ARTICLE IN PRESS

Journal of Cardiothoracic and Vascular Anesthesia 000 (2023) 113

Contents lists available at ScienceDirect

Journal of Cardiothoracic and Vascular Anesthesia

journal homepage: www.jcvaonline.com

Expert Review
Infective Endocarditis—Update for the Perioperative
Clinician
Ankit Jain, MBBS, FASE, FASA*, Sudhakar Subramani, MDy,
Brian Gebhardt, MD, MPHz, Joshua Hauser, MDx,
Caryl Bailey, MD*, Harish Ramakrishna, MD, FACC, FESCx
,1

*
Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia & Augusta
University, Augusta, GA
y
Department of Anesthesiology and Perioperative Medicine, University of Iowa, Iowa City, IA
z
Department of Anesthesiology and Perioperative Medicine, University of Massachusetts Memorial Medical
Center, MA
x
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN

Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive
review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of
infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considera-
tions for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the
clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge
about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of
current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug
abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a
norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus
on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.
Ó 2023 Elsevier Inc. All rights reserved.

Key Words: Infection; Endocarditis; Cardiac imaging; Valve disease; Echocardiography; Prognosis; Prosthetic valves

THE DIAGNOSIS OF infective endocarditis requires meet-
ing a rigorous set of criteria. It can be defined as an infection
of a native or prosthetic heart valve, the endocardial surface,
or an indwelling cardiac device.1 The overall incidence ranges
from 3-to-7 per 100,000 person-years.2 The improvement in
diagnostic and therapeutic modalities over the years has not
translated into a reduction in the mortality of this disease, with
quoted mortality of about 24%-to-30%.3 There is a preponder-
ance of male patients with infective endocarditis (IE).
1
Address correspondence to Harish Ramakrishna, MD, FACC, FESC,
FASE, Department of Anesthesiology and Perioperative Medicine (MB 2-
752), Mayo Clinic, 200 First Street SW, Rochester, MN 55901.
E-mail address: ramakrishna.harish@mayo.edu (H. Ramakrishna).
Multiple factors may contribute to the mortality of this dis-
ease, such as the protean manifestation of clinical signs and
symptoms, which is impacted by the offending microorganism,
the patient’s premorbid status, prior history of cardiac disease
or cardiac surgery, and the presence of nonnative devices. Due
to the clinical variability in presentation and the elevated mor-
tality and morbidity risks, a team-based collaborative approach
is useful in the management of these patients. A multispecialty
heart valve team comprising, at its core, infectious disease,
cardiology, and cardiac surgery, is recommended in referral
centers. Nishimura et al. also stated the need for a neurologist
and cardiac anesthesiologist to be involved in the care in the
appropriate settings (eg, neurologic complications such as
stroke) and because approximately half of the patients with

https://doi.org/10.1053/j.jvca.2022.12.030
1053-0770/Ó 2023 Elsevier Inc. All rights reserved.

Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 ARTICLE IN PRESS
2 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
infective endocarditis will require surgical intervention at
some point.4
Infective endocarditis is a disease in evolution. With the
increase in intravenous drug abuse and increasing contact with
healthcare providers, Staphylococcus aureus is now the lead-
ing cause of IE in the industrialized world. These trends also
are associated with a growing number of invasive procedures
and increasing use of implantable cardiac devices, with
increasing incidence in older age groups and decreasing pro-
portions of rheumatic heart diseases.1,2 Skin commensals
including coagulase-negative staphylococci (eg, S. epidermi-
dis, S. lugdunensis, and S. capitis) colonize the indwelling
lines and devices, and are the most frequently identified patho-
gen in early prosthetic valve endocarditis. Viridans group
streptococcus continues to be a frequent culprit in developing
nations.5
With the continued evolution of the disease and higher inci-
dence of mortality, the goal here is to highlight the most up-to-
date information to understand the clinical diagnosis, imaging
criteria, and updates in the guidelines, and discuss the different
manifestations of IE in native, prosthetic, and transcatheter
valves.
Diagnosis and Imaging Criteria
The Modified Duke Criteria are the well-validated and cur-
rent standard for diagnosing IE in a wide group of patients
including children, older people, native as well as prosthetic
valve endocarditis, injection versus noninjection drug users,
and a variety of clinical settings.6 The Modified Duke Criteria
include clinical, imaging, and bacteriologic criteria and are the
cornerstone of diagnosing IE, along with various cardiac imag-
ing like transthoracic echocardiography (TTE), transesopha-
geal echocardiography (TEE), computed tomography (CT),
Table 1
Diagnosis of IE According to the Proposed Modified Duke Criteria
Definite IE
Pathological criteria
Microorganisms demonstrated by culture or histological examination of a
vegetation, a vegetation that has embolized, or an intracardiac abscess
specimen; or
Pathological lesions: Vegetation or intracardiac abscess confirmed by
histological examination showing active endocarditis
Clinical criteria
2 major criteria; or
1 major criterion and 3 minor criteria; or
5 minor criteria
Possible IE
1 major criterion and 1 minor criterion; or
3 minor criteria
Rejected
Firm alternative diagnosis explaining evidence of IE; or
Resolution of IE syndrome with antibiotic therapy for <4 d; or
No pathological evidence of IE at surgery or autopsy, with antibiotic
therapy for <4 d; or
Does not meet criteria for possible IE as listed above
IE indicates infective endocarditis.
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
Table 2
Major and Minor Criteria in the Modified Duke Criteria for the Diagnosis of IE
Major criteria
Blood culture positive for IE
Typical microorganisms consistent with IE from 2 separate blood
cultures:
Viridans streptococci, Streptococcus bovis, HACEK group
(Haemophilus spp, Actinobacillusactinomycetemcomitans,
Cardiobacterium hominis, Eikenella spp, and Kingella kingae), S. aureus;
or community-acquired enterococci, in the absence of a primary focus; or
Microorganisms consistent with IE from persistently positive blood
culture results, defined as follows:
At least 2 positive culture results of blood samples drawn 12 h apart; or
All of 3 or most of
4 separate culture samples of blood (with first and
last samples drawn at least 1 h apart)
Single positive blood culture result for Coxiella burnetii or antiphase I
IgG antibody titer >1:800
Evidence of endocardial involvement
Echocardiogram positive for IE defined as follows:
Oscillating intracardiac mass on valve or supporting structures, in the
path of regurgitant jets, or on implanted material in the absence of an
alternative anatomic explanation
Abscess; or
New partial dehiscence of prosthetic valve
New valvular regurgitation (worsening or changing of preexisting
murmur not sufficient)
Minor criteria
Predisposition, predisposing heart condition, or injection drug use
Fever, temperature >38˚C (100.4˚F)
Vascular phenomena, major arterial emboli, septic pulmonary infarcts,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages,
and Janeway lesions
Immunological phenomena: glomerulonephritis, Osler’s nodes, Roth’s
spots, and rheumatoid factor
Microbiological evidence: positive blood culture but does not meet a major
criterion as noted above* or serological evidence of active infection with
organism consistent with IE
* Excludes single positive cultures for coagulase-negative staphylococci and
organisms that do not cause IE.IE indicates infective endocarditis; IgG,
immunoglobulin G; and spp, species.
Permission to reprint taken from “Otto CM, Nishimura RA, Bonow RO, et al.
2020 ACC/AHA Guideline for the Management of Patients With Valvular
Heart Disease: A Report of the American College of Cardiology/American
Heart Association Joint Committee on Clinical Practice Guidelines. Circula-
tion. 2021;143(5):e72-e227. doi:10.1161/CIR.0000000000000923”.
and positron emission tomography (PET)-CT imaging (See
Tables 1 and 2).
Imaging IE
Imaging IE is critical for diagnosis and directly impacts
patient outcomes. Although cost, access to care, and ability to
read and interpret the imaging may vary regionally and locally,
those considerations are not discussed in this review. Rather,
the individual imaging modalities are described generally.
There are broad aims and goals when evaluating different
imaging modalities, and include but are not limited to (1)
establishing or confirming a diagnosis of IE, (2) evaluating the
extent of the disease, (3) the ability to distinguish IE from
other pathology, (4) utility in guiding specific interventions
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
and therapy, and (5) the ability to diagnose IE on nonnative
cardiac valves and structures.
Preoperative Echocardiography Imaging
Both TTE and TEE are well-established diagnostic tools.
Echocardiography is highly sensitive and specific when
attempting to detect vegetation. A TTE has a sensitivity
between 50% and 90% and a specificity >90% for the detec-
tion of vegetation in native valve endocarditis. Although TTE
has a sensitivity of only 36%-to-69% in detecting prosthetic
valve endocarditis,6 multiple studies specifically commented
on the ability to evaluate associated pathology (ie, leaks,
dynamic obstruction, and fistulae).7-9 A TEE and 3-dimen-
sional TEE, especially, allow highly detailed imaging and help
describe anatomic locations relative to other structures.
Unfortunately, both TTE and TEE are highly operator-
dependent with significant interoperator variability. A TTE is
especially impacted by patient habitus and the ability to obtain
satisfactory windows. Sensitivity decreases when evaluating
very small lesions, abscesses, and lesions in the presence of
prosthetic valves.
A TTE is typically the first imaging modality considered
and employed when IE is suspected. According to the Modi-
fied Duke Criteria, echocardiographic evidence is a major cri-
terion for the diagnosis of IE and is defined as an “oscillating
intracardiac mass on valve or supporting structures, in the path
of regurgitant jets, or on implanted material in the absence of
an alternative anatomic explanation; or abscess; or new partial
dehiscence of prosthetic valve.”10 In the same criteria, TEE is
recommended for prosthetic valves possibly infected by clini-
cal criteria, or IE complicated by paravalvular abscesses or
other significant pathology.
Perioperative Considerations
The question of perioperative versus intraoperative use of
TEE is not specifically defined by the 2014 American College
of Cardiology (ACC)/American Heart Association (AHA)
guidelines, and TEE for open valve surgery is only a Class II
indication. However, the guidelines do note that intraoperative
TEE for valve surgery in the setting of IE is a Class I indica-
tion (evidence level B). Obtaining TTE or TEE imaging is also
a class I indication for known IE with significant clinical
changes or in patients at high risk of complications (also evi-
dence level B.)11 Furthermore, the use of TEE to evaluate
prosthetic valves in the setting of persistent fever, negative
bacteremia, and/or new murmur is a Class II indication.11 It
then can be inferred reasonably that these indications encom-
pass the perioperative period, and, collectively, the evidence is
strong that TEE should be used during the perioperative
period. A retrospective cohort study of nearly 220,000 open
valve procedures (in which 85% used intraoperative TEE)
demonstrated a significant 30-day mortality benefit.16
Although the data set does not specifically indicate if the
patients had endocarditis, it is likely safe to assume at least the
same clinical benefit of intraoperative TEE.
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
3
Other Imaging Modalities to Evaluate IE
Multislice/Multidetector CT
A CT is less frequently used but can provide useful informa-
tion, especially when ultrasound diagnosis is inconclusive.
Both the ACC/AHA and the European Society of Cardiology
(ESC) provide recommendations for CT imaging in certain
clinical scenarios. The sensitivity is slightly less than echocar-
diography in detecting native valve endocarditis, but may be
superior in the presence of non-native valves, significant cal-
cium deposits, and when abscesses, especially periannular
ones, are present.17-20 However, CT has less sensitivity than
TEE when evaluating leaflet perforation. Jain et al. provided
data from a meta-analysis and suggested concomitant use of
TTE/TEE and CT may provide more accurate information
together than each study separately.21
MRI and PET CT
Echocardiography and Multidetector Computed Tomogra-
phy (MDCT) are the main diagnostic tools for IE. An MRI,
cardiac MRI, and nuclear imaging (PET) also are described in
the literature but have not been evaluated to the same degree.
A PET-CT potentially can provide early diagnosis of an infec-
tive process and may hold some benefit in evaluating for sour-
ces of infections in tissue pockets, drive lines, and catheters,
but it is prone to false-positive errors in the setting of recent
prosthetic valve surgery and other patient-specific scenarios.
False-negative results may be related to organism type, bio-
films, and low inflammatory activity after antibiotic treat-
ment.22-24
An MRI evaluation can be evaluated separately in terms of
cerebral utility and cardiac utility. As this review focuses on
IE and not necessarily the extracardiac sequelae of the disease,
the discussion is limited to noting its use in diagnosing throm-
boembolic events related to IE. Cerebral MRI evaluation may
provide significant detail and information about cardiac struc-
tures, but its role in IE is limited. It has not been demonstrated
to be superior to TEE, CT, or a combination of those tests in
diagnosing IE.23
Clinical Risk Scores
Risk stratification is important in IE to determine surgical
decision-making, as well as to counsel the patient’s family to
assess the quality of care. Most of the current clinical risk
scores are based on predictive scoring systems, which inher-
ently are based on patients having cardiac surgery for reasons
other than endocarditis. Many such clinical risk scores are
used. The Society of Thoracic Surgery (STS) risk score for
IE,25 the De Feo score (for native valve IE),26 the PALSUSE
score (prosthetic valve, age
70, large intracardiac destruc-
tion, Staphylococcus spp, urgent surgery, sex [female], Euro-
SCORE
10),27 the ANCLA score (anemia, New York Heart
Association functional class IV, critical state, large intracar-
diac destruction, surgery of the thoracic aorta),28 the Risk-
 ARTICLE IN PRESS
4 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
Endocarditis Score (RISK-E, for active left-sided IE),29 the
score for heart valve or prosthesis IE (EndoSCORE),30 and the


Association pour l’Etude et la Pr
evention de l’Endocadite
Infectieuse (AEPEI) score I (the original model) and II (the
alternate model).31
When Gatti et al. compared these scores to each other, 5
scores (ANCLA score, STS risk score for IE, PALSUSE
score, and Association pour l’Etude
et la Pr
evention de
l’Endocadite Infectieuse score I and II) showed satisfactory
performance in predicting in-hospital mortality for surgery
for IE. In their analysis comparing individual scores against
each other, the accuracy of prediction was best for the
ANCLA score.32 Individual scores also can be more predic-
tive when individual biomarkers are added like preoperative
serum albumin.33 Fernandez-Felix et al. recently had devel-
oped prognostic meta-models after a systematic review and
aggregation of the existing prediction models for mortality
after cardiac surgery in patients with IE. In their assessment,
the meta-models outperformed the existing predictive mod-
els in predicting the individual risk of mortality in patients
with IE.34
Current Society Guidelines—ESC and STS/AHA Update
As new evidence emerges, society guidelines are updated to
mirror the best available evidence. It is beyond the scope of
this paper to discuss the guidelines in detail. Aside from the
Modified Duke Criteria, there are several specialty-specific
clinical practice guidelines that provide recommendations for
the use of echocardiography to aid in the diagnosis and man-
agement of IE. The 2014 AHA/ACC guidelines noted that
“TEE is recommended in all patients with known or suspected
IE when TTE is nondiagnostic, when complications have
developed or are clinically suspected, or when intracardiac
device leads are present” as a Class I recommendation (Level
of Evidence: B).11-13 Multiple guidelines were reviewed and
compared with each other and it was noted that the different
clinical practice guidelines tended to agree, but were not unan-
imous, that TEE is recommended for prosthetic valves, com-
plicated IE, and IE in the presence of cardiac implantable
electronic device devices (CIED) and leads.14 There is signifi-
cant discordance between the clinical practice guidelines on
the need for follow-up TEE in uncomplicated native valve IE.
It also should be considered that despite being the most com-
monly used imaging modalities, TTE and TEE are both limited
in their ability to detect all cases of IE.8 It has been estimated
that echocardiography alone can result in normal or nondiag-
nostic results in up to 30% of prosthetic valve endocarditis.15
The ESC does not give specific recommendations regarding
TEE for suspected intracardiac complications in patients with
a positive TTE; however, the AHA/ACC does recommend
this. Whereas the ESC specifically recommends that TEE
should be done in patients with TTE evidence of IE and good
imaging quality, the AHA does not. The ESC specifically rec-
ommends echocardiography for all patients with S. aureus
bacteremia; however, the AHA does not. Furthermore, the
AHA does not specifically recommend repeat
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
echocardiography for follow-up of uncomplicated IE cases;
however, the ESC makes this recommendation to detect silent
complications and monitor vegetation size.
The ESC recommends the use of advanced imaging tests
such as CT in patients with high clinical suspicion but not
meeting the criteria for diagnosis according to the Duke cri-
teria. The European guidelines also specifically recommend
TEE when there is a concern for prosthetic valve endocardi-
tis.
Both societies acknowledge the use of cardiac CT; however,
although the ESC considers the data to be strong enough to
recommend its use as a diagnostic modality, the AHA/ACC
contends that more studies are needed to define the full useful-
ness of nuclear imaging in this patient population.4,6,35 The
ESC goes further by recommending modified diagnostic crite-
ria based on the lesions on cardiac CT as a major criterion in
the diagnosis. They also recommend that abnormal uptake
activity at the implantation site in cases of suspected prosthetic
valve endocarditis should be a major diagnostic criterion in a
valve that has been implanted for >3 months.35
Native Valve Endocarditis
Timing of Surgical Intervention and Outcomes
Although guidelines and recommendations are useful to
determine surgical intervention in IE, the timing of surgery is
made purely based on individual case presentation in the
majority of situations. The ACC and AHA guidelines recom-
mend early surgical intervention during initial hospitalization
and before completion of a full therapeutic course of antibiot-
ics in the setting of destructive cardiac lesions, inadequate
response to the antibiotic treatments, infection with a highly
resistant organism, IE leading to new heart failure symptoms,
and if the size of the vegetations on the left-sided valves
>10 mm in length with or without clinical evidence of embolic
events. The ESC gives a more specific timing of surgery with
patients with IE, and stratifies timing into emergent (<24
hours), urgent (within days), and elective (after 1-2 weeks after
antibiotic treatment).36 Overall, early (<7 days) versus
delayed (>7 days) surgical intervention decision is based on
the presence of complications like congestive heart failure,
and the development of resistance to antibiotics treatment for
at least 5-to-7 days, as seen with signs of persistent sepsis and/
or relapsing IE, having large mobile vegetations, invasion
beyond valve leaflets, and presence of recurrent systemic
emboli.37 The importance of an early, multispecialty team
approach to surgical decision-making in patients with IE is
emphasized.38
Outcome Data Comparing Early Versus Delayed Surgical
Intervention
Liang et al. in their metanalysis (n = 8141 from 16 studies)
observed that compared with delay (>2 weeks) in surgery,
early (<2 weeks) surgery lowered the incidence of in-hospital
mortality (odds ratio [OR] 0.57, 95% CI 0.42, 0.77;
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113 5

Fig 1. In-hospital mortality in patients with IE, comparing early surgery versus nonearly surgery, including subgroup analysis for different operation time periods.
IE: infective endocarditis; OR: odds ratio; CI: confidence interval. (Adapted from Liang et al. Interact Cardiovasc Thorac Surg. 2016 Mar;22(3):336-45.) Permis-
sion granted to reprint.

Fig 2. Long-term mortality in patients with IE, comparing early surgery versus nonearly surgery, including subgroup analysis for different operation time periods.
IE: infective endocarditis; OR: odds ratio; CI: confidence interval. (Adapted from Liang et al. Interact Cardiovasc Thorac Surg. 2016 Mar;22(3):336-45.) Permis-
sion granted to reprint.

Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 ARTICLE IN PRESS
6 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
p = 0.000), and long-term mortality (OR 0.57, 95% CI 0.43,
0.77; p = 0.001). In addition, operating within 2 weeks had a
more favorable effect on long-term mortality (OR 0.63, 95%
CI 0.41, 0.97; p = 0.192, I2 = 39.4%) than nonearly surgery.
However, they were unable to determine the optimal timing
for surgical intervention (Figs. 1 and 2).39 Another meta-analy-
sis from studies over 2 decades (n=21 studies) observed a
lower risk of all-cause mortality between early surgery and
medical therapy. However, there was no significant difference
in all-cause mortality between surgery within 7 days and
between 8 and 20 days, (OR 0.61, 95% CI 0.39-0.96,
p = 0.034) 0.64 (95% CI 0.48-0.86, p = 0.003). There were no
significant differences in in-hospital mortality, embolization,
heart failure, and recurrence of endocarditis between
unmatched cohorts.40 Kousa et al., in their analysis of the
United States inpatient database from a total of 13,056
patients, found no difference in the in-hospital mortality
between early surgery (<7 days) versus late surgery (>7 days)
(5% v 5.4%). However, early surgery was associated with sig-
nificantly shorter length of stay (12.4 v 25.9 days) and lower
hospital costs, reduced by 28.3%.41 Overall, early surgery has
potential benefits, but optimal timing remains unclear.
Time of Surgical Intervention in IE Complicated By
Neurologic Injury
Surgical timing in IE with preexisting neurologic events
remains unclear. Tam et al., in their meta-analysis (n = 1,330),
observed that early surgery (7 or 14 days) in ischemic or hem-
orrhagic stroke was associated with elevated perioperative
mortality versus late surgery (Relative Risk (RR) 1.74; 95%
CI 1.34-2.25; p < 0.0001), and greater neurologic exacerbation
(RR 2.09; 95% CI 1.32-3.32; p = 0.002). However, in their
subgroup analysis, similar perioperative mortality and neuro-
logic exacerbation were noted for ischemic stroke for the
period between 7 and 14 days, and for hemorrhagic stroke,
early surgery (<21 days) showed higher mortality (RR 1.77 v
0.63) and neurologic exacerbation (RR 2.02 v RR 0.44) com-
pared with surgery after 28 days, and, overall, no difference in
their long-term mortality. They concluded that delaying sur-
gery by 7-to-14 days for ischemic, and >21 days for hemor-
rhagic stroke eventually will decrease perioperative
mortality.42 Zhang et al., in their data from a single center
(n = 183) showed 50% of patients had early surgery within
7 days (despite having ischemic infarction in more than two-
thirds of enrolled patients). Their overall rates of neurologic
complications were similar for early and late surgery groups
(10.9% v 11%) and no mention of early or late mortality. 43 In
terms of mid and late outcomes, Yokoyama in their meta-anal-
ysis of 624 patients demonstrated similar all-cause mortality
between the early and late surgery groups (HR 0.90, 95% CI
0.49-1.64; p = 0.10). Similar observation was noted for the
neurologic recurrence rates between both groups (HR 1.86,
95% CI 0.76-4.52; p = 0.43;). Their observation was predomi-
nantly from observational studies and significantly lacked data
from randomized controlled trials in this specific group of
IE.44
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
Management in High-Risk Patient Populations
IE in Substance-Abuse Individuals
In recent years, the number of IE cases associated with intra-
venous drug use has increased. Clinical guidelines suggest
deferring surgery for IE in people who inject drugs because of
concern for worse outcomes in comparison to noninjectors.
Goodman et al. showed a lower survival rate in both immedi-
ate and long-term periods after surgery in the drug-injector
group compared with the noninjectors. Survival at 30-days, 1-,
5-, and 10 years was 94.3%, 81.0%, 62.1%, and 56.6% in the
drug injector group, respectively, and 96.4%, 85.0%, 70.3%
and 63.4% in the noninjector group. The drug injector group
had a 47% greater hazard of death (HR 1.47, 95% CI 1.05-
2.05) and more than twice the hazard of reoperation (HR 2.37,
95% CI 1.25-4.50) than the noninjector group (Fig 3).45 Straw
et al., from their prospectively collected data from 2006 to
2016, showed a lower survival rate with drug injectors who
developed IE compared with other infections. Mortality was
even higher in patients who required surgery than in those who
did not (HR 1.8, 95% CI 0.95-3.3). They concluded that
although early survival was good, long-term survival was poor
due to ongoing infection risk in the drug injector group. Sur-
gery does not confer long-term survival advantage, and more
efforts are needed to reduce reinfection risks in the drug injec-
tor group.46
IE in End-Stage Renal Disorders
End-stage renal disorder patients requiring chronic dialysis
are considered at high risk for the development of IE. From a
nationwide database over 3 decades (n = 9,392), Ludvigsen
and the group analyzed incidences and outcomes in dialysis
patients complicated by IE. They noted an increased risk of IE
(HR 1.57; 95% CI 1.09-2.27) in patients without aortic valve
fistula after adjusting for age, sex, valvular disease, diabetes,
and period of the first hemodialysis. They also observed fewer
incidences of IE in the elderly population (age
70 years,
HR = 0.59; 95% CI 0.37-0.93). The 90-day all-cause mortality
in IE was slightly higher in the dialysis group than in cohorts
without dialysis, 27% and 23%, respectively.47 Data from the
Danish national registry (n = 10,612) noted higher incidences
of IE in hemodialysis compared with peritoneal dialysis or
renal transplantation patients (1,092/100,000 person-years,
212/100,000 person-years, and 85/100,000 person-years,
respectively). Moreover, incidences were higher in patients
with central venous catheters compared with aortic valve (AV)
fistulae. Overall reported mortality was 22% in hospital and
51% at 1 year. Aortic valve disease, previous IE, and the first 6
months of renal replacement therapy were some of the contrib-
uting factors to developing IE.48 From pooled data meta-analy-
sis, Sadeghi et al. revealed overall in-hospital mortality of
29.5% (95% CI 26.7%-46.6%) and long-term mortality of
45.6% (95% CI 41.9%-49.3%) in hemodialysis patients suffer-
ing from IE.49 Data from the North American registry showed
higher in-hospital and 6-month mortality in hemodialysis
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113 7

Fig 3. Time-to-reoperation survival of PWID and non-PWID after cardiac surgery for infective endocarditis. Panel A denotes the three included studies. Panel B
denotes the aggregate survival curves by arm (PWID vs. non-PWID). Abbreviations: non-PWID, people who do not inject drugs; PWID, people who inject drugs.
(Adapted from Goodman-Meza D BMC Infect Dis. 2019 Nov 8;19(1):918) Permission granted to reprint.

versus nondialysis IE patients (30.4% v 17% and 39.8% v
20.7%, respectively; p < 0.001). Acute onset of cardiac fail-
ure, persistent bacteremia, Central Nervous System (CNS)
emboli, and Charlson score are some of the risk factors for
higher 6-month mortality in the dialysis group.50
with the 153,242 adult IE cases without congenital heart dis-
ease (7.1% v 16.1%, p < 0.001).52 Although the presence of
adult congenital heart disease per se does not increase overall
morality with IE, acquired comorbidities emerged as the main
predictors of adverse outcomes.

IE in Adult Congenital Heart Disorders IE in the CIED Population

Patients with adult congenital heart disease in general have
an increased risk of developing IE. A single-center database
by Tutarel et al. showed the mean age at the presentation of IE
was 32.3 § 22.7 years, of whom only a third had a complex
lesion. One-fourth of patients developed recurrent episodes of
IE, and a third of patients received surgical interventions dur-
ing the same admission. Twenty percent of patients died in
their 6-to-7 years’ follow-up, of whom 7% of mortality was
due to IE. Age and development of abscess (OR 7.23; 95% CI
1.81-28.94, p < 0.01) were the significant factors for IE-
related morality in congenital disorders.51 A national database
from Germany showed that the incidence of IE was 0.8%
(2,512 out of 309,245, congenital heart disorder). Their
observed morality in IE was 6%, and 41.5% required surgical
intervention. However, the overall IE-associated mortality was
lower in patients with adult congenital heart disease compared
The number of electronic intracardiac devices such as pace-
makers, defibrillators, and nonelectronic devices (percutaneous
occluders) implanted worldwide has been increasing progres-
sively over the past few decades. In general, patients who
receive CIEDs share certain common characteristics, such as
underlying heart disease, advanced age, kidney disease, and
multiple associated pathologies, which have led to a change in
the spectrum of presentation of endocarditis. The CIED-asso-
ciated IEs pose diagnostic and therapeutic challenges due to
the complexity of the patients, the type of microorganisms
involved, and often the time required for either the percutane-
ous or surgical techniques in the removal of infected material.
All of these circumstances require a multidisciplinary
approach. Male sex, diabetes, renal impairment, chronic
obstructive pulmonary disease, cancer, and the use of immuno-
suppressors are some of the contributing factors to CIED-

Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 ARTICLE IN PRESS
8 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113

related infections.53 The risk of IE was higher in nonfirst
implants, with a greater number of electrodes and a prolonged
duration of the procedure. The CIED-IE has been associated
with high mortality (24.5%-29% with follow-up periods of up
to a year), and has high explant rates of 80-100%. Long-term
mortality is 2 times higher than in CIED carriers without infec-
tious complications. Abnormal renal function is the most con-
sistently identified risk factor for mortality. In many cases,
failure to remove an infected device is associated with relapse
and mortality.54 With the advancement of technology, it is
hoped that the use of subcutaneous devices, leadless devices,
and new antibiotic treatments will reduce the incidence of
lead-related endocarditis.
Type of Surgical Interventions and Valve Involvement
Mitral Valve Endocarditis
In mitral valve endocarditis, repair of the valve, as opposed
to replacement, generally results in decreased in-hospital and
long-term mortality, reduced recurrence rates, fewer postoper-
ative repeat surgeries on the mitral valve, and fewer cerebro-
vascular events. Repair of the valve is feasible in 78% of
patients, especially with an experienced team, and reported
mortality is between 3% and 21%.38,55 Mitral valve replace-
ment (MVR) is required when the damage is extensive, as well
as in patients with calcified or rheumatic disease of the mitral
valve. The type of prosthetic valve used for replacement is
determined by many factors such as age, comorbidities, and
patient willingness to continue lifelong anticoagulation. In
general, the current guidelines on MVR (AHA/ACC or the
ESC and the European Association for Cardio-Thoracic Sur-
gery guidelines) recommend using a mechanical valve for
patients <50 years and bioprosthesis for those who are >70
years. However, the choice of the mechanical or bioprosthetic
valve in the mitral position for patients aged 50-to-69 years is
uncharted territory in the current guidelines.4
From their single-center retrospective data, Hu et al. showed
that mechanical valve prostheses were associated with better sur-
vival and lower rates of reoperation compared with bioprostheses
within 15 years after MVR in IE patients aged 50-to-69 (Fig 4).56
Chikwe et al. demonstrated no difference in survival for patients
aged between 50 and 69 years requiring MVR; however, mechani-
cal valves were associated with a significantly increased risk of
stroke (HR 1.62; 95% CI 1.10-2.39) and bleeding events (HR
1.50; 95% CI 1.05-2.16), and a significant reduction in reoperation
(HR 0.59; 95% CI 0.37-0.94).57 Kulik et al. found similar results
in MVR patients aged 50-to-65. Although there was no significant
difference in late mortality, there was an increase in the require-
ment for reoperation for bioprosthetic valves (HR 7.1; 95% CI
1.8-27.8), and an increased risk of thromboembolism for mechani-
cal valves (HR 4.1; 95% CI 1.3-12.7).58 There have been reports
of higher mortality with bioprostheses than mechanical MVR
among those 50-to-69 years of age (HR 1.16; 95% CI 1.04-
1.30).59
Aortic Valve Endocarditis
In contrast to mitral valve IE, the majority of aortic valve IE
is treated via the replacement of the valve. The repair can be
achieved in up to 33% in experienced valve repair centers.
Moreover, there is limited evidence on whether repairing the
valve improves outcomes compared with replacement.35 In a
comparison of a homograft versus conventional prosthetic
valve, no differences in perioperative mortality or stroke were
noted despite a greater proportion of staphylococcal endocardi-
tis, abscess, and root replacements, but less multivalve

Fig 4. Fifteenyear survival after mitral valve replacement for infective endocarditis patients aged 50-to-69 years according to prosthetic type: bioprostheses (red
line) or mechanical (blue line) (Adapted from Hu et al. Clin Cardiol. 2020;43(10):1093-1099) Permission granted to reprint.

Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
involvement in the homograft group. Long-term outcomes of
all-cause mortality (Incidence Rate Ratio (IRR) 0.82, 95% CI
0.36-1.84, p = 0.63), recurrent endocarditis (IRR 1.04, 95% CI
0.49-2.19, p = 0.92), and reoperation (IRR 3.17, 95% CI 0.52-
19.44, p = 0.21) were similar between the 2 groups. However,
there was a significantly increased need for reoperation with
homograft versus mechanical prosthetic valves.60 Kyto et al.
demonstrated lower midterm mortality with mechanical com-
pared with bioprosthesis in aortic valve IE patients aged <70
years.61 Pulmonary homograft is used commonly in younger
patients to avoid anticoagulation.
Tricuspid Valve Endocarditis
Overall, tricuspid valve IE makes up only around 5%-to-
10% of IE. It is most noted in drug-injector groups, especially
if it also is associated with HIV or immunosuppression. S.
aureus accounts for 60%-to-90% of the infections, with methi-
cillin-resistant S. aureus on the rise. The reported mortality
with tricuspid valve IE is as high as 7%.62 The majority of the
patients with tricuspid valve IE are treated with antimicrobial
therapy, and surgical intervention is indicated only when the
infection is difficult to eradicate or there is persistent bacter-
emia for >1 week despite adequate treatment. Surgery also is
indicated with vegetations >2 cm with recurrent pulmonary
emboli, with evidence of right heart failure with a poor
response to diuretics. Most surgeries are valve replacements
using a bioprosthetic valve. Repair of the valve is preferred in
some exceptional cases; however, evidence shows that there is
no benefit in outcomes compared with the other options like in
other valves.
Pulmonary Valve Endocarditis
Isolated pulmonary valve endocarditis is extremely rare in a
healthy heart (<2%).48 Early symptoms of IE initially can be
misdiagnosed as a viral illness, which can result in delayed
intervention and an increased rate of complications. Intrave-
nous drug abuse, alcoholism, sepsis, immunosuppression, and
catheter-related infections are the most common predisposing
factors, and up to a third of pulmonary valve endocarditis do
not have predisposing factors. Although medical therapy with
prolonged antimicrobials is the primary treatment option in
pulmonary valve endocarditis, surgical valve replacement indi-
cates significant valvular regurgitation resulting in acute heart
failure. The presence of multidrug-resistant organisms or
fungi, persistent bacteremia or recurrent emboli despite appro-
priate antibiotic therapy, IE complicated by heart block or
abscess formation, and severe regurgitation with mobile vege-
tations >10 mm also may indicate replacement.63
Prosthetic Valve IE
Overall, there is no major difference in consensus between
native and prosthetic valve endocarditis. The timing of surgical
interventions remains unclear, similar to native valve endocar-
ditis. A metanalysis from Harky et al. showed no differences
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
9
in in-hospital mortality between early (<2 weeks) and non-
early(>2 weeks) surgery (OR 0.83, 95% CI 0.65, 1.06;
p = 0.413).38 Appropriate antimicrobial therapy should follow
the same recommendations as native valve endocarditis,
although some patients might require prolonged therapy. It is
unknown if prosthetic valve endocarditis rates differ between
mechanical valves and bioprosthetic valves, and, therefore, the
risk of endocarditis is not incorporated into the shared deci-
sion-making process. However there appears to be an unrecog-
nized higher risk of IE with bioprosthetic valves. These data,
along with patient characteristics, provide important informa-
tion to help guide the risk:benefit ratio discussion in individual
patients navigating the complexity of choice of the valve pros-
thesis in prosthetic valve IE.40
Updates on Transcatheter Valve Endocarditis
Background and Incidence
With the number of transcatheter aortic valve replacements
(TAVR) increasing and the indication for use broadening, opti-
mizing outcomes becomes paramount. Infective endocarditis is
a rare but severe complication that occurs in 0.3%-to-2.3% of
TAVR patients and carries 22.3%-to-36% 30-day and 66% 1-
year mortality after diagnosis.64-72 This process can be further
subcategorized based on the time from implant to diagnosis,
early (<2 months) intermediate (2-12 months), and later (>12
months).71 The median time from TAVR to IE hospitalization
may be around 6 months to a year (352 days) and have a cumu-
lative incidence of 5.8% at 5 years.70,72,73 Incidence of IE in
TAVR appears to be similar or even the same as surgical aortic
valve replacement (SAVR); however, there are a few distinct
differences in the epidemiology, risk factors, pathogenesis,
and treatment.69,70,74 Many recommendations for prevention
and treatment arise from data on IE in SAVR; however these
variables limit a direct interpretation. Identifying TAVR-spe-
cific risk factors may help guide preventative and therapeutic
options.
Pathogenesis
Where TAVR and SAVR share similarities are that biopros-
thetic material acts as a vector for bacterial adhesion. Mechan-
ical valves appear to hold less risk of IE as compared with
bioprosthetic; from here SAVR and TAVR begin to diverge.40
The primary causative organism of IE in TAVR is different
from that in SAVR. Enterococci are reported as the most com-
mon organism in TAVR, in contrast to SAVR in which Staphy-
lococcus and Streptococcus predominate. This may be
attributable to the surgical site, the groin, which is used in the
majority of TAVR procedures.72,73,75-78 Additionally, 47.9%
of those Enterococci samples were drug-resistant.79 Conse-
quently, perioperative prophylactic antibiotic choices may
influence outcomes; however, this has yet to be investigated.
Additional risk factors included younger age, male sex, lack
of predilation, intubation during TAVR procedure, new pace-
maker, and greater than grade 2 residual Aortic insufficiency
 ARTICLE IN PRESS
10 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113

Table 3 of focused interventions on outcomes has not yet been investi-

Risk Factors Associated with Infective Endocarditis After TAVR gated.
Risk Factor for IE Unique to Both Unique to
TAVR SAVR Prevention, Diagnosis, and Treatment
Age (Younger) x
Male x
Prevention of IE after TAVR could focus on modifiable risk
Diabetes x factors. Performing the procedure in the OR, under sedation,
Chronic Renal Insufficiency x use of a self-expanding valve, taking care in avoiding crimping
Atrial Fibrillation x or damage to the valve during prep, screening for Enterococ-
Sternal wound infection x cus, and focusing on prophylactic treatment may impact out-
Aortic Regurgitation
Moderate x
Self-Expandable Valve y comes (Table 3).68,74 However, addressing these risk factors
Orotracheal Intubation x has not yet been reported but could hold a significant impact
y
Transfemoral Approach factor.
New Pacemaker Implantation x Diagnosis of IE generally is performed using the Modified
Residual Aortic Regurgitation x Duke Criteria, which carries nearly an 80% sensitivity.81 How-
Vascular Injury x
Bleeding Complications x
ever, in patients after a prosthetic valve has been implanted,
the algorithm loses much of its diagnostic power.82,83 Trans-
Adapted from Cahill et al, Jian W et al and Alexis SL et al.5,11,27 thoracic echocardiographic imaging is noninvasive and is
y Denotes a benefit. associated with 28%-to-69% sensitivity. When suspicion
remains for IE, TEE can be performed and increases the sensi-
(AI) after implantation. Factors associated with a possible ben- tivity to 86%-to-94%. Reexamination with echocardiography
efit were the use of a self-expandable valve, older age, and after 3-to-7 days is recommended when suspicion of IE is still
treatment in a hybrid operating room versus the catheterization present.84 In patients in whom TTE and TEE are inconclusive,
laboratory (Table 1).79 In cases of IE, in-hospital mortality and suspicion of IE remains, CT and 18F-fluorodeoxyglucose
was increased in patients with septic shock, persistent bacter- PET/CT are effective at discriminating root abscesses after a
emia, acute renal failure, and heart failure. The addition of S. prosthetic valve replacement, and may be helpful when other
aureus or Entercocci bacteremia impacted all-cause mortality studies are inconclusive.74 Blood cultures can aid in diagnosis
at 1-year.80 Some of these items are modifiable but the impact as well as narrowing treatment. Investigating for embolism

Figure 5. Unadjusted All-Cause Mortality According to Treatment. (A) Unadjusted all-cause mortality was comparable between IE-CS and IE-AB. (B) In a land-
mark analysis, unadjusted long-term mortality of patients surviving the initial IE treatment episode was also not different between IE-CS and IE-AB. HRs, and cor-
responding 95% CIs are for 2-year all-cause mortality. IE-AB = infective endocarditis treated with antibiotics only; IE-CS = infective endocarditis treated with
cardiac surgery [and antibiotics]). Mangner N, del Val D, Abdel-Wahab M, et al. Surgical Treatment of Patients With Infective Endocarditis After Transcatheter
Aortic Valve Implantation. J Am Coll Cardiol. 2022;79(8):772-785. doi:10.1016/j.jacc.2021.11.056. Permission granted to reprint.

Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
with additional imaging also can aid in diagnosis, risk stratifi-
cation, and treatment planning.84
Treatment of IE after a bioprosthetic valve can be accom-
plished with 2 approaches, medical and/or surgical. Surgical
management after SAVR has a lower risk of 30-day mortality
and a higher chance of survival to follow-up compared with
medical management.85 However, for IE after TAVR, there is
no difference for in-hospital or 1-year mortality between those
who underwent cardiac surgery versus medical management
only (Fig 5).80 Surgical treatment has been used frequently in
cases that involve vegetation >10 mm, heart failure, systemic
embolization, persistent bacteremia, and periannular involve-
ment; however, less frequent in older patients or those with
neurologic complications.80 Approximately 77%-to-81% of
patients with IE after TAVR have an indication for surgery,
and only 11%-to-19% will undergo surgery. 73,80 Infective
endocarditis after TAVR carried an in-hospital mortality rate
of 31.9%-to-47.2%, and those who underwent surgery did not
have improved outcomes as compared with medical manage-
ment only.73,80 Considering that most of the patients in these
reports were poor surgical candidates, these findings may not
accurately reflect outcomes in lower-risk patients; data are not
yet available.
Medical management may often be the primary modality of
treatment and also should be used in conjunction with surgical
interventions; starting with the emprical treatment of confirmed
IE and in the case of negative blood cultures but suspected IE.
Recommendations include combination therapy of agents like
daptomycin and ceftriaxone or vancomycin and gentamicin.
Antibiotic therapy can be targeted with speciation and sensitiv-
ity studies. In negative blood culture-IE, causative organisms
include Coxiella, Bartonella, fungi, and the HACEK (Hemophi-
lus aphrophilus, Hemophilus paraphrophilus, Aggregatibacter
actinomycetemcomitans, Cardiobacterium hominis, Eikenella
corrodens, Kingella kingae), so diagnostic studies and treatment
should include these. With TAVR being performed in a higher
number of the intermediate-to-low-risk population, there may
be a shift in treatment choices toward surgery; however, this has
not yet been reported.
Timing of Surgical Intervention
The timing of intervention largely depends on the coexisting
disease and evidence of clinical deterioration. Surgical risk
assessment can be assessed with STSscore, EuroSCORE, or
JapanSCORE, and may help guide decision-making. Preopera-
tive assessment should include the investigation of concurrent
embolic events, cerebral vessels, coronary arteries, and solid
organs. There is a high rate of neurologic complications asso-
ciated with IE, and findings should be incorporated into the
surgical risk assessment. Based on data for IE after SAVR,
early surgery (defined as within 24 hours of diagnosis) is rec-
ommended when the possibility of progressive heart failure
and embolism are present without coexisting intracranial
involvement and/or severe comorbidities.84,86 Early surgery
also is recommended in patients who are refractory to antibi-
otic therapy or in the case of drug-resistant organisms.86
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
11
Although early surgery has led to favorable outcomes for IE in
the SAVR population, this may not translate to the same out-
come in the TAVR population, and evidence is currently lack-
ing. Thorough evaluation and risk stratification are needed for
appropriate treatment planning.
Focused Surgical Approaches
Althoughto date there are no data related to outcomes based
on surgical approaches specifically for IE in TAVR, the follow-
ing is based on data for IE after SAVR. When the infection is
confined to the valve, replacement may suffice as treatment.87 If
the annulus is involved but the abscess, is small a patch can be
used after debridement. If the abscess is large, root replacement
may be necessary. Concurrent replacement of the mitral valve
also can be considered in patients in whom the abscess is
large.84,86 There appears to be no significant difference in out-
comes between replacement with mechanical versus biopros-
thetic valves, but there is some evidence of a favorable outcome
with a Ross procedure.88 Reports of minimally invasive
approaches for mitral valve repair and replacement after IE
show a 1-year survival of 79.3%, with a low (1.8%) rate of con-
version to sternotomy; however, to the authors’ knowledge there
are no reports demonstrating this for the aortic valve after
TAVR.89
Conclusions
Infective endocarditis is associated with major morbidity
and mortality even though significant advances have been
made in diagnosis and treatment. With the increasing use of
prosthetic valves and devices within the heart, it is becoming
more prevalent in older patients and with more chronic comor-
bidities. Even though there are several predictive scoring mod-
els to predict the mortality and morbidity of patients
undergoing cardiac surgery for IE, a universal model is still
lacking that includes patient factors and is specific to IE. With
the increasing use of TAVRs, there is now an increasing inci-
dence of IE in older patients, with increased mortality. The
outcomes of IE after TAVR are associated with high in-hospi-
tal and 1-year mortality—numbers that exceed those reported
in SAVR. Intervention, such as a surgical explantation of the
infective valve, is currently uncommon and does not appear to
improve outcomes. This paradigm may shift, as TAVR is
being performed with increased frequency in intermediate-
and low-risk populations, but more data are needed before con-
clusions can be drawn. There are unique risk factors for IE
after TAVR, some of which are modifiable and may improve
with intervention, including prophylaxis targeting the primary
causative organism. Though much has been reported, signifi-
cant knowledge gaps exist and further research is required.
Conflict of Interest
None.
 ARTICLE IN PRESS
12 A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
References
1 Cahill TJ, Prendergast BD. Infective endocarditis. Lancet 2016;387:882–
93.
2 Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults:
Diagnosis, antimicrobial therapy, and management of complications. Cir-
culation 2015;132:1186–435.
3 Toyoda N, Chikwe J, Itagaki S, et al. Trends in infective endocarditis
in California and New York state, 1998-2013. JAMA 2017;317:1652–
60.
4 Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for
the management of patients with valvular heart disease: A report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines. J Am Coll Cardiol 2014;63:e57–185.
5 Yew H Sen, Murdoch DR. Global trends in infective endocarditis epidemi-
ology. Curr Infect Dis Rep 2012;14:367–72.
6 Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for
the management of patients with valvular heart disease: A report of the
American College of Cardiology/American Heart Association Joint Com-
mittee on Clinical Practice Guidelines. Circulation 2021;143:e72–227.
7 Avtaar Singh SS, Costantino MF, D’Addeo G, et al. A narrative review of
diagnosis of infective endocarditis-imaging methods and comparison. Ann
Transl Med 2020;8:1621.
8 Reynolds HR, Jagen MA, Tunick PA, et al. Sensitivity of transthoracic ver-
sus transesophageal echocardiography for the detection of native valve
vegetations in the modern era. J Am Soc Echocardiogr 2003;16:67–70.
9 San Rom
an JA, Vilacosta I, L
opez J, et al. Role of transthoracic and transe-
sophageal echocardiography in right-sided endocarditis: One echocardio-
graphic modality does not fit all. J Am Soc Echocardiogr 2012;25:807–14.
10 Roe MT, Abramson MA, Li J, et al. Clinical information determines the
impact of transesophageal echocardiography on the diagnosis of infective
endocarditis by the Duke criteria. Am Heart J 2000;139:945–51.
11 Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/
HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echo-
cardiography. J Am Soc Echocardiogr 2011;24:229–67.
12 Philip M, Tessonier L, Mancini J, et al. Comparison between ESC and
Duke Criteria for the diagnosis of prosthetic valve infective endocarditis.
JACC Cardiovasc Imaging 2020;13:2605–15.
13 Yuan X-C, Liu M, Hu J, et al. Diagnosis of infective endocarditis using
echocardiography. Medicine (Baltimore) 2019;98:e17141.
14 Xie P, Zhuang X, Liu M, et al. An appraisal of clinical practice guidelines for
the appropriate use of echocardiography for adult infective endocarditis-the
timing and mode of assessment (TTE or TEE). BMC Infect Dis 2021;21:92.
15 Eder MD, Upadhyaya K, Park J, et al. Multimodality imaging in the diag-
nosis of prosthetic valve endocarditis: A brief review. Front Cardiovasc
Med 2021;8:750573.
16 MacKay EJ, Neuman MD, Fleisher LA, et al. Transesophageal echocardi-
ography, mortality, and length of hospitalization after cardiac valve sur-
gery. J Am Soc Echocardiogr 2020;33:756–62;e1.
17 Iung B, Rouzet F, Brochet E, Duval X. Cardiac Imaging of infective endo-
carditis, echo and beyond. Curr Infect Dis Rep 2017;19:8.
18 Koo HJ, Yang DH, Kang J-W, et al. Demonstration of infective endocarditis
by cardiac CT and transoesophageal echocardiography: Comparison with
intra-operative findings. Eur Hear J Cardiovasc Imaging 2018;19:199–207.
19 Micha»owska I, Stok»osa P, Mi»kowska M, et al. The role of cardiac com-
puted tomography in the diagnosis of prosthetic valve endocarditis - a com-
parison with transthoracic and transesophageal echocardiography and
intra-operative findings. Eur J Radiol 2021;138:109637.
20 Oliveira M, Guittet L, Hamon M, et al. Comparative value of cardiac CT and
transesophageal echocardiography in infective endocarditis: A systematic
review and meta-analysis. Radiol Cardiothorac Imaging 2020;2:e190189.
21 Jain V, Wang TKM, Bansal A, et al. Diagnostic performance of cardiac
computed tomography versus transesophageal echocardiography in infec-
tive endocarditis: A contemporary comparative meta-analysis. J Cardio-
vasc Comput Tomogr 2021;15:313–21.
22 Gomes A, van Geel PP, Santing M, et al. Imaging infective endocarditis:
Adherence to a diagnostic flowchart and direct comparison of imaging
techniques. J Nucl Cardiol 2020;27:592–608.
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
23 Mgbojikwe N, Jones SR, Leucker TM, et al. Infective endocarditis:
Beyond the usual tests. Cleve Clin J Med 2019;86:559–67.
24 Sordelli C, Fele N, Mocerino R, et al. Infective endocarditis: Echocardio-
graphic imaging and new imaging modalities. J Cardiovasc Echogr
2019;29:149–55.
25 Gaca JG, Sheng S, Daneshmand MA, et al. Outcomes for endocarditis sur-
gery in North America: A simplified risk scoring system. J Thorac Cardio-
vasc Surg 2011;141:92–8.
26 De Feo M, Cotrufo M, Carozza A, et al. The need for a specific risk predic-
tion system in native valve infective endocarditis surgery. ScientificWorld-
Journal 2012;2012:307571.
27 Mart
ınez-Sell
es M, Mu~noz P, Arn
aiz A, et al. Valve surgery in active
infective endocarditis: A simple score to predict in-hospital prognosis. Int
J Cardiol 2014;175:133–7.
28 Gatti G, Benussi B, Gripshi F, et al. A risk factor analysis for in-hospital
mortality after surgery for infective endocarditis and a proposal of a new
predictive scoring system. Infection 2017;45:413–23.
29 Olmos C, Vilacosta I, Habib G, et al. Risk score for cardiac surgery in
active left-sided infective endocarditis. Heart 2017;103:1435–42.
30 Di Mauro M, Dato GMA, Barili F, et al. A predictive model for early mor-
tality after surgical treatment of heart valve or prosthesis infective endocar-
ditis. The EndoSCORE. Int J Cardiol 2017;241:97–102.
31 Gatti G, Perrotti A, Obadia J-F, et al. Simple scoring system to predict in-
hospital mortality after surgery for infective endocarditis. J Am Heart
Assoc 2017;6:e004806.
32 Gatti G, Sponga S, Peghin M, et al. Risk scores and surgery for infective
endocarditis: In search of a good predictive score. Scand Cardiovasc J
2019;53:117–24.
33 Huang S, Zhou Z, Luo L, et al. Preoperative serum albumin: A promising
indicator of early mortality after surgery for infective endocarditis. Ann
Transl Med 2021;9:1445.
34 Fernandez-Felix BM, Barca LV, Garcia-Esquinas E, et al. Prognostic mod-
els for mortality after cardiac surgery in patients with infective endocardi-
tis: A systematic review and aggregation of prediction models. Clin
Microbiol Infect 2021;27:1422–30.
35 Habib G, Lancellotti P, Antunes MJ, et al. [2015 ESC Guidelines for the
management of infective endocarditis. The Task Force for the Manage-
ment of Infective Endocarditis of the European Society of Cardiology
(ESC)]. G Ital Cardiol (Rome) 2016;17:277–319.
36 Wang A, Fosbøl EL. Current recommendations and uncertainties for surgi-
cal treatment of infective endocarditis: A comparison of American and
European cardiovascular guidelines. Eur Heart J 2022;43:1617–25.
37 Olaison L, Pettersson G. Current best practices and guidelines. Indications
for surgical intervention in infective endocarditis. Cardiol Clin
2003;21:235–51;vii.
38 Harky A, Zaim S, Mallya A, George JJ. Optimizing outcomes in infective endo-
carditis: A comprehensive literature review. J Card Surg 2020;35:1600–8.
39 Liang F, Song B, Liu R, et al. Optimal timing for early surgery in infective
endocarditis: A meta-analysis. Interact Cardiovasc Thorac Surg 2016;
22:336–45.
40 Anantha-Narayanan M, Reddy YN V, Sundaram V, et al. Endocarditis risk
with bioprosthetic and mechanical valves: Systematic review and meta-
analysis. Heart 2020;106:1413–9.
41 Kousa O, Walters RW, Saleh M, et al. Early vs late cardiac surgery in
patients with native valve endocarditis-United States Nationwide Inpatient
database. J Card Surg 2020;35:2611–7.
42 Tam DY, Yanagawa B, Verma S, et al. Early vs late surgery for patients
with endocarditis and neurological injury: A systematic review and meta-
analysis. Can J Cardiol 2018;34:1185–99.
43 Zhang LQ, Cho S-M, Rice CJ, et al. Valve surgery for infective endocardi-
tis complicated by stroke: Surgical timing and perioperative neurological
complications. Eur J Neurol 2020;27:2430–8.
44 Yokoyama Y, Goto T. Midterm outcomes of early versus late surgery for
infective endocarditis with neurologic complications: A meta-analysis. J
Cardiothorac Surg 2021;16:49.
45 Goodman-Meza D, Weiss RE, Gamboa S, et al. Long term surgical out-
comes for infective endocarditis in people who inject drugs: A systematic
review and meta-analysis. BMC Infect Dis 2019;19:918.
 ARTICLE IN PRESS
A. Jain et al. / Journal of Cardiothoracic and Vascular Anesthesia 00 (2023) 113
46 Straw S, Baig MW, Gillott R, et al. Long-term outcomes are poor in intra-
venous drug users following infective endocarditis, even after surgery.
Clin Infect Dis 2020;71:564–71.
47 Ludvigsen LUP, Dalgaard LS, Wiggers H, et al. Infective endocarditis in
patients receiving chronic hemodialysis: A 21-year observational cohort
study in Denmark. Am Heart J 2016;182:36–43.
48 Chaudry MS, Carlson N, Gislason GH, et al. Risk of infective endocarditis
in patients with end stage renal disease. Clin J Am Soc Nephrol
2017;12:1814–22.
49 Sadeghi M, Behdad S, Shahsanaei F. Infective endocarditis and its short
and long-term prognosis in hemodialysis patients: A systematic review
and meta-analysis. Curr Probl Cardiol 2021;46:100680.
50 Pericas JM, Llopis J, Jim
enez-Exposito MJ, et al. Infective endocarditis in
patients on chronic hemodialysis. J Am Coll Cardiol 2021;77:1629–40.
51 Tutarel O, Alonso-Gonzalez R, Montanaro C, et al. Infective endocarditis
in adults with congenital heart disease remains a lethal disease. Heart
2018;104:161–5.
52 Maser M, Freisinger E, Bronstein L, et al. Frequency, mortality, and pre-
dictors of adverse outcomes for endocarditis in patients with congenital
heart disease: Results of a nationwide analysis including 2512 endocarditis
cases. J Clin Med 2021;10:5071.
53 Fournier PE, Casalta JP, Habib G, et al. Modification of the diagnostic cri-
teria proposed by the Duke Endocarditis Service to permit improved diag-
nosis of Q fever endocarditis. Am J Med 1996;100:629–33.
54 Sandoe JAT, Barlow G, Chambers JB, et al. Guidelines for the diagnosis,
prevention and management of implantable cardiac electronic device
infection. Report of a joint Working Party project on behalf of the British
Society for Antimicrobial Chemotherapy (BSAC, host organization), Brit-
ish Heart Rhythm Society (BHRS), British Cardiovascular Society (BCS),
British Heart Valve Society (BHVS) and British Society for Echocardiog-
raphy (BSE). J Antimicrob Chemother 2015;70:325–59.
55 Antoniou A, Harky A, Bashir M, et al. Why I choose to repair and not to
replace the aortic valve? Gen Thorac Cardiovasc Surg 2019;67:20–4.
56 Hu X, Jiang W, Xie M, et al. Bioprosthetic vs mechanical mitral valve
replacement for infective endocarditis in patients aged 50 to 69 years. Clin
Cardiol 2020;43:1093–9.
57 Chikwe J, Chiang YP, Egorova NN, et al. Survival and outcomes following
bioprosthetic vs mechanical mitral valve replacement in patients aged 50 to
69 years. JAMA 2015;313:1435–42.
58 Kulik A, B
edard P, Lam B-K, et al. Mechanical versus bioprosthetic valve
replacement in middle-aged patients. Eur J Cardiothorac Surg
2006;30:485–91.
59 Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or biologic prosthe-
ses for aortic-valve and mitral-valve replacement. N Engl J Med
2017;377:1847–57.
60 Yanagawa B, Mazine A, Tam DY, et al. Homograft versus conventional
prosthesis for surgical management of aortic valve infective endocarditis: A
systematic review and meta-analysis. Innovations (Phila) 2018;13:163–70.
61 Kyt€ o V, Sipil€a J, Ahtela E, et al. Mechanical versus biologic prostheses for
surgical aortic valve replacement in patients aged 50 to 70. Ann Thorac
Surg 2020;110:102–10.
62 Iftikhar SF, Ahmad F. Tricuspid valve endocarditis. Treasure Island, FL:
StatPearls Publishing; 2022.
63 Pettersson GB, Coselli JS, Pettersson GB, et al. 2016 The American Asso-
ciation for Thoracic Surgery (AATS) consensus guidelines: Surgical treat-
ment of infective endocarditis: Executive summary. J Thorac Cardiovasc
Surg 2017;153:1241–58;e29.
64 Lanz J, Reardon MJ, Pilgrim T, et al. Incidence and outcomes of infective
endocarditis after transcatheter or surgical aortic valve replacement. J Am
Heart Assoc 2021;10:e020368.
65 Fauchier L, Bisson A, Herbert J, et al. Incidence and outcomes of infective
endocarditis after transcatheter aortic valve implantation versus surgical
aortic valve replacement. Clin Microbiol Infect 2020;26:1368–74.
66 Prasitlumkum N, Vutthikraivit W, Thangjui S, et al. Epidemiology of
infective endocarditis in transcatheter aortic valve replacement: Systemic
review and meta-analysis. J Cardiovasc Med (Hagerstown) 2020;21:790–
801.
Descargado para Anonymous User (n/a) en Government of Castile and Leon Ministry of Health de ClinicalKey.es por Elsevier en febrero 04, 2023.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
13
67 Summers MR, Leon MB, Smith CR, et al. Prosthetic valve endocarditis
after TAVR and SAVR: Insights from the PARTNER trials. Circulation
2019;140:1984–94.
68 Jiang W, Wu W, Guo R, et al. Predictors of prosthetic valve endocarditis
following transcatheter aortic valve replacement: A meta-analysis. Heart
Surg Forum 2021;24:E101–7.
69 Kolte D, Goldsweig A, Kennedy KF, et al. Comparison of incidence, pre-
dictors, and outcomes of early infective endocarditis after transcatheter
aortic valve implantation versus surgical aortic valve replacement in the
United States. Am J Cardiol 2018;122:2112–9.
70 Butt JH, Ihlemann N, De Backer O, et al. Long-Term Risk of Infective
Endocarditis After Transcatheter Aortic Valve Replacement. J Am Coll
Cardiol 2019;73:1646–55.
71 Kuttamperoor F, Yandrapalli S, Siddhamsetti S, et al. Infectious endocardi-
tis after transcatheter aortic valve replacement: Epidemiology and out-
comes. Cardiol Rev 2019;27:236–41.
72 Regueiro A, Linke A, Latib A, et al. Association between transcatheter aor-
tic valve replacement and subsequent infective endocarditis and in-hospital
death. JAMA 2016;316:1083–92.
73 Amat-Santos IJ, Messika-Zeitoun D, Eltchaninoff H, et al. Infective endo-
carditis after transcatheter aortic valve implantation: Results from a large
multicenter registry. Circulation 2015;131:1566–74.
74 SL Alexis, Malik AH, George I, et al. Infective endocarditis after surgical
and transcatheter aortic valve replacement: A state of the art review. J Am
Heart Assoc 2020;9:e017347.
75 Mangner N, Woitek F, Haussig S, et al. Incidence, predictors, and outcome
of patients developing infective endocarditis following transfemoral trans-
catheter aortic valve replacement. J Am Coll Cardiol 2016;67:2907–8.
76 Latib A, Naim C, De Bonis M, et al. TAVR-associated prosthetic valve
infective endocarditis: Results of a large, multicenter registry. J Am Coll
Cardiol 2014;64:2176–8.
77 Yeo I, Kim LK, Park SO, et al. In-hospital infective endocarditis following
transcatheter aortic valve replacement: A cross-sectional study of the
National Inpatient Sample database in the USA. J Hosp Infect
2018;100:444–50.
78 Khan A, Aslam A, Satti KN, et al. Infective endocarditis post-transcatheter
aortic valve implantation (TAVI), microbiological profile and clinical out-
comes: A systematic review. PLoS One 2020;15:e0225077.
79 Stortecky S, Heg D, Tueller D, et al. Infective endocarditis after transcath-
eter aortic valve replacement. J Am Coll Cardiol 2020;75:3020–30.
80 Mangner N, del Val D, Abdel-Wahab M, et al. Surgical treatment of
patients with infective endocarditis after transcatheter aortic valve implan-
tation. J Am Coll Cardiol 2022;79:772–85.
81 Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke crite-
ria for the diagnosis of infective endocarditis. Clin Infect Dis
2000;30:633–8.
82 Hill EE, Herijgers P, Claus P, et al. Abscess in infective endocarditis: The
value of transesophageal echocardiography and outcome: A 5-year study.
Am Heart J 2007;154:923–8.
83 Vieira MLC, Grinberg M, Pomerantzeff PMA, et al. Repeated echocardio-
graphic examinations of patients with suspected infective endocarditis.
Heart 2004;90:1020–4.
84 Nakatani S, Ohara T, Ashihara K, et al. JCS 2017 guideline on prevention
and treatment of infective endocarditis. Circ J 2019;83:1767–809.
85 Mihos CG, Capoulade R, Yucel E, et al. Surgical versus medical therapy
for prosthetic valve endocarditis: A meta-analysis of 32 studies. Ann
Thorac Surg 2017;103:991–1004.
86 Pettersson GB, Hussain ST. Current AATS guidelines on surgical treat-
ment of infective endocarditis. Ann Cardiothorac Surg 2019;8:630–44.
87 David TE. Aortic valve repair for active infective endocarditis. Eur J Car-
diothorac Surg 2012;42:127–8.
88 Chauvette V, Bouhout I, Lefebvre L, et al. The Ross procedure is a safe
and durable option in adults with infective endocarditis: A multicentre
study. Eur J Cardiothorac Surg 2020;58:537–43.
89 Shih E, Squiers JJ, DiMaio JM. Systematic review of minimally invasive
surgery for mitral valve infective endocarditis. innovations (Phila)
2021;16:244–8.