) is widely believed to signify more advanced infective endocarditis (IE) and a generally worse outcome. PURPOSE: To determine the prevalence and clinical significance of PE in a series of patients with confirmed native and prosthetic valve infections. METHODS: Data were collected from 338 consecutive patients with definite or possible IE who visited a single referral center; these patients were examined for the presence of PE as detected by transthoracic echocardiography. Clinical characteristics, the incidence of complications, and outcomes were compared between patients with IE with and without PE. IE patients with PE were then divided into two subgroups: those with and those without cardiac prostheses. RESULTS: Eighty-eight patients out of the total 338 (26%) were found to have PE. Compared with patients who did not have PE, patients who did were significantly younger (32.9 ± 13.4 vs 29.0 ± 9.2, p = 0.003), had more left-sided vegetation (55.6% vs 77.3%, p < 0.001), more root abscesses (9.2% vs 25.0%, p < 0.001), needed surgery more frequently (68.0% vs 84.1%, p = 0.001), and had a higher mortality rate (22.0% vs 32.9%, p = 0.03). PE was not found to be a predictor of mortality. No significant difference was found between IE patients with PE with (n = 13) and without (n = 75) prostheses with regard to causative organisms, clinical characteristics, or clinical outcomes. CONCLUSION: Regardless of whether the IE was in native or prosthetic valves, compared with patients without PE, patients with PE had more severe infections and a worse prognosis, but PE was not an independent predictor of mortality.

The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis.

AIMS: In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. METHODS AND RESULTS: Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)]. CONCLUSION: Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.

Impact of routine cerebral CT angiography on treatment decisions in infective endocarditis.

BACKGROUND: Infective endocarditis (IE) is commonly complicated by cerebral embolization and hemorrhage secondary to intracranial mycotic aneurysms (ICMAs). These complications are associated with poor outcome and may require diagnostic and therapeutic plans to be modified. However, routine screening by brain CT and CT angiography (CTA) is not standard practice. We aimed to study the impact of routine cerebral CTA on treatment decisions for patients with IE. METHODS: From July 2007 to December 2012, we prospectively recruited 81 consecutive patients with definite left-sided IE according to modified Duke's criteria. All patients had routine brain CTA conducted within one week of admission. All patients with ICMA underwent four-vessel conventional angiography. Invasive treatment was performed for ruptured aneurysms, aneurysms ≥ 5 mm, and persistent aneurysms despite appropriate therapy. Surgical clipping was performed for leaking aneurysms if not amenable to intervention. RESULTS: The mean age was 30.43 ± 8.8 years and 60.5% were males. Staph aureus was the most common organism (32.3%). Among the patients, 37% had underlying rheumatic heart disease, 26% had prosthetic valves, 23.5% developed IE on top of a structurally normal heart and 8.6% had underlying congenital heart disease. Brain CT/CTA revealed that 51 patients had evidence of cerebral embolization, of them 17 were clinically silent. Twenty-six patients (32%) had ICMA, of whom 15 were clinically silent. Among the patients with ICMAs, 11 underwent endovascular treatment and 2 underwent neurovascular surgery. The brain CTA findings prompted different treatment choices in 21 patients (25.6%). The choices were aneurysm treatment before cardiac surgery rather than at follow-up, valve replacement by biological valve instead of mechanical valve, and withholding anticoagulation in patients with prosthetic valve endocarditis for fear of aneurysm rupture. CONCLUSIONS: Routine brain CT/CTA resulted in changes in the treatment plan in a significant proportion of patients with IE, even those without clinically evident neurological disease. Routine brain CT/CTA may be indicated in all hospitalized patients with IE.