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Background 18F-Fluorodeoxyglucose Positron Emission Tomography (18F-FDG PET) has been shown to be useful for the diagnosis of infective endocarditis (IE), but its prognostic value remains unknown. Objectives This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE). Methods We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent an 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event. Results 18F-FDG PET/CT was positive in 100 (58%) patients, 83% (n = 90/109) in the PVE and 16% (n = 10/64) in the NVE group. At a mean follow of 225 days (199 to 251 days), the primary end-point occurred in 94 (54%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR = 2.6, IC95% = 1.04 to 6.6; P = 0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR = 2.1; IC95% = 1.1 to 4.0; P = 0.03) and to new embolic events, (OR = 7.5; IC95% = 1.24 to 45.2) P = 0.03). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point. Conclusion In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and of embolic events during the first year following IE episode.

Background 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that PET/CT was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with NVIE. Purposes 1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE). 2. Secondary objectives: – to determine the usefulness of PET/CT concerning embolic or neoplastic detection; – to describe a new PET/CT feature, i.e. the diffuse splenic uptake. Methods Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Results Significant valvular uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (P Conclusion 1. The value of 18F-FDG PET/CT in NVE diagnosis is poor 2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection. 3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on PET/CT.

Background In infective endocarditis (IE), neurological complications (NC) may be a cause of delayed cardiac surgery. However, whether this delay impact prognosis or not is unknown. Purpose To evaluate prognosis in patients presenting IE with NC compared to a control group. To describe the impact of temporary surgical contraindication on patient mortality and evaluate the predictive factors for death among patients with NC. Methods In a prospective single-center study, all patients with IE had a systematic screening for cerebral complication. Six months mortality was compared and in patients presenting NC, prognosis according to surgical status was analyzed. The Cox regression model was used to analyze variables predictive of mortality in case of NC. Results Between 2014 and 2018, 351 patients with a diagnosis of left-sided IE were included. 94 patients (26.8%) presented at least one NC. Fifty-nine patients (17.9%) died in the first 6 months of follow-up. Six-months mortality was not significantly different between patients with NC and the control group (P = 0.6). Regarding patients with NC, mortality was higher in non-operated vs. operated patients when cardiac surgery was indicated (P = 0.02). Forty patients had temporary surgical contraindication due to NC. During the period of surgical contraindication, 7 patients (17.5%) died, 6 patients (15%) presented new embolic event, 12 patients (30%) presented cardiac or septic deterioration. By multivariate analysis, predictive factors for mortality among patients with NC were temporary surgical contraindication (HR 7.36; 95% CI 1.61–33.67; P = 0.01) and existence of mechanical prosthetic valve (HR 16.4; 95% CI 2.22–121.17; P = 0.006). Conclusion With current management of IE, mortality of patients with NC is not higher than in control patients. Patients with temporary surgical contraindication because of NC were high-risk patients: they presented a higher risk of death and frequent major complications while waiting for surgery.

Background Embolic events (EE) are major complications of infective endocarditis (IE). Animal models have demonstrated the benefit of aspirin (ASP) and statins (ST) in their prevention, but clinical studies have given conflicting results. Purpose To evaluate the benefit of prior ASP or ST therapy on embolic risk in patients with IE. Methods In a retrospective study from 2010 to 2016, the impact of daily ASP or ST therapy on admission on the risk of EE in patients with IE was assessed. The primary end point was EE occurring before or during hospitalization. Results Among 529 pts with IE, 135 (25%) were treated by ASP, 130 (24%) were treated by ST at the time of diagnosis. EE occurred in 264 (50%) pts including 242 (46%) before and 61 (11%) after initiation of antibiotics. As compared with the 394 pts without prior ASP therapy, the 135 ASP pts were older (67.8 ± 11 vs. 64.4 ± 16 P = 0.02), had more frequent history of renal failure (P = 0.0008) and presented with less frequent EE [53 (39%) vs. 211 (53%) P = 0.01] and similar hemorrhagic complications (8 (5.9%) vs. 45 (11%) P = NS). As compared with the 399 patients without previous ST therapy, the 130 ST patients were older (63.6 ± 16 vs. 70.2 ± 9 P Conclusions Prior aspirin and statin therapy reduces EE in patients with IE without increasing hemorrhagic risk. Additional prospective studies are warranted to assess the benefit of both therapies in reducing morbidity and mortality in IE.

Background Infective endocarditis (IE) is a severe disease requiring early diagnosis and treatment. Although echocardiography (ECHO) is the key diagnostic method, CT-scan (CT) has recently been added as a new ESC diagnostic criterion. However, published data are scarce and included few patients. Purpose To assess the additional value of CT over ECHO for the diagnosis of IE. Methods Between 2014 and 2017, 246 pts with suspected IE underwent both ECHO and CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 222 IE were confirmed (112 native [NVE] and 110 prosthetic [PVE]) and 24 were rejected. The primary end-point was the comparison between ECHO and cardiac CT (CCT) findings. The secondary end-point was the change in diagnostic criteria sensitivity and specificity associated with the addition of CT results. Results Among the 110 cases of definite PVE, Vegetations were found in 49 (44%) pts by ECHO and 45 (40%) by CCT (agreement in 71 [64%] pts). Periannular lesions were found in 33 (30%) pts by ECHO and 46 (41%) by CCT (agreement in 86 [77%] pts). CCT found a new cardiac lesion missed by ECHO in 10 (9%) pts. Among the 112 cases of definite NVE, Vegetations were found in 84 (76%) pts by ECHO and 90 (81%) by CCT (agreement in 84 [76%] pts). Periannular lesions were found in 34 (30%) pts by ECHO and 29 (26%) by CCT (agreement in 58 [52%] pts). CCT found a new cardiac lesion missed by ECHO in 3 (3%) pts. Including CT findings as major and minor criteria increased the sensitivity of Duke criteria from 60 to 70% in 124 suspected PVE, and from 73 to 80% in 122 suspected NVE, without significant decrease in specificity. Conclusions This study is the largest prospective study assessing the value of CT in the diagnosis of IE. Adding CT findings significantly increases the sensitivity of Duke criteria, both in NVE and PVE. Our results support the use of ESC criteria including CT rather than Duke criteria.

Background and Objectives In native mitral valve infective endocarditis (NMVIE), the respective values of mitral valve repair (MVR) and mitral valve replacement (MVRP) are still debated. We compared MVR and MVRP in a large prospective series of pts operated on for NMVIE in La Timone Hospital, Marseille. Methods Between 2010 and 2017, 151 pts with NMVIE underwent early ( Results As compared with MVR, MVRP pts had more associated aortic abscess (15 vs 4%, P = 0.03), and more restrictive lesions (28 vs 3%, P Conclusion Early MVR for NMVIE is associated with better outcome than MVRP, without excess reoperation rate, residual mitral regurgitation, or recurrence. In experienced hands, early MVR is technically feasible in 76% of NMVIE and should be the preferred option in these pts.

Background Despite improvements in medical and surgical therapy, infective endocarditis (IE) is still associated with a severe prognosis and remains a therapeutic challenge. We aimed to evaluate the impact of a standardized diagnostic and therapeutic protocol on mortality and to correlate the outcome with the compliance to our management-based protocol. Methods Observational before-after study including 333 consecutive patients treated for IE at a referral center conducted from 1991 to 2006 and divided in two periods: period 1 (1991 to 2001), before implementation of our therapeutic protocol (n=173) and period 2 (2002 to 2006) after implementation of our protocol (n=160) created by a multidisciplinary task force including a sampling of biological specimens, the use of only four antimicrobials, a standardized duration of treatment, standardized surgical indications, and one year follow-up. Because our protocol was based on a local consensus by physicians and surgeons, it was impossible to randomize the study. Results The one-year mortality significantly decreased from 18.5% during period 1 to 8.2% during period 2 (hazard ratio=0.41; 95% confidence interval, 0.21-0.79; p=0.0075). After multivariable analysis, the management during the period 2 remained a strong protective factor (adjusted hazard ratio=0.26; 95% confidence interval, 0.09-0.76; p=0.014). During period 2, we observed a significant better compliance in antimicrobial therapy and fewer cases of renal failure. Deaths by embolic events and multiple organ failure syndrome also significantly decreased during period 2. Conclusions A dramatic reduction in mortality was observed during this study suggesting that a management-based approach has a significant impact on IE outcome.