Infective Endocarditis Involving the Pulmonary Valve

Pulmonary valve endocarditis after transcatheter pulmonary valve implantation has been an emerging concern due to the increasing prevalence of transcatheter placement of pulmonary valve in the treatment of residual right ventricular outflow tract stenosis or regurgitation. Pulmonary valve endocarditis is a dreadful complication of transcatheter pulmonary valve implantation that have been reported with Melody valve (Medtronic, Inc., Minneapolis, MN) and Edward Sapien valve (Edwards Life Sciences, Irvine, CA) till date. There are scanty available literatures for pulmonary valve endocarditis with Venus P valve (Venus Medtech, Hangzhou, China) implantation. Furthermore, cardiovascular comorbidity is common in COVID-19 infection with limited evidence of COVID-19 infection concomitant with infective endocarditis. This case happens to be the first reported case of infective endocarditis of pulmonary valve with concomitant COVID-19 infection and also delayed presentation of pulmonary valve endocarditis with Venus P valve implantation.

Background: Percutaneous treatment of pulmonary valve disease is a safe and minimally invasive alternative with favorable mid-term outcomes, especially in congenital heart disease. However, feasibility depends on right ventricular outflow tract (RVOT) anatomy, with dilation being the main limitation. Infective endocarditis (IE) of the native pulmonary valve (PV) without predisposing factors is extremely rare. We present a case of severe pulmonary regurgitation secondary to prior native PV endocarditis, treated with two percutaneous valves implanted at the origin of the pulmonary artery branches. Case Description: A 57-year-old male, hypertensive and former smoker, with a history of native PV IE in 2015 (no predisposing factors), treated with antibiotics and good clinical outcome, presented in May 2024 with NYHA class II dyspnea and lower limb edema. Echocardiography showed right ventricular (RV) dilation (basal: 61 mm; mid: 58 mm), TAPSE 29 mm, thickened and partially calcified PV with severe regurgitation (PHT 90 ms; diastolic reflux in branches), and no pulmonary hypertension. Cardiac MRI confirmed severe RV dilation (EDV: 387 ml; iEDV: 150 ml/m 2 ) (Image 1), RV ejection fraction 30%, severe pulmonary regurgitation (regurgitant fraction 63%), and dilation of the pulmonary artery trunk and branches. Given symptomatic severe RV dysfunction and high surgical risk, a percutaneous approach was selected. Cardiac CT revealed a dilated RVOT (minimum diameter 35.4 x 37.7 mm; area 10.5 cm 2 ), trunk (43.8 x 45.5 mm; area 15.1 cm 2 ), right branch (28.6 x 29.7 mm; area 6.67 cm 2 ), and left branch (27.6 x 30.2 mm; area 6.55 cm 2 ). Due to unsuitable anatomy for RVOT or main trunk valve placement, two Myval N 32 valves were implanted percutaneously in each pulmonary artery branch (Image 2). The procedure was successful and uneventful. The patient improved clinically; follow-up echocardiogram showed well-functioning prostheses, minimal paravalvular regurgitation, and reduced RV dimensions (basal: 56 mm; mid: 47 mm). Discussion: This is a rare case of severe pulmonary regurgitation due to native PV endocarditis without predisposing factors, successfully treated with bilateral percutaneous valve implantation in the pulmonary artery branches. This novel strategy offers a viable option in cases with unfavorable RVOT anatomy and emphasizes the importance of tailored interventions in complex structural heart disease.

Highlights. A rare case of pulmonary valve infective endocarditis in a patient without medical and social risk factors is reported. The presented treatment strategy is of particular interest to general physicians, cardiologists, and cardiac surgeons.The incidence of isolated pulmonary valve infective endocarditis is extremely rare in the general population. Thus, clinical physicians do not have their own experience in the differential diagnosis of this pathology. There is a prejudice that Abstract infective endocarditis involving the right side of the heart is commonly associated with intravenous drug abuse. Healthcare professionals lack caution when making this diagnosis in patients. We report a rare clinical case of pulmonary valve infective endocarditis in a patient without medical and social risk factors.

Infective endocarditis in children: A 10-year multicentric study

Contemporary epidemiology of infective endocarditis in patients with congenital heart disease: A UK prospective study

Aims Isolated pulmonic valve infective endocarditis (PV-IE) is a rare form of endocarditis. Methods and results The authors report a case of giant vegetations detected by transthoracic echocardiography on pulmonic valve in a 33 year-old patient, with drug abuse history (Figure 1). Patient underwent surgical intervention by pulmonary valved bioconduit implantation. After operation a pulmonary embolism episode was treated by a direct oral anticoagulant. The final outcome was favourable. We report a short review of this rare pathology. Conclusions The difficulty in diagnosing PV-IE is due to inability to properly visualize the pulmonic valve by echocardiography. In this case, with such large vegetations, transthoracic echocardiography (TTE) allowed a correct diagnosis and an effective surgical planning, confirming its importance as diagnostic tool.

Contemporary cohort study in adult patients with infective endocarditis.

Infective endocarditis in children: A 10-year multicentric study

Transparent sharing of digital health data: A call to action

HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices.

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children. A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed. Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000-2007 to 20 (74%) cases in 2008-2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%). The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.

Knowledge of infective endocarditis (IE) caused by Streptococcus dysgalactiae (SD) is limited. This study aimed to identify the clinical and microbiological features of SD-caused IE and to investigate any possible synergy between penicillin and gentamicin on SD isolates. Cases of IE 2008–2016 due to SD reported to the Swedish Registry of Infective Endocarditis (SRIE) were identified. Isolates were emm typed and synergy between antibiotics was determined in time-kill experiments. Medical records were reviewed and SD-cases were compared to cases of IE due to other pathogens reported to the SRIE. Fifty cases of SD-caused IE were confirmed. emm types stC74a, stG62647, and stG643 were most commonly encountered. The patients had a median age of 74 years (range 38–93) and were significantly older compared to patients with Staphylococcus aureus-caused IE, (65 years (p = 0.003)). The median time to diagnosis from symptom onset was 1 day for patients with SD-caused IE which was less compared to patients with IE due to the other pathogens (2–15 days). Embolization was seen in 46% and the in-hospital mortality was 8%. Etest-based methods did not indicate any synergy between penicillin and gentamicin whereas synergy was noted for four out of nine isolates applying time-kill assays. This is the largest study of SD-caused IE, a condition with an acute onset predominantly affecting elderly people. Synergy between penicillin and gentamicin against some SD isolates was distinguished but the potential benefit of this must be weighed against the risk of aminoglycoside side effects.

Prolonged Fever, Travel, and the Changing Examination in an 8-year-old Girl.

The diagnosis of infective endocarditis (IE) is often challenging and based on careful integration of clinical, microbiological, and imaging findings. The classical diagnostic scores (e.g. Duke criteria) have drawbacks as they leave clinicians with a considerable number of uncertain cases, in which further management is unclear and important therapeutic actions possibly delayed. Transoesophageal echocardiography is the preferred imaging technique for the diagnosis of IE as it can visualize valvular vegetations and paravalvular complications with high accuracy. However, transoesophageal echocardiography has limitations in the case of device-associated endocarditis (i.e. prosthetic valve (PVE) or cardiovascular implantable electronic device (CIED) infection). Radionuclide imaging techniques using 18F-fluorodeoxyglucose positron emission tomography (FDG PET) or white blood cell single-photon emission computed tomography (WBC SPECT) are accurate techniques to pick-up inflammatory cells. They have shown incremental diagnostic value for detecting PVE and CIED infection. Adding computed tomography angiography allows accurate co-registration of inflammatory signal and anatomical structure, and improves the detection of paravalvular complications such as abscesses or pseudoaneurysms. Current European Society of Cardiology guidelines have recently adopted the use of FDG PET/CT or WBC SPECT/CT in their recommendations for the work-up of suspected or uncertain PVE.

BackgroundWe noted an increase in infective endocarditis (IE) cases in recent years. The purpose of the study was to examine the changes in incidence, risk factors, microbiology, complications and outcome of IE in our patient population.MethodsRecords of children < 18 yrs with discharge diagnosis of IE during 2002-2020 at Children’s Hospital of Michigan, Detroit were reviewed. Modified Duke criteria were used to determine “definite” and “possible” IE cases.Results101 patients with IE were identified, representing annual incidence of 4.9/10,000 admissions. During 2002-2011 (early period), the incidence was 2.8/10,000 (33 cases). However, during 2012-2020 (late period), the incidence was 7.0/10,000 (68 cases): a 2.5-fold increase. Males were 53.4%. The age range was 1 mo – 17 yrs (median 6 yrs). Of 101 patients, 37 (36.6%) met criteria for definitive and 64 (63.4%) for possible IE. The most common predisposing conditions included congenital heart disease (CHD) (50.5%), central venous catheter (CVC) (25.7%), and immunosuppression (13.9%). CHD was more frequent in the late period (41/68, 60.3%) compared to early period (10/33, 30.3%) (p = 0.0059). Cardiac surgery had been performed in 28/51 (55%) prior to IE diagnosis. CVC related infections were more frequent in the early period (16/33, 48.5%) than the late period (10/68, 14.7%), (p = 0.0005). Overall, 16 (15.8) cases were culture negative. In culture-positive IE, S. aureus was most common (33/101, 32.7%) followed by streptococci (17), S. epidermidis (10), Gram negative bacilli (8), Enterococci (7), fungi (5) and HACEK group (4). Causative organisms were similar in both periods except for fungal organisms (5) and B. henselae (1) in the late period only. Valve replacement or valvuloplasty were performed in 19 (18.8%) patients. Complications included acute kidney injury (9) and emboli to brain (10) and to lungs (7). Mortality occurred in 15 (14.8%): 8 had CHD, 5 had CVC and 1 had fulminant MRSA infection.ConclusionMost of our IE patients had underlying medical conditions. The higher incidence of IE during the late period is likely due to an increase in the number of patients with complex cardiac conditions who underwent surgery at our institution. S. aureus was the predominant pathogen followed by streptococci. Mortality rate in our patients was 14.8%.DisclosuresAll Authors: No reported disclosures.