Endocarditis – ABC CARDIOL

IJCS

Editorial

Infective Endocarditis Epidemiology Over Time: An Analysis of a National Registry Between 1996 and 2023

Alfredo Jose Mansur

One of the approaches of studying diseases is how they evolve over time in different scenarios. Time may refer to years, decades, even centuries; scenarios may refer to different geographic peculiarities, epidemiological conditions, clinical and surgical therapeutic medical facilities available, access to proper health care, access to the diagnosis, and access to the treatment.

Infective endocarditis has been subject to this approach over time after the description of the disease in seventheenth century. Among the historical outstanding contributions were the three famous Gulstonian Lectures delivered by William Osler. As a rare disease, incidence of infective endocarditis was estimated to be between 3 and 10 episodes per 100,000 person-years in different surveys. Decades ago, institutional reports of large series of patients over time were traditional in the literature.^– Some of these series were published before the advent of large epidemiological studies that were feasible due to new technologies related to data science and data analyses. More recent reports have studied the changing nature of the disease over time: in France, in an American county, in England, in Italy, in Europe, in an international collaboration, and in one Brazilian institution over a four-decade period.

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IJCS

Case Report

PET-CT in Infectious Endocarditis Diagnosis

Matheus Werlang Donadel et al. Laura Werlang Donadel Laura Cristina Pudell Eduardo Hunsche Grossman Gabriel Blacher Grossman

Introduction

A 63-year-old male patient, with a history of mitral valve replacement with a bioprosthesis in 2019 due to native valve dysfunction secondary to bacterial endocarditis, and under regular medical follow-up since the procedure, presented to the cardiology emergency department with a complex clinical case. The patient reported a two-week history of fever (with temperature peaks of 38°C), night sweats, dry cough, weight loss, cervical pain when moving the neck, increased urinary frequency and urinary incontinence. At presentation, there were no classic cardiovascular symptoms, signs of valve dysfunction, or embolic phenomena. Notably, he had recently undergone a dental procedure without antibiotic prophylaxis. He denied symptoms such as rhinorrhea or pharyngitis. His physical and cardiovascular examinations were unremarkable.

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IJCS

Original Article

Endocarditis – A 27-Year Epidemiological Analysis of Mortality in Brazil

Leticia da Costa Santana Silva et al. Luana Yasmim Fernández Avelaneda Castanheira Maria Dalila Santos Salim Ruy Felipe Melo Viegas … Gilson Fernandes Ruivo Sheila Cavalca Cortelli Davi Romeiro Aquino Taciana Mara Rezende Fortes Viégas

Abstract

Background:

Infective endocarditis (IE) is frequently caused by viridans streptococci. Short-term in-hospital mortality in high-income settings ranges from 11% to 25%. In Brazil, rheumatic heart disease remains a leading valvular substrate; however, its declining prevalence in developing nations has limited country-specific analyses.

Objective:

To describe the epidemiological profile of mortality from IE in Brazil, characterizing its magnitude and temporal trend.

Methods:

We conducted a retrospective, exploratory epidemiological study with descriptive and analytic components using data from the Mortality Information System of the Department of Informatics of Brazil’s Unified Health System. Chi-square tests of independence were applied (p < 0.05), and results were summarized in tables and figures. Variables included International Statistical Classification of Diseases and Related Health Problems, 10th Revision categories, year of death, region, and sex.

Results:

From 1996 to 2022, 40,157 deaths associated with IE were recorded in Brazil (chi-square = 1,701.43). The Southeast region accounted for the greatest burden, with 21,429 deaths (53.36%; chi-square = 15,236.00). By sex (chi-square = 999.32), men were more affected than women (55.57% [22,315] vs 44.41% [17,835]); in 0.02% of records, sex was unspecified.

Conclusions:

IE remains a condition of national and international concern, with substantial mortality in Brazil over the last 27 years. This overview of mortality patterns highlights regional disparities and sex differences and can inform public-health strategies and evidence-based interventions.

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ABCIC

Review Article

Infective Endocarditis in Brazil: A Narrative Review and Critical Analysis of Population and Hospital Case Data

Diego Augusto Medeiros Santos et al. Flávio Tarasoutchi João Ricardo Cordeiro Fernandes Milena Ribeiro Paixão … Tânia Mara Varejão Strabelli Karen Francine Köohler Alfredo José Mansur Rinaldo Focaccia Siciliano

Abstract

Infective endocarditis remains a serious condition with high morbidity and mortality rates despite advances in diagnostic and therapy. While the Global North has seen a shift toward older patients with prosthetic valve infections, Brazil’s understanding of the disease is hindered by reliance on fragmented, hospital-based data, primarily from the Southeast region. This narrative review synthesizes recent evidence to outline the national panorama. Population studies indicate an increase in incidence and mortality, primarily affecting men and the elderly, but with marked regional heterogeneity. Analyses of hospital case series reveal an epidemiological profile characterized by patients younger than international averages, with a high prevalence of comorbidities, underlying structural heart disease, and prosthetic valves. The microbiological landscape is diverse, with no consistent predominance between staphylococci and streptococci. Nevertheless, a particularly concerning finding is the high incidence of negative blood cultures. Severe complications are frequent, and variability exists in surgical intervention rates and in-hospital mortallity across studies. In light of this scenario, the authors propose a set of strategic actions to guide future advances: the creation of a Brazilian Registry of Infective Endocarditis, the development of Contextualized National Guidelines, the strengthening of multidisciplinary teams (Endocarditis Teams), and the implementation of measures with the potential to reduce regional disparities, such as telemedicine and the regionalization of care. The consolidation of these initiatives has the potential to transform the current landscape by enhancing epidemiological knowledge, standardizing care practices, and ultimately improving clinical outcomes nationwide.

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ABCIC

Case Report

Prosthetic Valve Endocarditis: A Multidisciplinary Challenge

Ana Beatriz Aisemann Goulart Paiva et al. Ana Carolina de Azevedo Pastori Gabriel Silva Vaz Martins Lucas Norambuena Aulicino Marcelo Goulart Paiva

Clinical case

We report the case of a 55-year-old male patient who was admitted to the hospital in July 2019 with sudden left hemiplegia, mitral systolic murmur 4+, and aortic systolic and diastolic murmurs 2+. He had a history of aortic valve replacement in 2015, with a mechanical prosthetic aortic valve (PAV) due to infective endocarditis (IE). Cranial computed tomography (CT) revealed a right frontoparietal hematoma (), and blood tests revealed hyperglycemia and elevated C-reactive protein. His electrocardiogram (ECG) showed sinus rhythm with repolarization abnormalities (), and a chest X-ray showed cardiomegaly +/4 (). Transthoracic echocardiography (TTE) showed preserved function, thickening of the mobile elements of the mechanical PAV, mild double aortic lesion, pseudoaneurysm of the mitral-aortic intervalvular fibrosa, and important eccentric mitral regurgitation (). Blood cultures were requested, and ceftriaxone 4 g/d and teicoplanin 800 mg/d were started. Transesophageal echocardiography (TEE) showed vegetations on the ventricular side of the mechanical PAV leaflets and periprosthetic abscess (). Group B Streptococcus agalactiae was identified, and surgical treatment was indicated after 4 weeks due to cardiovascular stability and hemorrhagic stroke.

On day 22 of hospitalization, the patient presented pulmonary congestion and respiratory failure. Repeated TTE revealed partial loosening of the mechanical PAV and severe periprosthetic leak. Emergency surgery was performed to clean and replace the mechanical PAV with a biological PAV, without mitral valve approach. Culture of the explanted prosthesis revealed no bacterial growth.

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ABC

Case Report

Percutaneous Retrieval of a Vegetation in a Pediatric Patient with Patent Ductus Arteriosus: A New Technique to Avoid Thoracotomy

Miguel Fabian Barrerra-Colín et al. José Luis Colín-Ortiz Carlos Alfonso Corona-Villalobos

Abstract

Infective endocarditis in the pediatric population is a rare condition that may or may not be associated with a congenital heart disease. Current treatment modalities are based on long-term antibiotic therapy and surgical resection as the first option for cases of persistent vegetation. We present a case of successful percutaneous retrieval of a vegetation in a patent ductus arteriosus, that extended to the pulmonary artery trunk in a pediatric patient. This is the first report in the literature on this type of extraction of vegetation in the ductus arteriosus without thoracotomy.

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IJCS

Editorial

Risk Stratification in Patients Hospitalized With Infective Endocarditis Undergoing Cardiac Surgery: How Sharp Are We?

Ana Margarida Martins et al. Catarina Sousa

Infective endocarditis (IE) is an infrequent yet life-threatening and disabling condition, with an estimated incidence between 3 and 12 cases per 100,000 subjects per year.^, Recent epidemiological studies have suggested a rising trend in the incidence of IE, potentially attributable to factors such as an aging population and a growing group of susceptible patients with congenital heart disease, intracardiac prosthesis or devices, and chronic renal failure on dialysis. Limited information is available concerning Brazil’s temporal trends on IE incidence and clinical outcomes. The primary source of evidence regarding the IE scenario in Brazil stems from single or multicenter observational studies.^– Analyzing available data, it appears that IE predominantly affects younger male patients in Brazil. The most prevalent microbial culprits are Staphylococcus, followed by Enterococcus and Streptococcus species; rheumatic heart disease is an important underlying heart condition as well.

The diverse clinical spectrum of IE, coupled with the substantial risk of complications and the limited availability of randomized clinical trials on IE, justify that it continues to be a prognostic challenge. Despite the unquestionable diagnostic and therapeutic advances in the management of IE in recent decades, its prognosis is still marked by high rates of complications and significant in-hospital mortality. In developed countries, IE is associated with mortality rates of approximately 20%,^,, whereas in low- and middle-income countries, the mortality of IE ranges from 15% to 30%. The predominant focus in studies on IE has been the evaluation of clinical factors that may influence the course of the disease. In one of these studies, a machine learning-based analysis identified peripheral stigmata, nosocomial IE, the absence of vegetation, and surgery in the presence of neurologic complications as characteristics associated with higher in-hospital mortality.

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IJCS

Case Report

Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

Janayna Rabelato et al. Iuri Betuel Gomes Antonio Adnaldo da Silveira Maia Daniel Chagas Dantas … Antonio Flávio de Almeida Mario Issa

Abstract

We present the case of a 55-year-old patient who underwent the Bentall-De Bono procedure with mechanical prosthesis in 2005 and was admitted to the emergency department in July 2020 with mixed shock. Complementary exams showed an abscess involving the prosthetic tube, two thirds of the aortic valve circumference and the left ventricle, with a neocavity of about 45 mm in diameter from the aortic sinus to the ascending aorta. The patient underwent surgical repair, with a new procedure using the Bentall-De Bono technique, now associated with coronary artery bypass grafting with a great saphenous vein graft between the aorta and the anterior descending artery. Culture of samples collected intraoperatively showed Staphylococcus epidermidis. The patient received antibiotic therapy for 30 days, evolving favorably, and is under regular outpatient follow-up.

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ABC

Research Letter

Mitral Valve Endocarditis – An Unusual Culprit in a Cancer Patient

Fabiana Duarte et al. Carina Machado Luis Oliveira Duarte Machado Raquel Dourado

Introduction

Cancer patients are prone to infective endocarditis (IE), associated with specific causative agents, leading to poorer outcomes. The prevalence of IE in cancer patients ranges from 5.6% to 18%, with a reported 1-year mortality rate of nearly 30%. ^– Risk factors, such as a suppressed immune system, intravascular catheter use, and hypercoagulability, predispose malignancy patients to IE. ^,

Clinical evolution is unfavorable due to high mortality rates related to antibiotic resistance, underlying medical conditions, lack of performed surgical interventions, and antitumoral therapy regimen discontinuation. ^–

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IJCS

Original Article

Analysis of the SHARPEN Score in the Prediction of In-Hospital Mortality of Patients With Infective Endocarditis Undergoing Cardiac Surgery

Mateus Correa Lech et al. Joel Stefani Lucas Fernando Fabra Miguel Gus Fernando Pivatto Júnior

Abstract

Background

The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out.

Objective

To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores.

Methods

Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant.

Results

A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores.

Conclusions

The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

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ABCIC

Case Report

Prosthetic Aortic Valve Endocarditis With Extensive Para-Aortic Abscess: The Relevance of Multimodal Imaging

Bernardo Boccalon et al. André Barcellos Amon Thiago Ferreira Serafini Álvaro Schmidt Albrecht … Murilo Foppa Angela Barreto Santiago Santos

Introduction

Infectious endocarditis (IE) is defined as the infection of the endocardium or prosthetic material in the heart, whose pathogenesis is bacterial adherence to the vulnerable endocardium or implanted prosthetic material during a bacteremia. Its clinical presentation is highly variable, depending on the micro-organism that causes it, underlying heart conditions and preexisting comorbidities. The annual estimated incidence of IE is up to 10/100,000 in western countries, and mortality of up to 30% in 30 days.

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ABCIC

Case Report

Dual Mechanism of Mitral Valve Injury: Additional Value of Three-Dimensional Transesophageal Echocardiography

Larissa Neto Espíndola et al. Angele Azevedo Alves Mattoso Geórgia dos Santos Couto Pompílio Sampaio Britto

Abstract

Infective endocarditis (IE) is a life-threatening condition and during its course several complications may occur, including embolic events, perivalvular extension and valvular destruction. Echocardiography is fundamental across all stages of the disease, from the diagnosis until the follow-up after completion of the definitive therapy. Three-dimensional transesophageal echocardiography (TEE) can demonstrate a better anatomical definition and it is especially useful in the assessment of perivalvular extension of the infection, prosthetic valve dehiscence and valve perforation. In this article we report a case of double damage in the same mitral valve: leaflet perforation and rupture of chords in a patient with IE.

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ABCIC

Review Article

My Approach To Nuclear Medicine in the Evaluation of Prosthetic Valve and Cardiac Implantable Electronic Device Endocarditis

Claudio Tinoco Mesquita et al. Maria Fernanda Rezende Davi Shunji Yahiro Isabella Caterina Palazzo

Summary

Nuclear medicine has played an increasing role in the evaluation of patients with a suspected or confirmed diagnosis of infective endocarditis. Scintigraphy with marked leukocytes (ML) is a method widely used in clinical practice to detect sites of infection, being especially indicated in patients with suspected infective endocarditis (IE) in prosthetic valves or implantable cardiac devices (ICD) when other conventional imaging methods studies are not conclusive. The technique involves labeling the patient’s own leukocytes with a radiotracer, such as 99m Tc-HMPAO, maintaining its biological properties. Upon injection into the bloodstream, leukocytes actively mark sites of active inflammation, allowing detection of infection.

Blood collection for ML scintigraphy requires a sufficient amount of leukocytes, which can be a major limiting factor in patients with neutropenia. Another point of limitation is that the leukocyte labeling process and the start of obtaining scintigraphic images can take about 2 hours. The images are acquired at different times, and the presence of capture in the 4-hour and 24-hour images is important to confirm the presence of active infection.

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ABCIC

Case Report

Three-Dimensional Transesophageal Echocardiography in Native Valve Endocarditis: A Case Report and Similarities Between Echocardiography and Surgical Findings

Giulia Bevilacqua Schmitz et al. Amadeu Antonio Bertuol Filho Solano Vinicius Berger Rodrigo Petersen Saadi … Álvaro Albrecht Angela Barreto Santiago Santos

Abstract

Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings.

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ABC

Research Letter

Coxiella Burnetii Endocarditis: Can Positron Emission Tomography be an Alternative to Diagnosis?

Marjorie Hayashida Mizuta et al. Cristhian Espinoza Romero Santiago Castro Vintimilla Tatiana de Carvalho Andreucci Torres Leal … Paulo Rogério Soares Alexandre de Matos Soeiro

Introduction

Coxiella burnetii infective endocarditis (IE) represents a rarely reported zoonosis in Brazil. It is estimated that Coxiella burnetii is responsible for up to 5% of all IE cases worldwide. The disease affects mostly valvulopathy patients and immunocompromised subjects.

Different from the classical acute and sub-acute endocarditis, the clinical picture is frustrating, and, because this is an obligate intracellular microorganism, hemocultures (HMC) are predominantly negative, which makes the clinical suspicion more difficult.

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ABCIC

Case Report

Libman-Sacks endocarditis in a male patient with systemic lupus erythematosus

Álvaro Augusto Vedana Filho et al. Vivien Ritchie Bittencourt Thaíssa Antunes Mattar Valente Fernando Silva Botelho Marco Stephan Lofrano Alves

Introduction

Libman-Sacks endocarditis (LSE), also known as marantic or verrucous endocarditis, is a form of non-bacterial thrombotic endocarditis (NBTE) that involves the presence of sterile vegetations in the heart valves. These vegetations may be associated with malignancy, systemic lupus erythematosus (SLE), or antiphospholipid syndrome (APS), and although they are more commonly found in the mitral and aortic valves, other valves may be involved. Diagnosis requires high clinical suspicion when evaluating specific populations.

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ABCIC

Image

A Complicated Mitral Prosthesis Endocarditis: An Inevitable Outcome?

Sofia Alegria et al. Ana Marques Inês Rosário Cruz Nádia Junqueira Otília Simões

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ABCIC

Case Report

Trivalvular Endocarditis: A Rare Multivalvular Condition

Renata Della Giustina et al. Maurício Felippi de Sá Marchi Marcelo Moser Fiamoncini Eduardo Zanghelini Mazon … Maurício Pais Bussoletto Altair Fiamoncini

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ABCIC

Case Report

Giant vegetation in patient with a pacemaker with infective endocarditis

Antonio José Lagoeiro Jorge et al. Diane Xavier de Avila Carolina Martins Lemos Mario Luiz Ribeiro … Eduardo Nani Silva Wolney de Andrade Martins Humberto Villacorta Júnior Evandro Tinoco Mesquita

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ABCIC

Case Report

Isolated Infundibular Pulmonary Stenosis with Infective Endocarditis: a Rare Ecocardiographic Finding

Leonardo de Souza Carneiro et al. Nelson Lopes Evangelista Carlos José Mota de Lima Maria Suely Bezerra Diógenes … Ana Carolina Brito de Alcantara Maria Luiza Calixto de Lima

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ABCIC

Review Article

Use of Echocardiography in Infectious Endocarditis Associated with Implantable Cardiac Devices

Mauricio Vitor Machado Oliveira et al. Pedro Henrique Oliveira Murta Pinto Gustavo Brandão de Oliveira Luan Salvador Machado Barbalho … André de Oliveira Parreiras Fernanda Alves Gelape Teresa Cristina Abreu Ferrari Maria Carmo Pereira Nunes

Abstract

In recent decades, the increase in indications for cardiac implantable electronic devices (CIEDs) has been accompanied by an increased number of complications related to their use, including infectious endocarditis (IE). IE has high morbidity and mortality rates despite advances in diagnostic and therapeutic strategies. The case studies on this topic have significant limitations in terms of diagnostic criteria and methods, which affect decision-making on CIED removal and increase the risk of complications and death. Notwithstanding, echocardiography is critical for diagnosing CIED-associated IE and related potential complications. The limitations and challenges in its diagnosis demand the need for further studies on the topic. The objective of this study was to elucidate the epidemiology, microbiology, risk factors, pathogenesis, diagnosis, and treatment of IE associated with CIEDs to demonstrate the importance of imaging techniques in diagnosis of IE, especially echocardiography.

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ABCIC

Review Article

The Role of PET/CT in the Diagnosis of Infective Endocarditis

Gabriel Blacher Grossman et al. Lara Terra F. Carreira

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ABCIC

Editorial

Embolic Complications in Infective Endocarditis: How Can We Predict Using a Risk Evaluator Score (SORTIE or ABCDE)

Cesar Augusto da Silva Nascimento

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ABCIC

Case Report

Fistulous Periprosthetic Aortic Abscess to the Left Ventricle Viewed on Three-Dimensional Transesophageal Echocardiography

Debora Tabosa de Almeida et al. Leticia Braga Paciello da Silva Vanessa G Esmanhoto Andrioli Marcos Valerio de Resende Marcelo Luiz Campos Vieira

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