Staphylococcus capitis Endocarditis

Coagulase-negative staphylococci (CoNS) are an infrequent cause of native valve endocarditis (NVE), and our understanding of NVE caused by CoNS is incomplete. The International Collaboration on Endocarditis-Prospective Cohort Study includes patients with endocarditis from 61 centers in 28 countries. Patients with definite cases of NVE caused by CoNS who were enrolled during the period June 2000-August 2006 were compared with patients with definite cases of NVE caused by Staphylococcus aureus and patients with NVE caused by viridans group streptococci. Multivariable logistic regression was used to determine factors associated with death in patients with NVE caused by CoNS. Of 1635 patients with definite NVE and no history of injection drug use, 128 (7.8%) had NVE due to CoNS. Health care-associated infection occurred in 63 patients (49%) with NVE caused by CoNS. Comorbidities, long-term intravascular catheter use, and history of recent invasive procedures were similar among patients with NVE caused by CoNS and among patients with NVE caused by S. aureus. Surgical treatment for endocarditis occurred more frequently in patients with NVE due to CoNS (76 patients [60%]) than in patients with NVE due to S. aureus (150 [33%]; P=.01) or in patients with NVE due to viridans group streptococci (149 [44%]; P=.01). Despite the high rate of surgical procedures among patients with NVE due to CoNS, the mortality rates among patients with NVE due to CoNS and among patients with NVE due to S. aureus were similar (32 patients [25%] and 124 patients [27%], respectively; P=.44); the mortality rate among patients with NVE due to CoNS was higher than that among patients with NVE due to viridans group streptococci (24 [7.0%]; P=.01). Persistent bacteremia (odds ratio, 2.65; 95% confidence interval, 1.08-6.51), congestive heart failure (odds ratio, 3.35; 95% confidence interval, 1.57-7.12), and chronic illness (odds ratio, 2.86; 95% confidence interval, 1.34-6.06) were independently associated with death in patients with NVE due to CoNS (c index, 0.73). CoNS have emerged as an important cause of NVE in both community and health care settings. Despite high rates of surgical therapy, NVE caused by CoNS is associated with poor outcomes.

Staphylococcus lugdunensis Prosthetic Mitral Valve Endocarditis Complicated by Paravalvular Abscess and Septic Emboli

Coagulase negative staphylococci (CNS) were a rare cause of native valve endocarditis. However, they are emerging as an important cause of native valve endocarditis (NVE) in both community and healthcare settings. We describe a 64 yrs. old male who developed mitral valve endocarditis caused by coagulase negative staphylococci. There were no predisposing conditions or underlying cardiac disease that could have been the risk factor for the development of native valve infection. The patient had good recovery after six weeks of treatment with anti-staphylococcal antibiotics.

In a 1998 survey of New York metropolitan area anesthesiologists, surgeons, and cardiologists, the three specialties were in general agreement that important purposes of a cardiology consultation are to treat an inadequately treated cardiac condition before surgery (e.g., unstable angina or congestive heart failure [CHF]), to provide data to use in anesthesia management (e.g., ischemic threshold of tachycardia on stress test or left ventricular ejection fraction), and possibly to diagnose a medical condition before surgery (e.g., the cause of a new-onset atrial fibrillation). The yield of a cardiology consultation, in terms of new therapy or significant effect on patient management strategy prior to surgery, has, however, been reported to vary widely from 10% to more than 70%. The reasons why the consultation process often falls short of ideal are probably multifold, but may often originate from vague understanding of the consultation process. The physician initiating the consultation, whether an anesthesiologist or a surgeon, may not make it clear to the cardiologist why the consultation is being sought. In a retrospective review of 202 cardiology consultations at a university hospital, it was found that 108 just asked for an “evaluation,” 79 asked for a “clearance,” and 9 did not specifically request anything. Only six posed a specific question. As a result, the consultant often makes broadly inclusive, general remarks about perioperative management of the patient and may recommend preoperative diagnostic work-up that does not influence the patient’s outcome but prolongs the hospital stay. In this review are presented (1) the indications for cardiology consultations as implied in the American College of Cardiology–American Heart Association (ACC–AHA) guidelines on preoperative cardiac evaluation, and (2) suggestions on how the ACC–AHA guidelines may be critically applied to, and improve, the consultation process. Preoperative Cardiac Consultation Based on the ACC–AHA Guidelines The ACC–AHA guidelines on preoperative cardiac evaluation were published initially in 1996 and were also endorsed by the Society of Cardiovascular Anesthesiologists and the Society for Vascular Surgery. An updated version of the guidelines was published in 2002. The guidelines were based on the then-available literature as well as expert opinions from the disciplines of anesthesiology, cardiology, electrophysiology, vascular medicine, vascular surgery, and noninvasive cardiac testing. The guidelines provided an 8-step algorithm for stratifying the patient’s risks and triaging to either surgery or cardiac evaluation. The first three steps of the guidelines consider the urgency of the operation and the recency of cardiac evaluation and intervention. If the operation is not emergent and if there has not been recent cardiac evaluation and/or intervention with no significant interim changes, then the remainder of the guidelines are applied. Steps 4 through 7 deal with an assessment of the patient’s clinical predictors of cardiac risk, functional status, and the risk of the surgery proposed. Step 8, or noninvasive cardiac testing to further define the patient’s risk, is indicated (1) if the patient has a major clinical predictor, (2) if the patient has an intermediate clinical predictor and either has poor functional status or is undergoing a high-risk surgery, or (3) if the patient has poor functional status and is undergoing a high-risk surgery. As defined by the ACC–AHA, major clinical predictors are unstable coronary syndrome, decompensated congestive heart failure (CHF), significant arrhythmias, and severe valvular disease. Intermediate clinical predictors are mild angina pectoris, history of myocardial infarction (MI) or CHF, diabetes mellitus, and chronic renal failure with serum creatinine greater than 2 mg/dl. A high-risk surgery carries a greater than 5% perioperative risk of cardiac events such as MI, CHF, or death and is exemplified by emergent major operations, especially in the elderly, aortic, and other major vascular procedures, peripheral vascular bypass procedures, and anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss. An intermediate-risk surgery carries 1–5% perioperative risk of cardiac events and is exemplified by carotid endarterectomy, intraperitoneal and Director of Vascular Anesthesia, Department of Anesthesia & Critical Care, Beth Israel Deaconess Medical Center, and Associate Professor of Anaesthesia, Harvard Medical School.

Surgical pathology of native valve endocarditis in 310 specimens from 287 patients (1985–2004)

Background and Objectives: Characterization of patients with endocarditis regarding demographic, clinical, biological and imagistic data, blood culture results and possible correlation between different etiologic factors and host status characteristics. Material and methods: This is a retrospective observational descriptive study conducted on patients older than 18 years admitted in the past 10 years, in the Cardiology Clinic of the Clinical County Emergency Hospital Oradea Romania, with clinical suspicion of bacterial endocarditis. Demographic data, clinical, paraclinical investigations and outcome were registered and analyzed. Results: 92 patients with definite infective endocarditis (IE) according to modified Duke criteria were included. The mean age of patients was 63.80 ± 13.45 years. A percent of 32.6% had health care associated invasive procedure performed in the 6 months before diagnosis of endocarditis. Charlson’s comorbidity index number was 3.53 ± 2.029. Most common clinical symptoms and signs were: shortness of breath, cardiac murmur, fever. Sixty-six patients had native valve endocarditis, 26 patients had prosthetic valve endocarditis and one patient was with congenital heart disease. Blood cultures were positive in 61 patients. Among positive culture patient’s staphylococcus group was the most frequently involved: Staphylococcus aureus (19.6%) and coagulase negative Staphylococcus (18.5%). Most frequent complications were heart failure, acute renal failure and embolic events. Conclusions: Staphylococcus aureus IE was associated with the presence of large vegetations, prosthetic valve endocarditis and intracardiac abscess. Coagulase negative Staphylococcus (CoNS) infection was associated with prosthetic valve dysfunction. Streptococcus gallolyticus etiology correlated with ischemic embolic stroke and the presence of large vegetations. Cardiovascular surgery was recommended in 67.4% of patients but was performed only on half of them. In hospital death occurred in 33.7% of patients and independent predictors of mortality were congestive heart failure and septic shock.

Changing spectrum of infective endocarditis in India: An 11-year experience from an academic hospital in North India

Disseminated Candida parapsilosis infection complicated by native aortic valve endocarditis and peripheral arterial embolization

Surgery for active culture-positive endocarditis: determinants of early and late outcome

Objectives: This study aimed to analyze all the reported cases of definitive infective endocarditis, based on the modified Duke criteria in a tertiary hospital over the past five years, focusing on the causative organism/s, predisposing factors, and outcomes.Methods: This is a cross-sectional retrospective study. Patients with a confirmed diagnosis of infective endocarditis using modified Duke criteria were included. The demographic data, predisposing factors, the causative microorganisms, laboratory and echocardiography results, and treatment were collected.Results: In total, 37 patients were identified, 22 were male, and the median age was 59 years. Native valve endocarditis was found in 29 (78.3%) patients. The most frequently involved valves were the mitral valve in eight (42.1%) and aortic valve in six (31.6%) patients. Fever occurred in 22 patients (59.5%). The most frequent organisms were Staphylococcus aureus in 14 (37.4%) patients, coagulase-negative staphylococci in seven (18.9%) patients, and streptococci in seven (18.9%) patients. The majority (n=27) of the patients (72.97%) were treated medically, with 10 (27.02%) requiring in-hospital surgical intervention. The in-hospital mortality rate was 24.3%. Late presentation, reluctance to undergo surgery, and the past history of rheumatic fever were the contributing factors.Conclusion: Native valve endocarditis is the major type of infective endocarditis. The most frequent organisms were Staphylococcus aureus, Streptococcus, and coagulase-negative staphylococci. In our study, infective endocarditis was more common among males, surgical intervention was low, and a high in-hospital mortality rate was noted in our series.

Staphylococcus lugdunensis – A wolf in sheep's clothing

Mechanical haemolytic anaemia following mitral valve plasty or replacement is not uncommon. However, to our knowledge, there are no reports of haemolytic anaemia caused by native mitral valve regurgitation requiring surgical intervention. A 70-year-old woman was admitted for acute decompensated heart failure with moderate mitral regurgitation and haemolytic anaemia. Although her heart failure responded promptly to medical therapy, her renal function progressively deteriorated, ultimately requiring haptoglobin supplementation. Haematologic conditions potentially causing haemolysis were excluded, and mitral regurgitation (MR) was suspected as the underlying cause. Cardiac magnetic resonance imaging and transoesophageal echocardiography identified an MR jet through a pinhole perforation of the A3 segment of the mitral valve, which was subsequently confirmed intraoperatively. The patient's haemolytic anaemia improved markedly following mitral valve replacement. We concluded that the mechanical haemolysis was due to MR through a pinhole perforation of the native mitral valve. A prior study suggested the presence of subclinical intravascular haemolysis in patients with primary MR. In the present case, an accelerated MR jet through a pinhole perforation, in addition to a jet directed against the atrial wall, appears to have caused clinically significant haemolysis. This case highlights that native mitral valve perforation can induce mechanical haemolysis in a manner similar to that seen following mitral valve surgery.

Infusion of Microbially Contaminated Hematopoietic Cell Products Has No Adverse Effect on Clinical Outcome.

Infective endocarditis (IE) is associated with high mortality if left untreated and is associated with many complications such as: septic emboli, abscesses, valvular rupture or congestive heart failure. We present below the case of a 69-year-old male who presented to the emergency room for exertional dyspnea, malaise and fatigue, symptoms that started for several months with progressive worsening. The cardiac examination highlighted a systolic murmur in the mitral area in concordance with the echocardiographic findings that revealed severe mitral regurgitation along with a degenerative-myxomatous appearance of the mitral valve, suggestive for Barlow’s disease, as well as a hyperechogenic mass on the mitral valve. Empirical therapy was initiated intravenously with vancomycin and gentamicin after three blood cultures were harvested. The blood cultures were positive for Staphylococcus (S.) epidermidis and given the antibiogram’s susceptibility to vancomycin and daptomycin, the treatment was subsequently continued only with vancomycin. Albeit coagulase negative staphylococci such as S. epidermidis are usually found at patients with risk factors: valvular prostheses, implantable devices, hemodialysis or intravascular catheters, in our case the patient had no such risk factors, but instead developed IE on a native, degenerated valve. The patient was referred to the cardiovascular surgeon and subsequently, a prosthetic, bidisc mitral valve was implanted along with tricuspid annuloplasty. The recovery was uneventful and at 6 months of follow-up the patient was asymptomatic with no complications.

Aim: To investigate echocardiography (EchoCG) parameters and clinical prognosis in elderly patients with chronic heart failure (CHF) and complete left bundle branch block (LBBB). Material and methods: The study included 248 patients (163 men and 85 women), aged 60–85 years, with Functional Class II–IV CHF (NYHA classification) due to coronary heart disease (CHD) and arterial hypertension (AH). All participants were divided into two groups: Group I (n=37) included patients with complete LBBB, while Group II (n=211) included patients without LBBB. Results: In 14,9% of the elderly CHF patients, complete LBBB was observed. Group I and II patients were comparable by age, gender, CHF duration, and hemodynamic parameters. However, clinical course of CHF was more severe in participants with complete LBBB. LBBB was associated with myocardial infarction (MI) in anamnesis (p=0,029; odds ratio, OR, 5,11; 95% confidence interval, CI, 1,19–22,03), anterior MI (р=0,020; OR 3,03; 95% CI 1,19–1,71), left ventricular (LV) end-diastolic dimension (р=0,001; OR 2,09; 95% CI 1,35–3,26), LV end-systolic dimension (р=0,001; OR 1,98; 95% CI 1,34–2,95), LV end-diastolic volume (р=0,001; OR 1,012; 95% CI 1,01–1,02), LV end-systolic volume (р=0,002; OR 1,01; 95% CI 1,01–1,02), and low LV ejection fraction (EF) (р=0,003; OR 1,05; 95% CI 1,02–1,08). Over the follow-up period, the survival levels in elderly CHF patients with or without LBBB were 59,5% and 76,8%, respectively. The leading mortality cause in patients with LBBB was sudden death. Conclusion: Complete LBBB was associated with LV remodelling progression. Sudden death was the leading mortality cause in LBBB patients.