Search Results (373)

Background and Clinical Significance: The Ozaki procedure offers excellent hemodynamics and mid-term durability, but infective endocarditis (IE), although rare, remains its most serious complication and frequently requires complex redo surgery. Sutureless valve technology, particularly the Perceval bioprosthesis, has shown value in high-risk endocarditis due to reduced annular manipulation and rapid deployment. Case Presentation: We describe the first reported case of Perceval sutureless valve implantation as a bail-out strategy for IE after a prior Ozaki procedure. A 68-year-old male previously treated with Ozaki reconstruction and LIMA-LAD bypass presented with septic and cardiogenic shock caused by Streptococcus bovis endocarditis, two years after the first surgery. TOE revealed torrential aortic regurgitation from destruction of the anterior neocuspid and large vegetations. Despite a EuroSCORE II of 89.5%, emergent redo surgery was undertaken. Redo sternotomy revealed extensive leaflet destruction and a sub-annular abscess involving two sinuses. Following radical debridement and annular reconstruction, a medium Perceval valve was implanted due to severe tissue fragility. The prosthesis seated securely with no paravalvular leakage. Conclusions: This case demonstrates that the Perceval sutureless valve can be an effective bailout option for post-Ozaki infective endocarditis, particularly when annular integrity is compromised, and conventional sutured prostheses are high risk. The combination of rapid deployment and minimal annular stress may expand therapeutic possibilities in complex redo aortic surgery. Full article

Background: Cardiovascular implications in systemic lupus erythematosus (SLE) are common and varied, including impacts on the pericardium, myocardium, valves, coronary arteries, and conduction system; all of these could be potential substrates or triggers of cardiac arrhythmias by interfering with disease severity and specific medication. Therefore, this narrative review aimed to assess the cardiac involvement in SLE underlying, mainly, cardiac arrhythmias. Methods: We analyzed studies, published between 2015 and 2025 on PubMed, which explore cardiovascular involvement with a focus on arrhythmias in SLE from the perspectives of epidemiology, underlying mechanisms, diagnostic techniques, and the impact of standard and biologic therapies. Results: The cardiac manifestation of LES (lupus pericarditis, lupus myocarditis, Libman–Sacks endocarditis, coronary artery disease, coronary vasculitis or myocardial fibrosis) represents a substrate for arrhythmia risk. These substrates, in association with other arrhythmias mechanisms considered as triggers or conduction abnormalities, determined arrhythmogenic conditions in these patients. In addition to structural heart disease, arrhythmias in SLE are caused by ongoing inflammation, immune system irregularities, microvascular problems, autonomic imbalance, oxidative stress, and side effects from treatments. Despite this complex background, arrhythmias are often overlooked and not routinely investigated in SLE care. Data that show how disease-modifying drugs may affect arrhythmias are limited and inconsistent, highlighting significant gaps in knowledge. Cardiac arrhythmias are a significant but, as yet, insufficiently underrecognized aspect of SLE, with serious implications for prognosis. Conclusions: Systemic lupus erythematosus causes cardiovascular involvement that is associated with arrhythmias through various and complexes mechanisms, mainly related to direct cardiovascular structural damage, systemic inflammation or specific therapies. Data on arrhythmias secondary to cardiovascular damage in patients with SLE in the literature are limited. Therefore, early detection of electrical issues, regular cardiovascular evaluation in high-risk patients, and careful management of treatment effects are vital. A coordinated, multidisciplinary cardio-rheumatology approach is essential to improving arrhythmia detection, tailoring treatments, and ultimately decreasing cardiovascular complications and deaths in SLE patients. Full article

Background: Sex-based disparities in the presentation, management, and outcomes of infective endocarditis (IE) remain insufficiently characterized despite their growing recognition. This study systematically evaluates current evidence on sex differences in the presentation, treatment, and outcomes of IE. Methods: A systematic review and meta-analysis were conducted according to PRISMA and Cochrane guidelines. EMBASE, MEDLINE, PubMed, the Cochrane Library, and Google Scholar were searched up to October 2024. Twenty-four studies including 139,952 patients (79,698 men and 60,254 women) were analyzed. Primary outcomes were mortality (in-hospital, 30-day, and 1-year), stroke, and treatment modality (medical vs. surgical). Secondary outcomes included complications, procedural characteristics, and hospital course. Results: Men were younger at diagnosis and had higher rates of substance abuse and coronary artery disease, while women more often had hypertension, diabetes, chronic lung disease, and prior valvular pathology. Men more frequently had aortic and prosthetic valve IE, whereas women had mitral and tricuspid involvement. Men were about 65% more likely to undergo surgery for infective endocarditis than women, while women were predominantly managed medically. Men had lower in-hospital (OR 0.81, 95% CI 0.72–0.92) and 1-year mortality (OR 0.76, 95% CI 0.61–0.94), though 30-day mortality did not differ significantly. Women experienced shorter hospital stays but longer ICU admissions and more heart failure, whereas men had more recurrent IE. Conclusions: Men underwent surgery more often and had better short- and long-term survival. Women presented later, with greater comorbidity and higher complication rates. Enhanced recognition of sex-specific risk and equitable surgical referral may improve IE outcomes. Full article

Background: The Ross procedure provides excellent outcomes in young adults requiring aortic valve replacement, with lower rates of infective endocarditis (IE) compared to prosthetic valves. Early postoperative IE of the autograft is exceptionally rare, with only isolated cases reported in major registries. Case Summary: We report a 40-year-old man with bicuspid aortic valve and a history of two previous episodes of native valve endocarditis who underwent Ross procedure with Ozaki modification. Ten days postoperatively, he developed fever and was diagnosed with early autograft IE with perivalvular abscess formation. Despite negative blood cultures (due to prior antibiotic administration), clinical findings met modified Duke criteria for possible IE. Imaging revealed perivalvular abscess with subsequent pseudoaneurysm development, while the autograft leaflets remained functional. The patient was successfully treated with 6-week combination antibiotic therapy without requiring surgical reintervention. After one year of follow-up, he remains asymptomatic with stable pseudoaneurysm size and preserved valvular function. Conclusions: Early IE following Ross procedure, though rare, should be considered in patients presenting with postoperative fever. This case demonstrates that conservative management with appropriate antibiotic therapy can be successful even with perivalvular complications, provided there is hemodynamic stability and close multidisciplinary monitoring. Long-term surveillance remains essential given the persistent structural abnormalities. Full article

The gut–heart axis represents a key determinant of cardiovascular (CV) system health. Emerging evidence indicates that intestinal dysbiosis can induce a state of chronic systemic inflammation which, together with mechanisms of endothelial dysfunction, increases the risk of CV diseases. Infective endocarditis (IE) exemplifies this concept, as microbiota alterations may promote bacterial translocation from the gut into the bloodstream, leading to colonization of cardiac valves and subsequent endocardial infection. This narrative review examines current scientific evidence on the relationship between the gut microbiota and CV diseases, with a particular focus on IE. We also summarize the mechanisms underlying impaired intestinal barrier integrity, immune activation, and the production of microbiota-derived metabolites that contribute to CV disease. Special attention is given to potential preventive and therapeutic strategies, including microbiota modulation, targeted antibiotic management, and personalized medicine approaches tailored to individual patient profiles. Full article

Background/Objectives: Aortic valve therapy increasingly follows a lifetime management concept. As all bioprostheses ultimately degenerate, optimal outcomes rely on the appropriate selection and timing of treatment modality. This study evaluates outcomes of redo surgical aortic valve replacement (redo-SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) in a consecutive, unselected real-world cohort treated for bioprosthetic valve failure (BVF). Methods: A single-center retrospective analysis of all patients undergoing redo-SAVR or ViV-TAVR for BVF between June 2019 and December 2024 was conducted. The primary endpoint was survival at 30 days and at 1, 3, and 5 years; the secondary endpoint was time to reintervention. Cox proportional hazards models were used; proportionality was tested; subgroups were defined by indication and presence of concomitant procedures. Results: Eighty-three patients were included (redo-SAVR n = 42; ViV-TAVR n = 41). All active endocarditis cases were managed surgically. In isolated procedures, 30-day survival was 95.5% after redo-SAVR (100% when excluding endocarditis) and 100% after ViV-TAVR; 5-year survival was 81.3% and 94.1%, respectively (94.4% for isolated redo-SAVR excluding endocarditis). Because hazards were non-proportional and risk sets were sparse beyond 5 years, we fitted a time-split Cox model (0–5 years). In multivariable analysis, endocarditis (HR 4.45, 95% CI 1.16–17.04) and NYHA IV (HR 4.87, 95% CI 0.98–24.17)—not treatment modality—were associated with mortality. Conclusions: In a real-world, all-comers setting, early outcomes for isolated reinterventions were favorable with both pathways. Mortality patterns were case-mix driven—especially by endocarditis and the need for concomitant surgery. Accordingly, ViV-TAVR and redo-SAVR should be viewed not as competing procedures but as complementary, scenario-specific options within a lifetime management strategy. Full article

Drug use–associated infective endocarditis (DUA-IE) is an increasingly important clinical problem that affects younger patients and poses substantial diagnostic, therapeutic, and surgical challenges. We conducted a retrospective cohort study of adults with definite infective endocarditis treated at a tertiary referral center between 2017 and 2022, comparing patients with DUA-IE to those with non–drug use–associated infective endocarditis. Of the 189 patients, 43 (22.8%) had DUA-IE. These patients were significantly younger and had higher rates of HIV and hepatitis C coinfections. Staphylococcus aureus was the predominant pathogen, and right-sided valve involvement was more frequent; however, left-sided disease predominated among patients requiring valve surgery. Compared with non-DUA-IE patients, those with DUA-IE had larger vegetations, higher inflammatory markers, more frequent complications(including sepsis, embolic events, and heart failure), higher rates of emergency surgical intervention, longer hospitalizations, and increased in-hospital mortality rates. In conclusion, DUA-IE represents a distinct and more aggressive form of infective endocarditis, characterized by severe infection, increased complication rates, and a substantial surgical burden despite the younger patient age, underscoring the need for integrated infectious disease, surgical, and addiction-focused care models for these patients. Full article

Background/Objectives: Transcatheter aortic valve implantation (TAVI) has become the leading treatment option for patients suffering from aortic valve stenosis aged over 70, except in cases of specific contraindications like bicuspid valves, inappropriate access routes, or endocarditis. Minimally invasive aortic valve replacement (MIAVR) has emerged as a potential way to combine the durability of surgery with reduced procedural trauma. This study aims to assess the safety and feasibility of MIAVR in elderly patients. Methods: A total of 990 patients were included in this retrospective cohort study. Among them, 261 (26%) were aged 70 years or older (elderly cohort), and 729 (74%) were younger than 70 years (younger cohort). All patients were followed for at least 30 days postoperatively, with survival data collected through May 2025. Multivariable logistic regression, linear regression, and Kaplan–Meier survival analyses were performed. Results: Elderly patients were more likely to be female (51% vs. 40%, p = 0.001) and carried a heavier burden of vascular and renal comorbidity: renal impairment 33% vs. 17% and extracardiac arteriopathy 45% vs. 30% (both p < 0.001). Major bleeding occurred more frequently in the elderly cohort (7.7% vs. 4.1%; p = 0.02), as did new permanent pacemaker implantation (10% vs. 5.8%; p = 0.021) and sepsis (3.4% vs. 1.1%; p = 0.012). Rates of stroke, perioperative myocardial infarction, ECMO/right-heart failure, re-thoracotomy, and postoperative dialysis were low and comparable across age groups (all p > 0.20). Overall, 30-day mortality was 2.4% (24/990), with crude mortality approximately threefold higher among patients aged ≥70 years (4.6% vs. 1.6%). Conclusions: Our findings indicate that MIAVR is a feasible and safe surgical option across age groups; Elevated morbidity in elderly patients is primarily due to bleeding, pacemaker implantation, and sepsis, while rates of stroke, renal failure, and myocardial infarction are low. Full article

Background/Objectives: Infective endocarditis (IE) remains a severe and complex disease despite advances in diagnosis and treatment. The changing epidemiological profile, with an ageing population, has reshaped its presentation and management. This study describes the epidemiological, clinical and microbiological characteristics of IE at a Portuguese tertiary referral hospital prior to the establishment of a multidisciplinary Endocarditis Team. Methods: A retrospective analysis was conducted including all adult patients diagnosed with definite or possible IE according to the 2015 ESC criteria, admitted to ULS São João, Porto, between January 2019 and December 2023. Data were collected from electronic medical records and included demographic characteristics, comorbidities, microbiology, imaging, surgical indications and outcomes. Results: A total of 143 IE episodes were identified. Median age was 71 years, with a predominance of heterologous material-related infections (81%). Enterococcus faecalis, viridans group streptococci and coagulase-negative staphylococci were the most frequent pathogens. Surgical indication was present in 74% of cases, although surgery was not performed in 22% due to comorbidities or frailty, contributing to a high in-hospital mortality rate. Conclusions: This study provides a contemporary overview of IE in Portugal, reflecting an elderly, comorbid population and a predominance of prosthetic disease. The results highlight the need for multidisciplinary management and early surgical decisions, supporting the creation of Endocarditis Teams in tertiary centres. Full article

Background: The aim of this study was to explore the baseline characteristics, risk factors, and prognosis of surgical patients with left-sided valvular infective endocarditis (IE) complicated by preoperative neurological complications, as well as the impact of complication subtypes and surgical timing on outcomes. Methods: A retrospective analysis of 605 consecutive surgical patients with left-sided valvular IE (May 2012–June 2024) was performed. Patients were stratified into neurological complication and non-complication groups, with 1:1 propensity score matching (PSM) balancing baseline confounders. Six neurological complication subtypes were defined; surgical timing was categorized as early (≤7 days for infarction, ≤30 days for hemorrhage) or delayed. Logistic/Cox regression analyzed risk factors and prognosis; subgroup analyses compared modified Rankin Scale (mRS) scores, and Kaplan–Meier curves evaluated long-term survival. Results: Mitral valve involvement, highly mobile vegetations, and longer IE symptom-to-surgery time were risk factors for neurological complications. After PSM balancing, the neurological complications group had similar in-hospital, long-term mortality to the control group, but a significantly higher new-onset cerebral complication rate. In total, 81.5% of complication patients achieving mRS ≤ 2 (good functional status) with infarction showed improved postoperative mRS scores. Cerebral hemorrhage was an independent predictor of in-hospital mortality, while cerebral hemorrhage and regional infarction were independent predictors of new-onset cerebral complication. Early surgery in infarction patients increased the neurological complication rate. Conclusion: Neurological complication incidence was 27.8%. Mitral valve involvement, high vegetation mobility, and preoperative emboli were risk factors. Except for preoperative cerebral hemorrhage and regional infarction, which increase the risk of in-hospital mortality, neurological complications overall do not affect short-term and long-term mortality rates, but increase the risk of postoperative neurological deterioration. Individualized surgical timing is recommended. Full article

Background and Objectives: Infective endocarditis (IE) continues to represent a life-threatening clinical entity, particularly in patients with advanced involvement of the cardiac fibrous skeleton. This study was designed to determine the incidence and to evaluate both short- and long-term outcomes in patients undergoing complex surgical intervention necessitating patch reconstruction for extensive and destructive IE. Materials and Methods: Between January 2008 and December 2024, 678 patients underwent cardiac surgery for IE at University Hospital Frankfurt/Main. The primary endpoint was long-term survival; the secondary endpoint was freedom from reoperation. Results: Ninety-six patients (14%) required complex patch reconstruction, owing to the severe involvement of the cardiac fibrous skeleton. The median age was 68 years (interquartile range [IQR], 16.5 years). Forty-three patients underwent redo surgery following previous cardiac procedures. Abscess formation was identified in 88% of cases (n = 85). Infective endocarditis was predominantly left-sided in 97% of patients (n = 94). In 40 patients (41%), the aortomitral continuity or the left ventricular outflow tract (LVOT) was involved. Combined surgical procedures were performed in 85 patients (87.6%), including 19 commando or hemi-commando operations. Thirty-day mortality was 20% (n = 19). The estimated 5- and 10-year survival rates were 46.5 ± 5.5% and 26.1 ± 6.8%, respectively. Survival did not differ significantly between native and prosthetic valve endocarditis, nor between commando/hemi-commando procedures and cases with abscess formation but preserved aorto-mitral continuity. Conclusions: In industrialized countries, extensive IE with abscess formation or destruction of the cardiac skeleton is predominantly associated with Staphylococcus aureus. Patients undergoing commando or hemi-commando procedures do not experience inferior survival compared with other patients with extensive IE. No survival advantage was observed for native versus prosthetic valve IE in the presence of extensive abscess formation. Full article

Infective endocarditis (IE) is a life-threatening condition with a rising incidence, demanding rapid and precise diagnosis. While echocardiography remains the cornerstone of initial evaluation, its limitations in complex cases—such as those involving prosthetic valves or cardiac devices—are well-known. This review synthesizes current evidence and guidelines to outline a practical, multimodality imaging approach for IE. We emphasize that integrating advanced techniques like cardiac computed tomography (CT) and [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) early in the diagnostic pathway, particularly in high-risk scenarios, significantly enhances diagnostic certainty, guides therapeutic decisions, and improves patient outcomes. A tailored imaging strategy, driven by clinical presentation and integrated within a multidisciplinary endocarditis team, is paramount for modern IE management. Full article

Objectives: Infective endocarditis (IE) is a feared and life-threatening complication, requiring a multidisciplinary approach. Prosthetic valve endocarditis (PVE) accounts for 20–30% of IE, is one of the most severe forms of IE, and is associated with high morbidity and mortality. We aim to compare and analyze baseline characteristics, microbiology, clinical presentation, complications, and prognosis between biological and mechanical PVE; we also carried out a subgroup analysis of patients aged 45–65 at the time of onset of prosthetic surgery. Methods: The present study is a post hoc analysis of a prospective multicenter cohort of patients with PVE between January 2008 and December 2023. Patients were divided into two groups regarding the type of prosthesis, mechanical vs. biological. Results: A total of 1544 patients were included. 733 (47.47%) patients with mechanical PVE (mPVE) and 811 (52.52) with biological PVE (bPVE). We found that bPVE appeared earlier than mPVE, had more healthcare-related infections and paravalvular complications. Both groups had similar clinical presentations; moreover, there was no difference in surgical indication and if surgery was performed. On the other hand, mPVE has a higher incidence of Staphylococcus aureus (SA) and Gram-negative bacteria, while bPVE has more coagulase-negative staphylococci. Multivariable logistic regression identified the following independent risk factors of mortality: EuroSCORE I, age, mPVE, SA, IE comprising two valves, and severe sepsis. mPVE had a higher mortality on admission, probably due to a higher incidence of septic shock and CNS embolism. The subgroup analysis of patients between 45 and 65 years at the time of prosthesis implantation showed similar results. Conclusions: The present analysis shows that bPVE appears earlier than mPVE, even in the subgroup of patients aged 45–65. bPVE has more healthcare-related infections and more paravalvular complications. After adjusting for baseline differences, mPVE had higher in-hospital mortality. Full article

Background and Clinical Significance: Creutzfeldt–Jakob disease (CJD) is a rare and fatal neurodegenerative disorder caused by prion protein misfolding. The disease poses significant diagnostic challenges, particularly when its initial symptoms mimic other conditions, such as transient ischemic attacks. Early recognition and differentiation from other neurological conditions are critical, as misdiagnosis may lead to unnecessary interventions. This case highlights a unique presentation of CJD in a male Caucasian patient with a history of cardiac surgery and mitral valve prosthesis, emphasizing the role of multidisciplinary evaluation in complex neurological cases. Case Presentation: A male patient in his mid-sixties with a history of mitral valve mechanical prosthesis and prior infective endocarditis presented with progressive cognitive decline, memory impairment, and episodes of confusion. Initial cardiovascular investigations suggested mitral valve prosthesis thrombosis, while neurological assessment pointed toward transient brain ischemia. However, brain imaging remained inconclusive. Given the rapid deterioration of cognitive and motor functions, further diagnostic workup was performed. MRI findings revealed cortical diffusion restrictions consistent with probable CJD. Despite symptomatic management, the patient’s condition worsened, leading to akinetic mutism and death within eight days of diagnosis. Conclusions: This case underscores the diagnostic complexity of CJD, particularly when initial symptoms overlap with transient ischemic events. It highlights the importance of comprehensive neuroimaging and an interdisciplinary approach in recognizing atypical neurodegenerative diseases to improve diagnostic accuracy and patient management. Full article

Background: Aspergillus endocarditis is a rare but life-threatening form of infective endocarditis that typically occurs in patients with a history of cardiac surgery, prosthetic valve implantation, or profound immunosuppression. Native valve involvement in non-traditional hosts remains exceptionally rare and is diagnostically challenging. Case presentation: We describe a 56-year-old woman with CREST syndrome and advanced liver disease awaiting transplantation who developed native aortic valve endocarditis. Blood cultures and serum biomarkers (galactomannan and β-d-glucan) were also negative. Transthoracic echocardiography revealed vegetation on the aortic valve. Valve replacement was performed, and Aspergillus fumigatus was isolated from two valve cultures. Liposomal amphotericin B was initiated; however, the patient died of multiorgan failure two weeks later. Systematic review: To contextualise this case, we conducted a systematic review of the literature following the PRISMA guidelines. We included microbiologically confirmed cases of native valve Aspergillus endocarditis based on valve or embolic tissue analysis. Forty-three studies met the inclusion criteria, comprising 45 patients in total. Data were independently extracted by two reviewers and narratively synthesised due to clinical heterogeneity. Conclusions: This case illustrates the diagnostic and therapeutic challenges of native-valve Aspergillus endocarditis in patients without classical risk factors for the disease. Early imaging and a high index of suspicion are crucial for diagnosis. Combined surgical and antifungal therapy remains the cornerstone of management, although the mortality rate remains high. Full article