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International audience; Purpose: The purpose of this study was to investigate the potential additional value of cardiac magnetic resonance (CMR) in the assessment of left ventricular (LV) dilatation and dysfunction by comparison to standard echocardiography in patients with chronic left-sided valvular regurgitation.Materials and methods: We prospectively enrolled patients with chronic severe mitral regurgitation (MR) or aortic regurgitation (AR). They underwent standard echocardiography and CMR using aortic flow and LV-function sequences. LV dilatation or dysfunction was assessed with each technique, based on thresholds used for surgery indication. Reference regurgitation severity was defined following previously reported CMR-based regurgitant volume thresholds.Results: A total of 71 patients with chronic severe MR (n= 44) or severe AR (n= 27) were prospectively included. There were 60 men and 11 women with a mean age of 61 + 14 (SD) years (range: 18-83 years). CMR-based regurgitation severity was significantly greater in the LV dysfunction group when assessed with CMR (MR, P = 0.011; AR, P= 0.006) whereas it was not different when LV dysfunction was assessed using standard echocardiography. Among standard echocardiography and CMR volumetric indices, CMR-derived end-diastolic volume showed the best ability to predict regurgitation severity (area under the curve [AUC] = 0.78 for MR; AUC = 0.91 for AR). Diagnostic thresholds identified on receiver operating characteristics-curve analysis were lower than those of current European recommendations and closer to North-American guidelines.Conclusion: CMR assessment of LV end-diastolic volume in chronic severe left-sided regurgitations is more reliably associated with CMR-based regurgitant volume by comparison with standard echocardiography diameter. CMR may provide useful evaluation before surgery decision for severe asymptomatic regurgitations. (C) 2020 Societe francaise de radiologie.

Objectives: This study sought to describe the current practices and compare outcomes according to the use of balloon aortic valvuloplasty (BAV) or not during transcatheter aortic valve repl...

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.

Introduction Bicuspid aortic-valve (BAV) is the most common congenital malformation. Complications include aortic stenosis and regurgitation, endocarditis, aortic dilatation and dissection. Although BAV is associated with early valve degeneration, its pathophysiology remains unknown. Purpose The objective of this study was to examine at clinical, histological and molecular levels, a cohort of BAV patients with pure aortic regurgitation (AR-BAV). Methods From 2011 to 2018, patients with BAV were prospectively included. We performed histological and transcriptomic analysis of explanted BAV and compared differences between characteristics of prolapsed leaflet and non-prolapsed leaflet, using a normal tricuspid valve leaflet at reference. Aortic-valves from patients with long term left ventricular assist device (LVAD) were used as a model of acquired aortic regurgitation. Results A total of 350 patients with BAV were included. Among 316 patients (90%) with dysfunctional BAV, 66 (21%) presented severe AR-BAV. Mechanism of AR was prolapse in 37 patients (56%). Histologically, analysis of 2 explanted AR-BAV showed disorganization of extracellular matrix, loss of laminar structure and proteoglycans accumulation on prolapsed leaflet. Inversely, trilaminar structure of the non-prolapsed aortic leaflet was preserved. Transcriptomic analysis revealed upregulation of genes involved in extracellular matrix homeostasis and downregulation of endothelial cell markers on the prolapsed leaflet. The aortic-valve LVAD analysis found histological and molecular results similar to those described in BAV prolapsed leaflet and was associated with occurrence AR. Conclusion AR-BAV is a mood of BAV dysfunction that occurs in young male subjects, as a consequence of myxomatous degeneration similar to that described in mitral valve prolapse. LVAD model suggests that altered hemodynamic environment could account for the acquired nature of valve degeneration.

Background Among intermediate-risk patients with severe aortic stenosis(AS),trans-catheter aortic-valve replacement(TAVR)and conventional aortic-valve replacement provide similar outcomes. However, data are missing to compare Rapid-deployment aortic-valve replacement(RDAVR)and TAVR. Purpose We compare the 1year outcomes of RDAVR with INTUITY and TAVR with SAPIEN 3 in intermediate-risk patients. Methods Inclusion criteria: severe symptomatic aortic stenosis implanted with TAVR or RDAVR; intermediate risk defined with 4≤EUROSCORE2≤10. Regression adjustment for the propensity score was used to compare RDAVR patients with TAVR patients. Patients follow-up was 2years. Primary endpoints: composite of death, stroke, or rehospitalization. Secondary endpoints: occurrence of major bleeding complication, paravalvular regurgitation ≥ grade 1(PVR), patient-prosthesis mismatch (PPM)and pacemaker implantation. Results A total of 152 patients were included from September 2012 to April 2017:104 in the TAVR group and 48 in the RDAVR group. Mean age was 82,7 ± 6, 48.7% male, mean Euroscore II was 6.03 ± 1.6% and mean baseline LVEF was 56 ± 13%,mean indexed AVA was 0.41 ± 0.1 cm/m2, mean gradient was 51.7 ± 14.7 mmHg. Patients with RDAVR were younger(79,5 ± 6 vs. 84,2 ± 6, P Conclusion RDAVR with INTUITY provides similar 1 year outcomes and better 2 years outcomes than TAVR with SAPIEN3 despite a higher EUROSCORE2 and more combined surgery.

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 Little is known about the impact of prosthesis-patient mismatch (PPM) on outcomes after trans-catheter aortic valve replacement (TAVR). We reported previously an increased risk of PPM with Sapien 3 transcatheter Heart valve (S3-THV). Purpose We aimed to investigate the one-year outcomes of patients operated on for severe aortic stenosis (AS) with S3-THV based on the occurrence of PPM. Methods Indexed effective orifice area (iEOA) was estimated by post-procedural echocardiography(TTE). PPM was defined as moderate when 0.65 cm2 ≤ Ieoa ≤ 0.85 cm2, or severe if iEOA Results A total of 227 consecutives patients were included between January 2015 and December 2016. Of the 208 patients with complete follow-up, mean age was 81.9 ± 6, mean Euroscore2 was 4.35 ± 3.4, mean baseline LVEF was 58 ± 13%. At post-procedural TTE, moderate and severe PPM were observed in 69 (33%) and 10 (4.8%) patients respectively. Patients with PPM were younger (80.4 ± 7 vs. 82.9 ± 5, P = 0.007), had a larger body surface area (1.84 ± 0.19 vs. 1.77 ± 0.19, P = 0.01), a lower iEAO (0.73 ± 0.1 vs. 1.1 ± 0.2, P Conclusion PPM after TAVR with S3-THV is not a risk factor for midterm mortality but is an independent predictor of CHF, especially in the subset of patients with MR ≥2.

Background The physiopathology of bicuspid aortic valve (BAV) degeneration remains unknown. Altered hemodynamic environment could favor valve degeneration. Aim (1) To compare clinical and echocardiographic data of normally functioning and dysfunctional BAV; and (2) to correlate BAV phenotype to valve function. Methods Consecutive patients with normally functioning (NF-BAV) or dysfunctional BAV (D-BAV) were prospectively included. Sievers’ classification was used to compare BAV regarding valve function. Results A total of 223 patients with BAV were prospectively included. Mean age was 52.9 ± 16.5 years with a male predominance (n = 168, 75.3%). Twenty-four patients had NF-BAV and 199 patients had D-BAV. One hundred and seventy-eight patients (82.4%) had a Sievers’ type 1 BAV, mainly with an intercoronary leaflet fusion (n = 155, 87.1%). BAV aortopathy was found in 86 patients (38.5%). By multivariable analysis, age > 50 years (5.5 [2.2–17.4], P = 0.0006), male gender (3.4 [1.2–9.3], P = 0.01) and the presence of a raphe (3.6 [1.2–9.9], P = 0.01) were significantly associated with BAV dysfunction. Among D-BAV, 68 patients (34%) had AS and 91 patients (45%) had AR. Multivariate analysis revealed that a higher age (1.9 [1.85–1.94], P Fig. 1 ). Conclusions Commissural fusion of aortic cusps is associated with BAV dysfunction. By altering aortic blood flow and stiffening fused leaflet, the raphe could accelerate valve degeneration. These results suggested the emerging role of mechanobiology in BAV degeneration.

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.

Objectives This study sought to determine the value of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) for diagnosing prosthetic valve endocarditis (PVE). Background The diagnosis of PVE remains challenging. In PVE cases, initial echocardiography is normal or inconclusive in almost 30%, leading to a decreased diagnostic accuracy for the modified Duke criteria. Methods We prospectively studied 72 consecutive patients suspected of having PVE. All of the patients were subjected to clinical, microbiological, and echocardiographic evaluation. Cardiac PET/CT was performed at admission. The final diagnosis was defined according to the clinical and/or pathological modified Duke criteria determined during a 3-month follow-up. Results Thirty-six patients (50%) exhibited abnormal FDG uptake around the site of the prosthetic valve. The sensitivity, specificity, positive predictive value, negative predictive value, and global accuracy were as follows (95% confidence interval): 73% (54% to 87%), 80% (56% to 93%), 85% (64% to 95%), 67% (45% to 84%), and 76% (63% to 86%), respectively. Adding abnormal FDG uptake around the prosthetic valve as a new major criterion significantly increased the sensitivity of the modified Duke criteria at admission (70% [52% to 83%] vs. 97% [83% to 99%], p = 0.008). This result was due to a significant reduction (p l 0.0001) in the number of possible PVE cases from 40 (56%) to 23 (32%). Conclusions The use of 18 F-FDG PET/CT was helpful for diagnosing PVE. The results of this study support the addition of abnormal FDG uptake as a novel major criterion for PVE.

a Departement de Cardiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France b URMITE, CNRS-UMR 6236, Faculte de Medecine, Aix-Marseille Universite, France c Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France d Departement de Cardiologie, Centre Hospitalier Universitaire d'Amiens, France e INSERM, ERI 12, Amiens, France f Laboratoire de Microbiologie, Centre Hospitalier Universitaire Timone, Assistance Publique Hopitaux de Marseille, Aix-Marseille Universite, France g Departement de Chirurgie Cardiaque, Centre Hospitalier Universitaire d'Amiens, France h Departement d'Anesthesie, Centre Hospitalier Universitaire d'Amiens, France

Background Mortality and morbidity associated with infective endocarditis may extend beyond successful treatment. The primary objective was to analyze rates, temporal changes, and predictors of excess mortality in patients surviving the acute phase of endocarditis. The secondary objective was to determine the rate of recurrence and the need for late cardiac surgery. Methods An observational cohort study was conducted at a university-affiliated tertiary medical center, among 328 patients who survived the active phase of endocarditis. We used age-, sex-, and calendar year–specific mortality hazard rates of the Bouches-du-Rhone French district population to calculate expected survival and excess mortality. The risk of recurrence and late valve surgery was also assessed. Result Compared with expected survival, patients surviving a first episode of endocarditis had significantly worse outcomes ( P = .001). The relative survival rates at 1, 3, and 5 years were 92% (95% CI, 88%-95%), 86% (95% CI, 77%-92%), and 82% (95% CI, 59%-91%), respectively. This excess mortality was observed during the entire follow-up period but was the highest during the first year after hospital discharge. Most of the recurrences and late cardiac surgeries also occurred during this period. Women exhibited a higher risk of age-adjusted excess mortality (adjusted excess hazard ratio, 2.0; 95% CI, 1.05-3.82; P = .03). Comorbidity index, recurrence of endocarditis, and history of an aortic valve endocarditis in women were independent predictors of excess mortality. Conclusions These results justify close monitoring of patients after successful treatment of endocarditis, at least during the first year. Special attention should be paid to women with aortic valve damage.

Resume L’UMAC et l’UMAR permettent de mobiliser 7 j/7 et 24 h/24 une equipe medicale et paramedicale au chevet de patients dans un rayon d’action tres important. Cette mobilite et autonomie necessite un materiel d’assistance adapte. Pendant longtemps les equipes ont du s’accommoder d’instruments « bricoles » ou detournes de leur fonction premiere. Plus recemment devant l’engouement de l’assistance circulatoire et l’interet grandissant des laboratoires des dispositifs adaptes tant au niveau de la pompe elle-meme que des moyens de transport voient le jour. Nous decrivons notre experience quant aux diffi cultes materielles que nous avons rencontrees et les solutions que nous avons tente de mettre en œuvre.

Background Surgical treatment of active aortic infective endocarditis is challenging, and the type of prosthesis to be implanted during the active phase remains controversial. Methods All consecutive patients with definite diagnosis of aortic infective endocarditis operated on during the active phase were included. Endpoints were in-hospital mortality and a combined endpoint including infective endocarditis recurrence, prostheses dysfunction, or long-term cardiovascular mortality. Results Among 127 consecutive patients, mean age 57 ± 15 years, 87% male, 30% with preexisting aortic prosthesis, and 63 (50%) with annulus abscess, 54 (43%) were treated with aortic homograft and 73 (57%) with conventional prosthesis. Median time between diagnosis and surgery was 10 days. In-hospital mortality was 9%, not different between homograft and conventional prostheses (11% versus 8%, p[ = 0.6). By multivariable analysis, prosthetic valve endocarditis (8.5 95% confidence interval: 2.2 to 33.6, ]p = 0.001) was the only variable independently associated with in-hospital mortality, which was not influenced by type valvular substitute ( p = 0.6), even in the subset with annulus abscess ( p = 0.2). Ten-year survival free from the combined endpoint was 44% ± 10%, not different between homograft and conventional prostheses (log rank p = 0.2). By multivariable analysis, comorbidity index (2.6 [1.05 to 6.3], p = 0.04) and prosthetic valve endocarditis (2.3 [1.2 to 4.6], p = 0.02) were independently predictive of the combined endpoint, which was not determined by type of valvular substitute ( p = 0.6) even in the subset with annulus abscess ( p = 0.5). Conclusions Implantation of conventional prostheses during the active phase of aortic endocarditis yields similar low operative mortality and long-term prognosis as compared with aortic homografts, even in patients with annulus abscess.

Objective. - To review the perioperative anaesthetic management of pulmonary arterial hypertension. Data sources. - Extraction from Pubmed® database of French and English articles on the perioperative anaesthetic management of pulmonary hypertension for 9 years. Data selection. - The collected articles were reviewed and selected according their quality and originality. The more recent data were selected. Data synthesis. - Pulmonary arterial hypertension is classically divided in primary and secondary. Primary pulmonary hypertension (familial and sporadic) is relatively severe and rare. Muscularization of the terminal portion of the pulmonary vascular arterial tree, caused by smooth muscle cell hyperplasia is the first change. Pulmonary arterial hypertension linked with disorders of the respiratory system and hypoxemia or pulmonary venous hypertension including mitral valve disease and chronic left ventricular dysfunction are often associated with high morbidity and mortality. The main consequence of pulmonary hypertension development is the occurrence of right-sided circulatory failure. A better understanding of disease pathophysiology will contribute to the development of new therapies increasing then the prognosis of these patients. The management of primary pulmonary hypertension or secondary pulmonary arterial hypertension is a challenge for the anaesthesiologist because the risk of right ventricular failure is markedly increased. © 2005 Elsevier SAS. Tous droits reserves.

Donor heart and ventricular assist device excision can be extremely difficult at the time of heart transplant. We present a strategy of hypothermic circulatory arrest established with ventricular assist device cannulas for difficult heart transplants. The device inlet or outlet cannulas already in place, or both, are used to complement the safe cannulation sites available. This approach permits controlled excision of the recipient heart and device, easy access to convert to standard ascending aorta and bicaval cannulation, and minimizes the donor graft anoxia time. Two case reports are presented.

Resume Objectif. – Revue generale sur la prise en charge perioperatoire des assistances ventriculaires. Source des donnees. – Recherche sur la base de donnees Pubmed® des etudes de langue francaise et anglaise ayant fait l’objet d’une publication entre 1985 et 2002 et dans des ouvrages specialises sur la prise en charge des assistances ventriculaires. Quelques etudes anterieures ont ete citees du fait de l’absence de nouvelles donnees sur le theme developpe. Selection des donnees. – Les articles ont ete selectionnes en fonction de leur qualite et leur originalite. Les etudes les plus recentes ont ete citees. Les mots cles initiaux ont ete : perioperative ; heart assistance ; device management. Synthese des donnees. – La transplantation cardiaque est un traitement efficace pour certains patients en insuffisance cardiaque terminale, mais le delai moyen d’attente d’un greffon (17 mois) associe a la penurie d’organes (en 1996 : 357 patients transplantes sur 832 susceptibles de l’etre) majore le nombre de deces de patients en attente d’une transplantation cardiaque. Des 1985, l’apparition de systemes d’assistances ventriculaires a genere de nouveaux espoirs de prise en charge de l’insuffisance cardiaque terminale en attente de greffe (« pont a la transplantation »). La prise en charge anesthesique lors de la mise en place des assistances s’avere complexe. La severite de l’insuffisance cardiaque terminale devenue refractaire aux therapeutiques pharmacologiques habituelles, rapidement generatrice de dysfonctions d’organes est un parametre essentiel a prendre en compte dans l’evaluation preoperatoire et la conduite anesthesique. L’assistance circulatoire au long cours permet une recuperation hemodynamique, renale, hepatique, neuro-endocrine en 2 mois, ce qui permet d’amener le patient a la transplantation dans des conditions optimales. Mais elle est grevee d’un certain nombre de complications majorant la morbidite et la mortalite postoperatoires (20 % a 1 an en l’absence de facteurs de risque). L’infection (40 % des cas), les complications hemorragiques per- et postoperatoires (30 %), les complications thrombo-emboliques (30 %) et la defaillance ventriculaire droite (qui necessite une assistance mecanique circulatoire droite dans 10 % des cas) representent les principales consequences de cette technique. Une meilleure connaissance de leur mode de survenue et de leur physiopathologie respective devrait permettre une prise en charge plus efficace de ces patients.

Heparin-induced thrombocytopenia and thrombosis syndrome (type II) is associated with thromboembolic complications and a mortality rate up to 30%. We describe a patient who developed intracardiac and aortic Dacron prosthesis heparin-induced thrombosis after aortic root conservative surgery. Successive transoesophageal echocardiographies demonstrated a progressive regression of intracardiac thrombosis with oral anticoagulation by warfarin and antiplatelet therapy combining aspirin and clopidogrel.

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.