Abstract Background Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Our study aimed to describe IE’s features in octogenarians and to identify the independent predictors of mortality, focusing on the prognostic impact of disability. Methods We retrospectively analyzed 551 consecutive patients admitted to a single surgical centre with a definite diagnosis of non-device-related infective endocarditis; of these, 97 (17.6%) were older than 80 years. Results In patients under eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 53.6% of the total. Enterococci (29.8 vs. 17.4%, p = 0.005) were significantly more frequent than in younger people. Comorbidities were more frequent in elderly patients; consequently, EuroSCORE II was higher (median ± IQR 16.4 ± 21.1 vs. 5.0 ± 10.3, p = 0.001). In octogenarians, IE was more frequently left-sided (97.9 vs. 89.8%, p = 0.011). Octogenarians were more often excluded from surgery despite indication (23.7 vs. 8.1%, p = 0.001) and had higher three-year mortality (45.3 vs. 30.6%, p = 0.005) than younger patients. In elderly patients, age did not independently predict mortality, while exclusion from surgery and a high grade of disability did. Conclusions Octogenarians with IE have specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Age per se should not be a reason to deny surgery, while disability predicts futility.

Abstract Background Infective endocarditis still has high mortality and invalidating complications, such as cerebral embolism. The best strategies to prevent and manage neurologic complications remain uncertain. This study aimed to identify predictors of cerebral septic embolism and evaluate the role of surgery in these patients in a real-world surgical centre. Methods We retrospectively analyzed 551 consecutive patients admitted to our department with a definite diagnosis of non-device-related infective endocarditis; of these, 126 (23%) presented a neurologic complication. Results Cerebral embolism was significantly more frequent in patients with large vegetations (p = 0.004), mitral valve infection (p = 0.001), and Staphylococcus aureus infection (p = 0.025). At multivariable analysis, only vegetation length was an independent predictor of cerebral embolism (HR per unit 1.057, 95% CI 1.025–1.091, p 0.001), with a best predictive threshold of 10 mm at ROC curve analysis (AUC 0.54, p = 0.001). Patients with neurologic complications were more often excluded from surgery despite an indication to it (16% vs 8%, p = 0.001). If eligible, they were treated within two weeks from diagnosis in similar proportions as patients without cerebral embolism with a similar survival rate. Predictors of mortality were hemorrhagic lesions (p = 0.018), a GCS < 14 (p = 0.001) or a severe degree of disability (p = 0.001) at presentation. The latter was the only independent predictor of mortality at multivariable analysis (HR 2.3, 95% CI 1.43–3.80, p = 0.001). Conclusions The present study highlights the prognostic value of functional presentation and the safety of cardiac surgery, when feasible, in patients with cerebral septic embolism.

Abstract Funding Acknowledgements Type of funding sources: None. Background Anorexia Nervosa (AN) is a psychiatric disorder that can lead to cardiac complications, especially in severely malnourished patients. Cardiovascular involvement includes autonomic dysfunction (increased vagal tone, bradycardia, orthostatic hypotension, syncope), arrhythmias, pericardial effusion, heart failure and sudden death. A few studies have examined the echocardiographic abnormalities secondary to AN, reporting mainly a decreased cardiac mass and an increased incidence of pericardial effusion. No previous studies examined the changes of Global Longitudinal Strain (GLS), which has been shown to be an early marker of myocardial damage in other subsets. Purpose This study aimed to characterize echocardiographic abnormalities in AN, and to assess impairment of global and regional longitudinal strain (LS) and its clinical value in this context. Methods We prospectively enrolled 42 consecutive patients (1 male) admitted to a highly specialized AN unit between November 2020 and July 2021 with AN (Mental Disorders, 4th Edition-DSM IVr). We also selected 34 healthy controls, matched for age and sex. In all subjects, we reported the cardiac frequency, systolic and diastolic blood pressure, blood examinations, and we performed an echocardiography, including GLS measurement. Eighteen patients were treated with enteral or parenteral feeding. A subset of 26 AN patients performed a second echocardiography after one month of follow up; 14 of them received forced feeding. Results Compared with healthy subjects, AN patients had significantly lower albumin levels (45.1 ± 10.3 vs 66.0 ± 4.8 mg/dl, p = 0.031), lower FT3 levels (3.7 ± 1.0 vs 7.9 ± 6.4 pg/mL, p = 0.001), higher FT4 levels (13.8 ± 1.8 vs 9.6 ± 8.1 pg/mL, p = 0.008), a lower cardiac frequency (63 ± 18 vs 73 ± 12 bpm, p = 0.004), a higher incidence of pericardial effusion (9/42 vs 0/34, p = 0.008), a lower myocardial mass (62.3 ± 15.0 vs 98.5 ± 28.5 g, p < 0.001), a lower absolute value of GLS (-18.8 ± 2.8 vs -20.3 ± 2.0 %, p = 0.014) and basal LS (-15.4 ± 6.1 vs -19.6 ± 2.8 %, p < 0.001). The bull’s eye mapping showed a plot pattern with blue basal areas in 17/42 AN patients vs 1/34 healthy subjects (p < 0.001). The 17 anorexic patients with a blue basal pattern needed forced feeding in a higher proportion (11/17 vs 7/25, p = 0.018) and presented more frequently amenorrhea (14/17 vs 11/25, p = 0.046). During the follow up (26 AN patients performed a second echocardiography), of 13 patients with blue areas in the first bull’s eye mapping, 11 recovered a completely red pattern, and of 13 patients with a red bull’s eye in the first examination, no one presented blue areas on the second one. Conclusions GLS is significantly altered in AN patients and a basal blue pattern on bull’s eye mapping individuates more severe cases. These changes seem to be reversible (Figure 1), although further studies are necessary to understand which factors influence this pattern besides BMI. Abstract Figure 1

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Infective endocarditis (IE) is a severe disease associated with high morbidity and mortality. The EURO-ENDO registry reported a mean age of 59.25 ± 18.03 years; 46.3% of patients were over 65 and 12.0% over 80 years. Little is known about the best management of elderly patients with IE. In these patients, surgery may be challenging. Purpose We aimed to determine the clinical and echographic characteristics, the therapeutic strategy, and the outcome of IE in octogenarians. Method We retrospectively included in the analysis 457 consecutive patients with definite active IE in a single surgical centre. Descriptive statistics are reported as mean ± standard deviation (SD) or median ± interquartile range (IQR) for continuous variables with normal and non-normal distribution and as frequencies and percentages for categorical variables. Between-groups comparisons were assessed by Student’s t-test, Mann-Whitney U test, Kruskal-Wallis, or chi-square test, as appropriate. Univariate long-term survival was analysed by the Kaplan-Meier method. Results In our cohort, octogenarians were 17% of the whole population (N = 77). In patients under the age of eighty, males were mostly involved with a sex ratio exceeding 2:1. This ratio was inverted in older people, where the female gender represented 57% of the total (0.001). Staphylococcus aureus (10.4 vs 20.5%, p =0.038) and Enterococci (29.9 vs 16.3%, p =0.008) were significantly less and more frequent than in younger people, respectively. Comorbidities were more frequent in elderly patients, such as hypertension (80.5 vs 53.2%, p = 0.001), dyslipidaemia (42.7 vs 27.3%, p = 0.008), and history of cancer (29.9 vs 19.2%, p = 0.036). Consequently, EUROSCORE II was higher (median ± IQR 19.18 ± 19.0 vs 11.9 ± 5.7, p = 0.001). In octogenarians, IE was more frequently left-sided (98.7 vs 89.2, p = 0.009) and complicated less often with peripheral embolism (31.2 vs 43.9%, p = 0.038). We found no differences between the two groups for the type of infected valve (native or prosthetic), the severity of valve dysfunction, paravalvular extension, and vegetation length. Octogenarians were more often excluded from surgery despite indication (19.5 vs 7.7%, p = 0.016) and had higher thirty-day (11.7 vs 7.9%, p = 0.001) and three-year (45 vs 30%, p = 0.001) mortality than younger patients. Conclusions Octogenarians represent a considerable proportion of overall cases of IE, with specific clinical and microbiological characteristics. Older patients are more often excluded from surgery, and the overall prognosis is poor. Abstract Figure.

Anorexia nervosa (AN) is a psychiatric disorder that may lead to cardiac complications. The objective of this study was to evaluate global and regional longitudinal strain changes in patients affected by AN as an early marker of myocardial damage. We prospectively controls. In all subjects, we performed echocardiography, including global longitudinal strain (GLS) measurement. A subset of 33 patients with AN had further echocardiographic examinations during the follow-up. Compared with healthy controls, patients with AN had a greater prevalence of pericardial effusion (9 of 48 vs 0 of 44, p = 0.003), a smaller left ventricular mass (63 +/- 15 vs 99 +/- 30 g, p < 0.001), a lower absolute value of GLS (-18.9 +/- 2.8 vs -20.2 +/- 1.8%, p = 0.010) and of basal LS (-15.4 +/- 6.0 vs -19.4 +/- 2.6%, p < 0.001). The bull's eye mapping showed a plot pattern with blue basal areas in 18 of 48 patients with AN versus 1 of 44 controls (p < 0.001). During the follow-up, of 13 patients with blue areas in the first bull's eye mapping, 11 recovered completely, and of 20 patients with a red bull's eye at the first examination, none presented blue areas at the second one. In conclusion, GLS is significantly altered in patients with AN, and a basal blue pattern on bull's eye mapping identifies more severe cases. These changes seem to be reversible. (c) 2022 Elsevier Inc. All rights reserved. (Am J Cardiol 2022;175:152-157)

Introduction Drug-induced thrombotic microangiopathy (DITMA) is an acquired condition resulting from exposure to a drug that induces the formation of platelet-rich thrombi in small arterioles or capillaries secondary to drug-dependent antibodies or direct tissue toxicity. Carfilzomib is a selective proteasome inhibitor approved to treat selected patients with Multiple Myeloma (MM). It is one of the drugs with the strongest evidence for a causal association with non-antibody-mediated DITMA. Case Report A 75-year-old man presented to the emergency department for the outbreak of vomit, asthenia, oliguria and dark stool emission. He was recently diagnosed with multiple myeloma, treated with lenalidomide, dexamethasone and carfilzomib. Laboratory exams were significant for microangiopathic haemolytic anaemia, thrombocytopenia and new-onset renal failure. ADAMTS-13 levels were in range, and no infectious signs were found both in blood nor in stool test. Management & Outcome A carfilzomib induced thrombotic microangiopathy was soon suspected. Thus, since daily haemodialysis and supportive care did not seem to get a fast enough recovery, the patient was treated with eculizumab with a good general outcome. Discussion Drug-induced thrombotic microangiopathy is a rare and often life-threatening acquired condition whose diagnosis can be challenging and whose therapy is not always limited to supportive treatment and drug avoidance. Carfilzomib, along with other proteasome inhibitors, is one of the described potential drugs which can trigger such a manifestation.

Most cases of infective endocarditis (IE) involve a single valve, and little is known concerning IE that simultaneously affects two valves. The involvement of more than one valve may imply more severe and extensive cardiac lesions. In these patients, surgery may be challenging. We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of double-valve IE (DVIE). We retrospectively included in the analysis that 440 consecutive patients with definite active IE in a single surgical centre. DVIE occurred in 75 of the total enrolled 440 patients (17%) and involved mostly the combination of mitral and aortic valves (N = 63, 84%). Most patients had double-native IE (N = 45, 60%). Staphylococci were less frequent in patients with double-valve than single-valve IE (SVIE). The proportion of patients undergoing valve repair among those treated surgically was higher for patients with DVIE than for SVIE (p < 0.03). Valve repair of at least one valve was associated with non-significant better survival than double replacement. DVIE was associated with higher all-cause mortality than SVIE (p < 0.013) and a higher relapse rate (p = 0.023). DVIE was not associated with a higher risk of composite non-fatal adverse events. DVIE represents a considerable proportion of overall cases of IE, mainly involving aortic and mitral valves, with a jet lesion on the mitral valve; Staphylococcus is significantly less frequent than in SVIE; DVIE is independently associated with higher mortality and relapse rate; finally, mitral valve repair is feasible in a considerable proportion of surgical cases.

Abstract Introduction Injection drug use (IDU) is a known risk factor for infective endocarditis (IE) and is associated with frequent recurrences, but its prognostic impact is still debated. Moreover, the potential futility of surgery in this population is an unsolved matter. Purpose We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of injection drug use IE (IDUIE). Method We retrospectively included in the analysis 454 consecutive episodes of definite active IE admitted in a single surgical centre from January 2012 to December 2020; 14 out of them where a subsequent infective episode of the same patient. Results IDUIE cases were 63 (13.8%), without significant proportional differences over time. IDUIE patients were significantly younger (43.95±10.12 vs 67.84±13.33, p 0.00) and presented fewer comorbidities (p<0.001). They were admitted with a first episode of IE only in 60.3% of cases vs 92.8% of non-IDU (p<0.001). Embolism was present at admission in a higher percentage (60.3 vs 38.4%, p<0.001). IDUIE was more frequently associated with spondylodiscitis (15.9 vs 7.4%, p=0.026). The infection was less frequently left-sided than in non-IDU patients (57.1 vs 97.2%, p<0.001) and was more often polimicrobic (12.7 vs 4.9%, p=0.015). Most patients were positive for Staphylococcus aureus (54.0 vs 12.8%, p<0.001), while Streptococci were significantly less frequent in patients with IDUIE (11 vs 25%, p=0.015). The proportion of patients undergoing surgery was similar among the two groups (85.5 vs 78.8%, NS). IDUIE patients treated medically for absence of surgical indication had a better survival than patients undergoing surgery for complicated IE (p<0.001). IDUIE was associated with a higher proportion of relapse during follow-up (28.3 vs 3.3%, p<0.001). It was not associated with higher mortality (Figure 1) but was an independent predictor of mortality in multivariable analysis including age (HR per unit 1.048, 95% CI 1.038–1.063, p=0.00) and drug abuse (HR 3.2, 95% CI 1.8–5.6, p=0.00; Figure 2). Among IDUIE patients, we did not find predictors of futility of surgery, not even multiple relapses. Conclusions IDUIE represents a considerable proportion of overall cases of IE, mainly affecting young people. Staphylococcus aureus is the most common microbiologic agent. IDUIE is not associated with higher mortality but drug abuse is an independent predictor of mortality. Considering that patient with uncomplicated IE treated medically have a better prognosis, we should reserve surgery to patients with a strict indication for it. On the other hand, since there are no predictors of futility of surgery, all patients with a complicated IE should undergo surgery without delay. The main determinant of prognosis in these patients is not IE but drug abuse itself. For this reason, increased focus on addiction treatment following hospital discharge is mandatory to improve long term prognosis. Funding Acknowledgement Type of funding sources: None.

Background Intravenous drug abuse (IDA) is a known risk factor for infective endocarditis (IE) and is associated with frequent relapses, but its prognostic impact is still debated. The potential futility of surgery in this population is a further issue under discussion. We aimed to describe the clinical characteristics, the therapeutic strategy, and the prognosis associated with IDA in IE. Methods We retrospectively analysed 440 patients admitted to a single surgical centre for definite active IE from January 2012 to December 2020. Results Patients reporting IDA (N = 54; 12.2%) were significantly younger (p < 0.001) and presented fewer comorbidities (p < 0.001). IDA was associated with a higher proportion of relapses (27.8 vs. 3.3%, p < 0.001) and, at multivariable analysis, was an independent predictor of long-term mortality (HR 2.3, 95%CI 1.1–4.7, p = 0.015). We did not register multiple relapses in non-IDA patients. Among IDA patients, we observed 1 relapse after discharge in 9 patients, 2 relapses in 5 patients and 3 relapses in 1 patient. In IDA patients, neither clinical and laboratory variables nor the occurrence of even multiple relapses emerged as indicators of an adverse risk–benefit ratio of surgery in patients with surgical indication. Conclusions IE secondary to IDA affects younger patients than those with IE not associated with IDA. Probably due to this difference, IE secondary to IDA is not associated with significantly higher mortality, whereas the negative, long-term prognostic impact of IDA emerges in multivariate analysis. Considering the good prognosis of patients with uncomplicated IE treated medically, surgery should be reserved to patients with a strict- guidelines-based indication. However, since there are no clear predictors of an unfavourable risk–benefit ratio of surgery in patients with surgical indication, all patients with a complicated IE should be operated, irrespective of a history of IDA.

Purpose Mortality in infective endocarditis (IE) is still high, and the long term prognosis remains uncertain. This study aimed to identify predictors of long-term mortality for any cause, adverse event rate, relapse rate, valvular and ventricular dysfunction at follow-up, in a real-world surgical centre. Methods We retrospectively analyzed 363 consecutive episodes of IE (123 women, 34%) admitted to our department with a definite diagnosis of non-device-related IE. Median follow-up duration was 2.9 years. Primary endpoints were predictors of mortality, recurrent endocarditis, and major non-fatal adverse events (hospitalization for any cardiovascular cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), and ventricular and valvular dysfunction at follow-up. Results Multivariate analysis independent predictors of mortality showed age (HR per unit 1.031, p < 0.003), drug abuse (HR 3.5, p < 0.002), EUROSCORE II (HR per unit 1.017, p < 0.0006) and double valve infection (HR 2.3, p < 0.001) to be independent predictors of mortality, while streptococcal infection remained associated with a better prognosis (HR 0.5, p < 0.04). Major non-fatal adverse events were associated with age (HR 1.4, p < 0.022). New episodes of infection were correlated with S aureus infection (HR 4.8, p < 0.001), right-sided endocarditis (HR 7.4, p < 0.001), spondylodiscitis (HR 6.8, p < 0.004) and intravenous drug abuse (HR 10.3, p < 0.001). After multivariate analysis, only drug abuse was an independent predictor of new episodes of endocarditis (HR 8.5, p < 0.001). Echocardiographic follow-up, available in 95 cases, showed a worsening of left ventricular systolic function (p < 0.007); severe valvular dysfunction at follow-up was reported only in 4 patients, all of them had mitral IE (p < 0.03). Conclusions The present study highlights some clinical, readily available factors that can be useful to stratify the prognosis of patients with IE.

Abstract Background Valve repair is considered the treatment of choice for native mitral and tricuspid valve regurgitation but the rate of feasibility when the defect is caused by acute infective endocarditis (IE) is debated. We report the experience of valve repair versus replacement following IE in a high-volume surgical center. Methods We retrospectively analyzed 351 consecutive patients (123 women) admitted to our department with definite diagnosis of IE. IE occurred on native valves in 219 patients (62%) and on prosthetic valves in 132 (38%). Among native valves, IE involved the aortic valve in 105 cases (48%), mitral valve in 97 cases (44%) and tricuspid valve in 17 (8%). Since only native mitral and tricuspid valves are elegible for surgical repair, we limited the analysis to this subset (114 patients); of them, 92 (80.7%) underwent surgery (the final cohort) and 22 were treated conservatively, 13 due to absence of surgical indication and 9 due to prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence). Results Mean age at surgery was 61.9 years (SD 14.5). Mean vegetation length was 11.6 mm (SD 8.8). Endocarditis was left-sided in 80 (87%). Among the 92 surgical patients, 58 (63%) underwent valve replacement and 34 valve repair (37%). Mortality was similar between valve repair and replacement (15 vs 12%). Adverse events rate (19% vs 16%) and relapse were not statistically different between repair and replacement procedures. Conclusions The present study shows that a sizeable subgroup of consecutive patients with native mitral or tricuspid IE are amenable to valve repair in expert hands. Outcome of repair in IE is comparable to valve replacement mid-term, and should be considered whenever possible, as in degenerative valve disease. Funding Acknowledgement Type of funding source: None

Background: In patients with left-sided infective endocarditis (IE) and heart failure associated with large vegetations, early surgery prevents embolic events. However, optimal timing of surgery for other indications is still unresolved particularly when the presence of large vegetations represents the sole indication. Methods: We retrospectively analyzed 308 consecutive patients admitted to our department with definite left-sided IE. Of these patients, 243 (79%) underwent cardiac surgery (complicated IE), 34 patients with uncomplicated IE received medical treatment, 24 were not operated due to prohibitive general conditions and 7 refused surgery. Long-term follow-up was obtained by structured telephone interviews. Results: During the 6-year follow-up (average 121.8 weeks +/- 76), patients not operated because of general conditions or refusal had the worst prognosis, while outcome in operated patients for complicated IE was comparable to that of uncomplicated IE treated medically. Early (<2 weeks from diagnosis) surgery was associated with better survival compared to delayed surgery (HR 0.58, p = 0.23). Embolic events were detected at admission in 38% of cases; Staphylococcus Aureus etiology and vegetation size were independently associated with embolism (OR 2.4, p = 0.01; OR 1, p=0.008 respectively). Conclusions: Compared to uncomplicated medically-treated patients, complicated IE showed comparable survival when managed aggressively by surgical intervention, whereas a conservative approach was associated with an adverse prognosis. Staphylococcus Aureus infection and vegetation size were independent predictors of systemic embolism. Our data support aggressive surgical management of complicated IE patients and highlight the importance of etiological characterization in clinical decision-making.

Abstract Background Heart tumors are very rare lesions. Their prevalence is about 0.001 to 0.03 % in an autopsy series. In most cases, primitive lesions are benign, with atrial myxomas that represent up to 2/3 of cases. Malignant neoplasms have a high mortality; sarcomas are the most frequent typologies. The most aggressive tumors are characterized by greater size, muscle invasion and pericardial effusion. Clinical case A 39-year-old man with recent history of worsening dyspnea went to the emergency room because of an aggravation of the symptoms. An echocardiogram showed a large atrial inhomogeneous mass, adherent to the mitral ring and involving both left atrial and ventricle, causing a severe valvular stenosis, suggestive for malignancy. Thus the patient performed a cardiac-MRI, confirming the neoplasm localization with parietal infiltration, pericardial extension and effusion. A total-body CT scan ruled out metastasis. The patient underwent heart surgery and a partial excision was performed. Macroscopically the tumor had a scirrhous consistency and a diameter of about 5 cm. The histologic examination showed a high-grade sarcoma with fused cells and with condrosarcomatous areas. Discussion The study of heart massesincludes the execution of echocardiographies as first-line examinations, while the in-depth diagnostics (necessary in the anticipation of surgery) require cardiac-MRI or CT. Malignant lesions are characterized by an inomogeneous appearance, with a wide plant base and sizes larger than 5 cm, they are also able to take contrast medium during diagnostic examinations. High grade neoplasms are rapidly evolving with a very severe prognosis. The symptoms are essentially due to the localization and the mass bulk. In our case, its development on the mitral valve caused severe hemodynamic impairment, requiring immediate intervention. The treatment of these lesions is necessarily surgical. The only positive prognostic factor is a complete excision of neoplasm with free resection margins. As the diagnosis is often not early, chemotherapy or radiotherapy are often required after surgery. Conclusion Cardiac masses are rare entities and their evaluation may be a diagnostic challenge. Myxoma represent the most common primary cardiac neoplasm in adults, while about 25% of other primary ones are malignant. Our patient was suffering from a sarcoma, whose incomplete debulking made further therapies necessary. The correct interpretation of instrumental findings together with a possible radical surgery are mandatory for a successful therapeutic strategy. Abstract P1306 Figure.

Abstract Introduction Needle embolism is a rare complication of intravenous drug abuse which has only been reported on a handful of occasions. Potential sequelae include cardiac perforation, tamponade, infective endocarditis and recurrent pericarditis. We report the case of a young intravenous opiate abuser. Case Report A 23-year-old heroin addicted man presented to the emergency department because of chest pain ensued six months before; the pain was sharp, was relieved by sitting up and leaning forward and increased with coughing, swallowing, deep breathing or lying flat. He complained also fatigue and fever since one month before presentation. Echocardiography revealed non haemodinamic pericardial effusion and pleural effusion, treated with pleural drainage. Three haemocoltures were negative. Cardiac biomarkers were negative. HIV, HBV and HCV sierology was negative. He was treated with cochicine and ibuprofen and empiric antibiotic therapy with initial improvement of symptoms and rapid recurrence of them. After a few weeks an ECG showed widespread concave ST segment elevation and an echocardiogram revealed pericardial effusion relapse. A chest radiograph showed a needle near the right ventricle. The patient underwent computed tomography angiography that was able to localize a needle inside the pericardium. A second echocardiogram confirmed the presence of the fragment in the pericardial cavity, beside the right ventricle. The patient underwent minithoracototomy surgical removal of the needle fragment and of 500 cc of haematic pericardial fluid. Discussion and conclusions The presence of a foreign body in the heart may result from either a direct injury to the heart such as a gunshot injury or from some other embolization to the heart from distal penetration sites (eg, the migration of a catheter or a needle fragment from a peripheral vessel). It may cause fever, recurrent pericarditis and arrhythmia. Surgical extraction in the therapy of choice. Abstract P842 Figure.

Abstract Background Despite optimal medical and surgical treatment, mortality in infective endocarditis (IE) remains high. Aim of this study was to identify predictors of long term mortality for any cause, adverse event rate, relapse rate and valvular dysfunction at follow-up, in a high-volume surgical center. Methods We retrospectively analyzed 358 consecutive patients (127 women) admitted to our department with definite diagnosis of IE not device-related. IE occurred on native valves in 224 patients (63%); the infection involved the aortic valve in 192 (54%), mitral valve in 139 (39%) and tricuspid valve in 26 (7%). Overall 285 (80%) patients underwent surgery and 73 (20%) were treated conservatively, 38 due to absence of surgical indication and 35 due to refusal or prohibitive surgical risk. Long-term follow-up was obtained by structured telephone interviews. Primary endpoints were all-cause mortality, freedom from recurrent endocarditis, postoperative incidence of major adverse events (hospitalization for any cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), worsening of left ventricular ejection fraction (LVEF) and valvular dysfunction. Results Mean age was 65 years (SD 15.2). Mean vegetation length was 8.9 mm (SD 7.6). Endocarditis was left-sided in 332 (93%). Average follow-up was 6 months. At univariable analysis, mortality was associated with female gender (p=0.031), age (p<0.001), higher EuroSCORE 2 (p<0.001), chronic renal failure (p<0.001), diabetes (p=0.002), brain embolism on presentation (p=0.05), double valve infection (p=0.008), low ejection fraction (p<0.001), paravalvular extension (p=0.031), prosthetic infection (p=0.018), exclusion from surgery if indicated (p<0.001), high procalcitonin levels (p=0.035); factors associated with a significantly lower mortality were streptococcal infection (p=0.04; OR 0.34) and early surgery (p=0.009, OR 0.55). At multivariable analysis independent predictors of all-cause mortality were lower EF, EuroSCORE2, procalcitonin levels and diabetes. Non-fatal adverse events were associated with renal failure (p 0.035, OR 2.8). Relapse rate was associated with S aureus infection (p=0.005, OR 3.8), right-sided endocarditis (p<0.001, OR 6.7) and drug abuse (p<0.001, OR 9.4). Conclusions The present study shows that low EF, EuroSCORE2, procalcitonin levels and diabetes are independent predictors of death in patients with IE. Non-fatal adverse events are more frequent in patients with renal failure. Relapse rate is higher in drug abusers. These informations may help personalize follow-up strategies after acute admission for IE. Funding Acknowledgement Type of funding source: None

Abstract Background Hypocomplementemic Urticarial Vasculitis Syndrome (HUVS) is a very rare disease involving small vessels and characterized by chronic urticarial vasculitis, arthralgia, arthritis, and activation of the classical complement pathway. To our knowledge, just other seven cases of HUVS with cardiac valvular involvement have been reported in the literature. Unlike previous cases, ours shows a broader antibody positivity, (but no anti-C1q antibodies) with an early and serious cardiovascular involvement. Case summary A 32 years old woman was brought to the emergency department because of sudden onset of right hemiplegia and global aphasia due to cerebral haemorrage. She suffered from a severe HUVS form with cardiac valvular involvement and she was cronically treated with immunosuppressant drugs. During previous years she had already undergone cardiac surgery twice for chronic aseptic inflammatory process involving aortic and mitral valves. Right hemiplegia and global aphasia were caused by septic embolism to left cerebral artery complicated by cerebral haemorrage. The patient underwent neurosurgical intervention followed by antibiotic therapy. This condition was secondary to Listeria monocytogenes aortic infective endocarditis in an immunosuppressed patient. Transesophageal echocardiogram showed periaortic abscess with internal colliquation. A further surgical intervention would have been necessary, but operative risk was judged to high and the patient died one year later. Discussion The association between HUVS, Jaccaud"s arthropathy and cardiac valvular disease is rarely described in the literature. The presence of valvular involvement is a negative prognostic factor. Unlike most cases, it is interesting to note that our patient was negative for anti-C1q antibodies and exhibited an extremely severe cardiac involvement. The case was complicated by L monocytogenes endocarditis, that is also a rare condition associated with a high mortality rate. Abstract P1457 Figure. Abscess

Aims The EURO-ENDO registry aimed to study the management and outcomes of patients with infective endocarditis (IE). Methods and results Prospective cohort of 3116 adult patients (2470 from Europe, 646 from non-ESC countries), admitted to 156 hospitals in 40 countries between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Clinical, biological, microbiological, and imaging [echocardiography, computed tomography (CT) scan, F-18-fluorodeoxyglucose positron emission tomography/computed tomography (F-18-FDG PET/CT)] data were collected. Infective endocarditis was native (NVE) in 1764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and device-related (CDRIE) in 308 (9.9%). Infective endocarditis was community-acquired in 2046 (65.66%) patients. Microorganisms involved were staphylococci in 1085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). F-18-fluorodeoxyglucose positron emission tomography/computed tomography was performed in 518 (16.6%) patients and presented with cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, presence of a vegetation and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2160 (69.3%) patients, but finally performed in only 1596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson index, creatinine > 2 mg/dL, congestive heart failure, vegetation length > 10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated. Conclusion Infective endocarditis is still a life-threatening disease with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.

Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) European Endocarditis (EURO-ENDO) registry aims to study the care and outcomes of patients diagnosed with infective endocarditis (IE) and compare findings with recommendations from the 2015 ESC Clinical Practice Guidelines for the management of IE and data from the 2001 Euro Heart Survey. Methods and results Patients (n = 3116) aged over 18 years with a diagnosis of IE based on the ESC 2015 IE diagnostic criteria were prospectively identified between 1 January 2016 and 31 March 2018. Individual patient data were collected across 156 centres and 40 countries. The primary endpoint is all-cause mortality in hospital and at 1 year. Secondary endpoints are 1-year morbidity (all-cause hospitalization, any cardiac surgery, and IE relapse), the clinical, epidemiological, microbiological, and therapeutic characteristics of patients, the number and timing of non-invasive imaging techniques, and adherence to recommendations as stated in the 2015 ESC Clinical Practice Guidelines for the management of IE. Conclusion EURO-ENDO is an international registry of care and outcomes of patients hospitalized with IE which will provide insights into the contemporary profile and management of patients with this challenging disease.