Impact of Aortic Root Abscess on Surgical Outcomes of Infective Endocarditis.

Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.

Prosthetic Aortic Valve Endocarditis Creeping Into the Paravalvular Space.

Prosthetic valve endocarditis is a devastating infection with a challenging diagnosis and management. Despite advances in its diagnostic modalities, medical, and surgical interventions, prosthetic valve endocarditis still carries high morbidity and mortality rates. Here, we report a case of prosthetic aortic valve endocarditis that progressed to involve the paravalvular space and the importance of multimodality cardiac imaging in the early detection of paravalvular complications.

Surgery for paravalvular abscess in children.

Objective: To investigate the outcomes of surgery in children with paravalvular abscess at our institution. Methods: A retrospective review of all patients who underwent surgery for paravalvular abscess was performed. Results: Between 1989 and 2020, 30 patients underwent surgery for paravalvular abscess, of whom 5 (16.7%) had an intracardiac fistula and 6 (20.0%) had a pseudoaneurysm. Aortic annulus abscesses were most common, occurring in 23 patients (76.7%). Aortic root replacement was performed in 17 patients (56.7%), root reconstruction was performed in 4 (13.3%), and reconstruction of the central fibrous body was required in 5 (16.7%). Postoperatively, 7 patients (23.3%) required extracorporeal membrane oxygenation (ECMO) support, and 1 patient (3.3%) required permanent pacemaker insertion. There were 6 early deaths, 5 of whom were on ECMO, and no late deaths, with a 15-year survival of 79.7% (95% confidence interval [CI], 60.2%-90.3%). Deaths were from sudden cardiac arrest resulting in brain death in 3 patients, inability to wean from ECMO due to severe cardiac dysfunction in 2 patients, and cerebral mycotic aneurysm and hemorrhage in 1 patient. Freedom from reoperation was 40.0% (95% CI, 17.0%-62.3%) at 15 years Reoperation due to recurrence was rare, occurring in only 2 patients (6.7%). Streptococcus pneumoniae (hazard ratio [HR], 9.2; 95% CI, 1.6-51.7) and preoperative shock (HR, 6.4; 95% CI, 1.3-32.0) were associated with mortality. Central fibrous body reconstruction was associated with reoperation (HR, 4.4; 95% CI, 1.2-16.1). Conclusions: Although paravalvular abscess in children is associated with high early mortality, hospital survivors have good long-term survival. Reoperation is frequent, but is rarely due to recurrence of endocarditis.

Aortic root abscess from Enterococcus faecalis infective endocarditis: Case report and brief review of the literature.

Infective endocarditis is a life-threatening disease that is associated with a significant risk of morbidity and mortality. One of the most serious complications of infective endocarditis is perivalvular and aortic root abscess formation. Due to the high propensity for rupture and continued spread within the aorta and surrounding organs, surgical management is recommended and can improve long-term survival. Imaging plays a critical role in diagnosis of infective endocarditis and its sequalae. Initial workup includes transthoracic and/or transesophageal echocardiography, as part of the modified Duke criteria for diagnosing infective endocarditis. If paravalvular abscesses are suspected, CTA chest can characterize invasion and spread of the abscess. Here, we present a 55-year-old male with recurrent infective endocarditis with an aortic root abscess. The abscess was first identified through transesophageal echocardiography and subsequently confirmed using CTA chest. Surgically, the patient required pulmonic and aortic valve replacement along with aortic root reconstruction.

C-Reactive Protein at Hospital Discharge and 1-Year Mortality in Acute Infective Endocarditis: A Prospective Observational Study.

Background: An accurate biomarker at hospital discharge is needed to identify patients with acute infective endocarditis (IE) who are at high risk of mortality. This prospective observational study evaluated the prognostic value of C-reactive protein (CRP). Methods: Patients with acute IE (n = 343) and hospitalized at 2 university-affiliated medical centers from January 2014 to December 2019 were enrolled. Patients were categorized as having low or high CRP (n = 217 and 126, respectively) at hospital discharge according to the optimal cutoff (CRP = 6.5 mg/L) determined via receiver-operating characteristic curve analysis. The primary endpoint was all-cause death, from hospital discharge to 1 year. The secondary endpoint was the cumulative rate of rehospitalization or paravalvular abscess at 1 year. Results: At the 12-month follow-up, the mortality rate of the high-CRP group (21.43%) was significantly higher than that of the low-CRP group (2.76%, log-rank P < 0.0001). The multivariate regression analysis indicated that the high-CRP group had a higher excess mortality hazard risk (HR = 4.182; 95% CI: 2.120, 5.211; P < 0.001). The cumulative 1-year incidence of paravalvular abscess of the high-CRP group (11.90%) was significantly higher than that of the low-CRP (5.07%; P = 0.022). The cumulative rate of heart rehospitalizations of the 2 groups were similar (18.25% cf. 14.29%, P = 0.273). Conclusion: For hospitalized patients with acute IE, a high CRP at discharge suggests a poor prognosis for 1-year mortality and paravalvular abscess.

ACR Appropriateness Criteria® Infective Endocarditis.

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR appropriateness criteria infective endocarditis

Infective endocarditis can involve a normal, abnormal, or prosthetic cardiac valve. The diagnosis is typically made clinically with persistently positive blood cultures, characteristic signs and symptoms, and echocardiographic evidence of valvular vegetations or valvular complications such as abscess, dehiscence, or new regurgitation. Imaging plays an important role in the initial diagnosis of infective endocarditis, identifying complications, prognostication, and informing the next steps in therapy. This document outlines the initial imaging appropriateness of a patient with suspected infective endocarditis and for additional imaging in a patient with known or suspected infective endocarditis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cardiac computed tomography in the contemporary evaluation of infective endocarditis.

Increasing data have accumulated on the role of Cardiac Computed Tomography (CCT) in infective endocarditis (IE) with high accuracy for large vegetations, perivalvular complications and for exclusion of coronary artery disease to avoid invasive angiography. CCT can further help to clarify the etiology of infective prosthetic valve dysfunction (e.g. malposition, abscess, leak, vegetation or mass). Structural interventions have increased the relevance of CCT in valvular heart disease and have amplified its use. CCT may be ideally integrated into a multimodality approach that incorporates a central role of transesophageal echocardiography (TEE) with 18-FDG PET and/or cardiac magnetic resonance in individually selected cases, guided by the Heart Team. The coronavirus-19 (COVID-19) pandemic has resulted in renewed attention to CCT as a safe alternative or adjunct to TEE in selected patients. This review article provides a comprehensive, contemporary review on CCT in IE to include scan optimization, characteristics of common IE findings on CCT, published data on the diagnostic accuracy of CCT, multimodality imaging comparison, limitations and future technical advancements.

Infective endocarditis of an aortic bioprosthesis causing life-threatening incessant junctional tachycardia: a case report.

BACKGROUND: Infective endocarditis with paravalvular abscess can be complicated by atrioventricular block (AVB), but junctional ectopic tachycardia (JET) has as yet never been described. CASE SUMMARY: A 68-year-old male recently admitted with Staphylococcal aureus endocarditis of his aortic valve bioprosthesis, presented with a regular tachycardia at 240 b.p.m. with a pre-existent right bundle branch block pattern. Haemodynamic collapse necessitated electrical cardioversion, following which high-grade AVB was observed. Multiple recurrences of the same tachycardia required repeated electrical cardioversions and emergent electrophysiological study, which indicated JET. The tachycardia was unresponsive to overdrive pacing, adenosine and intravenous amiodarone, and external cardioversions. Radiofrequency catheter ablation of the atrioventricular node was performed emergently with interruption of the tachycardia. A temporary external pacemaker was implanted via a jugular route. The tachycardia recurred after 48 h at a slower rate, and the patient underwent redo ablation. Transoesophageal echocardiography revealed a pseudoaneurysm of the right sinus of Valsalva probably corresponding to an evacuated abscess. A permanent pacemaker was implanted after active infection had been ruled out. At 3 months of follow-up, the patient had complete AVB, without arrhythmia recurrence. DISCUSSION: This is the first case report of JET complicating a paravalvular abscess of the aortic valve with concomitant AVB. Junctional ectopic tachycardia is very rare arrhythmia which is usually seen in children as a congenital arrhythmia or following surgical correction of paediatric heart disease. The differential diagnosis is discussed in detail in the article.

A rare echocardiographic image of aortic prosthetic valve endocarditis complicated with paravalvular abscess, pseudoaneurysm and aorto-right atrial fistula.

Early infectious endocarditis (IE) occurs in 3% of prosthesis in the first 12 months. Early IE is more aggressive than late prosthetic valve endocarditis. Mortality remains high, despite combined medical and surgical treatment. We present a case of early IE in aortic prosthetic valve complicated with paravalvular abscess, pseudoaneurysm and aorto- right atrial fistula.