Infective endocarditis (IE) often presents with non-specific symptoms, which may delay diagnosis and treatment. Previous studies exploring symptom duration have been limited by small cohorts or single-centre studies. We aimed to investigate patient characteristics, microbial aetiology, treatment, and all-cause mortality of patients with IE according to symptom duration prior to diagnosis. We included all patients with first-time IE from the NatIonal Danish Endocarditis StUdies (NIDUS) registry (2016–2021). Patients with left-sided IE and available symptom duration were stratified as short, intermediate, or prolonged (≤ 7, 8–29, or ≥ 30 days). The primary outcome was six-month mortality. Among 2,938 patients with left-sided IE, median symptom duration was 8 days [IQR:4–20], and 17.6

AIMS:Recent advancements in transcatheter aortic valve implantation (TAVI) and patient selection have significantly improved the outcomes of TAVI. Yet it is unknown whether patients undergoing TAVI in the modern era have comparable mortality as the general population. METHODS AND RESULTS:All patients undergoing TAVI in Denmark (2015-23) were matched on age and sex with controls from the general population (1:4). Patients were followed from 30-day post-TAVI until death or end of study (12/23). The 5-year all-cause mortality was examined by cumulative incidence functions and Cox-regression analyses. The 5-year all-cause hospitalization burden was analysed among those alive at 5-year post-index. The study included 7250 patients undergoing TAVI [median age 81.2 years (IQR 77.0-84.9), 57.3% men] and 29 000 controls. The absolute risk of death was 39.6% [95% confidence interval (CI) 38.1-41.2] in the TAVI group, compared to 32.2% (95% CI 31.5-32.9) among controls. The associated all-cause mortality was similar between patients undergoing TAVI and controls [adjusted hazard ratio 0.95 (95% CI 0.90-1.01)]. Stratification by age revealed a higher risk of death among the TAVI group aged <80 years compared with controls, while patients aged ≥80 years showed a lower risk of death. Patients undergoing TAVI experienced longer and more frequent hospitalizations compared with controls, while the relative difference decreased over time. CONCLUSION:Our findings suggest that TAVI was associated with long-term mortality and hospitalization rates comparable to the general population. Stratified by age, mortality was higher among TAVI patients <80 years and lower among those ≥80 years. These findings support patient selection, safety, and long-term outcomes of TAVI.

BACKGROUND AND AIMS:According to ESC guidelines, patients with a cardiac implantable electronic device (CIED) are considered at moderate risk of infective endocarditis (IE), irrespective of CIED type. However, comparative data across CIED types and IE risk groups are limited. We examined IE rates according to CIED type compared with moderate- and high-risk groups. METHODS:Danish nationwide registries were used to identify patients with first-time CIED implantation and reference populations at moderate and high risk of IE (2000-2022), based on ESC guidelines. The high-risk group included patients with a left-sided prosthetic valve. Patients with prior IE or left-sided prosthetic valve were excluded from the CIED group. The primary outcome was incident IE within 10 years. RESULTS:The study included 84,171 CIED recipients, 127,966 moderate-risk patients, and 23,505 high-risk patients. Pacemakers were the most common CIED type (74.9%), followed by ICD (16.6%), CRT-D (4.6%), and CRT-P (3.9%). Pacemaker recipients were the oldest (median 78.2 years) and most frail. The 10-year cumulative incidence of IE was lowest in pacemaker recipients (1.0% [95% CI:0.9-1.1]) and highest in CRT-D recipients (2.2% [95% CI:1.7-2.9]). In adjusted analyses, all CIED types were associated with higher IE rates than the moderate-risk group but lower than the high-risk group. CONCLUSION:In this nationwide cohort, IE risk differed across CIED types, highest in CRT-D and lowest in pacemaker recipients. All CIED types were associated with higher risk than moderate-risk patients but lower risk than high-risk patients, supporting ESC classification. CRT-D recipients may warrant further evaluation of preventive strategies.

Background: Domiciliary care may serve as a marker of frailty and vulnerability and could influence outcomes following TAVI. However, its association with clinical outcomes has not been systematically evaluated and may have implications for patient selection and pre-procedural counselling. Method: ​The study included all adult patients with aortic stenosis undergoing first-time TAVI between January 1, 2015, and December 31, 2023. Patients were categorized according to receipt of domiciliary care within 1 year prior to TAVI. Follow-up was 1 year. All-cause mortality was assessed using Kaplan-Meier estimates and multivariable Cox regression. Cumulative hospitalization within 1 year was categorized as 0–14 days and >14 days, and analysed using multivariable logistic regression. Results: We identified 7,607 patients undergoing TAVI, 541 (7.1%) with domiciliary care (76.7% living alone; 39.4% men; median age 83 years) and 7,066 (92.9%) without domiciliary care (40.5% living alone; 59.4% men; median age 81 years). Overall, patients with domiciliary care carried a higher comorbidity burden and were more frequently classified in higher frailty groups. level. The 1-year mortality risk was 21.5% in patients with domiciliary care versus 6.4% in those without. In adjusted analyses, domiciliary care was associated with increased 1-year mortality (HR 3.30; 95% CI 2.65–4.10). It was also associated with higher odds of >14 cumulative hospitalization days within 1 year (OR 2.94; 95% CI 2.41–3.59). Conclusion: Domiciliary care prior to TAVI identifies a high-risk patient group with increased mortality and hospitalization, highlighting its potential role in risk stratification. ​

Aims Cardiac implantable electronic device (CIED)-related infective endocarditis (IE) presents distinct diagnostic and therapeutic challenges due to its unique characteristics and limited evidence supporting guidelines compared with left-sided valvular IE. We aimed to examine clinical characteristics, treatment, and mortality in patients with CIED-related IE vs. left-sided valvular IE. Methods and results We included patients with first-time IE using nationwide data from the NatIonal Danish endocarditis StUdieS (NIDUS) registry (2016-2021) and categorized them into isolated CIED-related IE without concomitant valvular IE and left-sided valvular IE. A total of 340 patients with isolated CIED-related IE and 2510 patients with left-sided IE were included. Patients with CIED-related IE vs. left-sided IE were older (76.1 vs. 73.2 years), and a higher proportion were males (78.5% vs. 65.9%), had diabetes (32.9% vs. 21.9%), heart failure (46.2% vs. 11.7%), Staphylococcus aureus (37.1% vs. 30.7%), coagulase-negative staphylococci (11.2% vs. 6.4%), and culture-negative IE (12.1% vs. 7.8%). However, fever at admission was lower in CIED-related IE (55.4% vs. 61.5%). Cardiac implantable electronic device removal was performed in 78.2% of patients with CIED-related IE. The 6-month cumulative incidence of mortality was 20.4% (95% CI: 16.2-24.9%) in CIED-related IE and 26.8% (95% CI: 25.1-28.6%) in left-sided IE (P = 0.009). In a multivariable Cox regression model, CIED-related IE was associated with lower 6-month mortality compared with left-sided IE (adjusted HR: 0.52 [95% CI: 0.40-0.68], P < 0.001). Conclusion In this nationwide study, patients with CIED-related IE were distinctly different from those with left-sided IE. Staphylococci were more prevalent, and despite higher age and differences in comorbidities, mortality was lower.

Background Staphylococcus aureus infective endocarditis (SA-IE) remains a serious condition, with in-hospital mortality rates ranging between 30% and 40%. While current guidelines suggest surgery may be considered in all SA-IE cases, robust data comparing outcomes between patients undergoing surgery and those receiving medical therapy alone are scarce.Methods Using the NatIonal Danish endocarditis stUdieS registry, we identified all patients with left-sided SA-IE between 2016 and 2021. Patients were categorised into two groups: surgical and non-surgical. Baseline characteristics were assessed, and in-hospital mortality was analysed using crude estimates and multivariable Cox regression.Results Of 918 patients identified, 160 (17%) patients underwent surgery (median age 63.7 years; 73% male), and 758 (83%) were treated non-surgically (median age 75.0 years; 58% male). Surgical patients had fewer comorbidities, including diabetes (18% vs 27%) and congestive heart failure (6% vs 19%). Surgical patients presented at admission with more severe conditions, including larger vegetations (56% vs 21%), sepsis (53% vs 33%) and emboli (24% vs 10%). Crude in-hospital mortality was lower in the surgical group (17% vs 28%), as was 1 year mortality (21% vs 45%). After adjusting for confounders, there was no significant difference in adjusted in-hospital mortality between the groups (HR 0.75 (95% CI 0.47 to 1.19)); however, 1-year mortality was statistically significantly lower in surgical patients (HR 0.61 (95% CI 0.41 to 0.91)).Conclusion In patients with SA-IE, surgical patients were younger and had fewer comorbidities, but had more severe disease status at admission, compared with non-surgical patients. Surgery was associated with lower 1-year mortality, but the heterogeneity of this patient population limits firm conclusions about the superiority of either treatment strategy.

BACKGROUND:Polycystic ovarian syndrome (PCOS) is associated with increased cardiovascular morbidity and a higher risk of atherosclerotic cardiovascular disease. PCOS has been associated with electrocardiographic alterations. However, the potential long-term risk of cardiac arrhythmias in women with PCOS remains insufficiently investigated. METHODS:Women diagnosed with PCOS in Denmark (1977-2024) were matched on age and year of index with female controls from the background population (ratio 1:4). The primary outcome was incident arrhythmia, with subtype of arrhythmia and cardiac implantable electronic device (CIED, ie, pacemaker and cardioverter defibrillator implantation) implantation as secondary outcomes. Patients were followed from date of PCOS diagnosis until date of event, emigration, death, or end of study (January 31, 2024). RESULTS:The study included 26 728 women with PCOS (median age, 27.8 years [interquartile range, 23.7-32.1]) and 106 912 controls. Women with PCOS had a higher comorbidity burden and pharmacotherapy use compared with controls. The 25-year associated risk of arrhythmias was higher among women with PCOS (6.3% [95% CI, 5.6-6.9]) compared with controls (4.2% [95% CI, 3.9-4.5]), equivalent to incidence rates of 23.8 (95% CI, 22.1-25.6) and 15.7 (95% CI, 15.0-16.4) per 10 000 person-years, respectively, an unadjusted hazard ratio (HR) of 1.56 (95% CI, 1.43-1.71), and an adjusted HR of 1.48 (95% CI, 1.35-1.63). Across subtypes of arrhythmias, women with PCOS were associated with a higher risk of advanced atrioventricular block (adjusted HR, 1.76 [95% CI, 1.05-2.93]), cardiac arrest (adjusted HR, 1.44 [95% CI, 1.03-2.08]), and atrial fibrillation or flutter (adjusted HR, 1.44 [95% CI, 1.20-1.73]) compared with controls. Women with PCOS were more likely to receive a CIED compared with controls (incidence rates of 1.9 [95% CI, 1.5-2.5] and 1.1 [95% CI, 0.9-1.3] per 10 000 person-years, respectively; adjusted HR, 1.85 [95% CI, 1.30-2.63]). The higher associated risk of arrhythmias and likelihood of receiving a CIED among women with PCOS was independent of use of metformin, oral contraception, spironolactone, antiandrogens, and glucagon-like peptide receptor analogs. CONCLUSIONS:Women with PCOS had a higher associated long-term risk of developing arrhythmias and a higher incidence of receiving a CIED compared with female controls from the background population. Despite low absolute event rates, these findings emphasize the clinical relevance of early cardiovascular risk assessment and preventive strategies for patients diagnosed with PCOS.

Background Current guidelines recommend complete removal of a cardiac implantable electronic device (CIED) in patients with infective endocarditis (IE), although these recommendations are largely based on expert opinion (level of evidence C). We aimed to examine outcomes stratified by CIED removal status in patients with IE. Methods Using Danish nationwide registries (2010–2021), we identified patients aged ≥18 years with first-time IE, who were alive at discharge, managed without valve surgery and had a CIED. Patients who underwent CIED removal during IE admission were compared with those without removal. The study outcomes were IE readmission, recurrent bacteraemia (including IE with the same microbial aetiology) and all-cause mortality within 6 months after discharge. Results The study population comprised 1040 patients with non-surgically managed IE and a CIED, and among these, 596 (57.3%) underwent CIED removal during admission. Patients who underwent removal were younger and less frail than those without removal. In the removal versus non-removal group, the 6-month cumulative incidences were 2.5% (95% CI 1.4% to 4.1%) vs 7.1% (95% CI 4.9% to 9.9%) for IE readmission (p value <0.001), 2.1% (95% CI 1.1% to 3.5%) vs 5.2% (95% CI 3.4% to 7.6%) for recurrent bacteraemia (p value=0.005) and 11.5% (95% CI 9.1% to 14.3%) vs 20.0% (95% CI 16.4% to 23.9%) for all-cause mortality (p value <0.001). In multivariable Cox regression models, CIED removal was associated with lower 6-month rates of IE readmission (HR 0.39 (95% CI 0.19 to 0.79)) and all-cause mortality (HR 0.70 (95% CI 0.49 to 0.996)), compared with no removal. Conclusions In this nationwide study of patients with non-surgically managed IE and a CIED, CIED removal was associated with significantly lower 6-month rates of IE readmission, recurrent bacteraemia and mortality compared with no removal, supporting current guideline recommendations. However, randomised clinical trials are warranted to determine the most effective treatment strategy.

Background Antithrombotic therapy post-transcatheter aortic valve implantation (TAVI) has been widely debated in the past two decades. Data describing practice patterns of antithrombotic therapy are warranted. This study examined the trends in use of antithrombotic therapy post-TAVI in Denmark.Methods Danish patients with aortic stenosis who underwent first-time TAVI from 2008 to 2021 were identified from Danish registries. Patients were categorized according to atrial fibrillation (AF) status and antithrombotic therapy post-TAVI based on prescription fillings: no antithrombotic therapy, single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), oral anticoagulant therapy (OAC), and oral anticoagulant therapy with antiplatelet therapy (OAC+). Use of antithrombotic therapy among survivors at 15 months was examined to assess persistence and possible changes in treatment.Results This study included 6447 patients undergoing TAVI. Among patients without AF (n = 3975), most patients received SAPT or DAPT. In AF patients (n = 2472), most patients received OAC or OAC+ . During the first 14 years of TAVI, there was a shift in the antithrombotic treatment pattern. For patients without AF, SAPT increased from 15.6% to 69.5%, with a concomitant decrease in DAPT from 56.3% to 9.1%. For AF patients, OAC increased from 13.0% to 77.9% and OAC+ decreased to 9.1%. Most patients without AF either remained with or shifted to SAPT. AF patients either remained in or shifted to the OAC group.Conclusion Antithrombotic therapy patterns post-TAVI have changed over the first 14 years of TAVI in Denmark. Use of DAPT and OAC+ decreased with a concomitant increase in SAPT and OAC.

OBJECTIVES:Contribute to data on the long-term real-world effectiveness of the BNT162b2 vaccine efficacy (VE) in adolescents. STUDY DESIGN:This observational study from July 2021 to June 2022 was designed to emulate a target trial. METHODS:Fully vaccinated adolescents 12-15 years of age were matched to unvaccinated adolescents. Outcomes were mild (positive PCR test without hospitalization), moderate (positive PCR test with hospitalization within 30 days), or severe infection (positive PCR test with intensive therapy or death within 30 days). VE was estimated as 1-risk ratio. RESULTS:We compared 235,636 vaccinated adolescents with 235,636 matched unvaccinated adolescents. On mild infection, the estimated VE declined from 42.88 % up to 25 days after full vaccination, to 33.86 %-37.26 % at 100 days and 8.85 %-8.37 % at 320 days. Estimated VE on moderate infection declined from 53.71 % up to 25 days to 22.06 %-22.73 % up to 320 days. A total of 5 events of severe infection among vaccinated, and 14 among unvaccinated individuals was observed. CONCLUSIONS:Our estimated VE is limited and rapidly decreasing over 11 months. These findings may be due to the vaccine's effect waning over time, or mutation of the virus.

Importance: Open surgical repair (OSR) should be prioritized for patients with asymptomatic abdominal aortic aneurysm (AAA) and long life expectancy, whereas endovascular repair (EVAR) is preferred for patients with suitable anatomy and life expectancy less than 2 to 3 years. However, life expectancy estimation and risk stratification are not well established. Objective: To evaluate risk-stratified survival differences between OSR and EVAR following elective AAA treatment. Design, Setting, and Participants: This cohort study used data from Danish national health registries. Patients older than 60 years undergoing elective AAA repair between 2004 and 2023 were categorized into 4 risk groups according to age, estimated glomerular filtration rate, and chronic obstructive pulmonary disease. Follow-up was until March 31, 2024. Exposure: OSR or EVAR for AAA. Main Outcomes and Measures: The primary outcome was overall survival. Secondary outcomes were incidence of AAA rupture and new cancer diagnosis. Comorbidities were balanced using inverse probability weighting. Kaplan-Meier estimators were generated for both treatments and the 4 risk score groups. Results: Of 6891 identified patients, 5757 (83.4%) were men. Women were older (median [IQR] age, 75.4 [70.9-79.3] vs 74.5 [70.5-78.5] years), more often had chronic obstructive pulmonary disease (156 women [13.6%] vs 512 men [8.9%]), and had lower estimated glomerular filtration rate (median [IQR], 68.4 [54.2-80.4] vs 70.4 [56.5-82.4] mL/min/1.73 m2) compared with men. The median follow-up was 8.28 years (95% CI, 8.10-8.50 years). OSR was associated with higher perioperative mortality in all risk groups. In low-risk patients, OSR was associated with a 10-month (95% CI, 2.2-18.3 months; P = .02) longer mean survival time restricted at 15 years compared with EVAR. In moderate-to-high-risk patients, OSR was associated with a 9-month (95% CI, 1.9-16.9 months; P = .008) shorter mean survival time restricted after 12.5 years compared with EVAR. No difference in mean survival time was seen in low-to-moderate-risk and high-risk patients at the study end. No differences in 10-year incidence of secondary AAA ruptures (OSR, 2.6% [95% CI, 1.9%-3.4%] vs EVAR, 2.2% [95% CI, 1.7%-2.7%]; P = .34) or solid malignant tumor (OSR, 18.6% [95% CI, 16.7%-20.5%] vs EVAR, 20.5% [95% CI, 18.9%-22.1%]; P = .35) were detected. Conclusions and Relevance: In this cohort study of 6891 patients with AAA, OSR was associated with higher perioperative mortality in all risk groups, but with longer mean survival only in low-risk patients. Conversely, EVAR was associated with longer mean survival in moderate-to-high-risk patients. These findings highlight the potential benefits of risk stratification when planning AAA treatment.

BACKGROUND:Valvular surgery for infective endocarditis (IE) can improve survival but carries substantial risk. Limited data exist on long-term outcomes for patients who survive surgery compared with a background population. We aim to compare long-term mortality and morbidity in patients with IE, who survive 90-days following valvular surgery to a matched Danish background population. METHODS:Using Danish registries, we identified patients who survived >90 days post-valvular surgery for first-time IE (2010-2023). Each patient was matched 1:3 with controls from the background population by age, sex and selected comorbidities. All-cause mortality was assessed at 5 and 10 years using the Kaplan-Meier estimator and the multivariate Cox model. Further, we examined the time spent in hospital during the first year following the index date. RESULTS:We identified 1050 patients (77.5% male, median age 65.8 years) surgically treated for IE and 3150 controls. The most common pathogens were: Viridans group streptococci (44.6%), Staphylococcus aureus (23.1%), Enterococci (17.9%). Patients with IE had higher absolute 5-year (20.1% vs 12.9%, p=0.001) and 10-year (38.5% vs 27.9%, p<0.001) mortality compared with controls. Adjusted 5-year and 10-year mortality rates were also higher in patients with IE (5-year HR=1.49 (95% CI 1.24 to 1.79) and 10-year HR 1.38 (95% CI 1.19 to 1.60)). Patients with IE experienced more frequent and longer hospitalisations within the first year postsurgery, as 36.8% patients with IE were hospitalised within the first year following index compared with 17.5% in the matched controls. 9.3% of patients with IE were hospitalised for >14 days compared with 3.0% in matched controls. 60 patients with IE (5.7%) died within the first year following index compared with 51 (1.6%) in the matched controls. CONCLUSION:Patients with IE who underwent valve surgery had a higher crude mortality than their controls from the background population. After adjusting for confounders, 5-year and 10-year mortality rates remained higher in the IE patient population.

OBJECTIVES:Infections from immunosuppressive treatment are a major cause of hospitalization and mortality in ANCA-associated vasculitis (AAV). This study examines bloodstream infections (BSIs) in incident AAV patients, comparing incidence, bacterial distribution and risk to the general population, with emphasis on central venous catheters (CVCs). METHODS:Using Danish nationwide registries, we studied patients diagnosed from 2010 to 2018, followed until first BSI, death or a maximum of 5 years. Controls were matched 1:4 by age and sex. Cumulative incidence was estimated using Aalen-Johansen, and adjusted Cox regression modelled survival time. RESULTS:A total of 111 BSIs were identified in 80 (8.5%) of 937 AAV patients, compared with 65 BSIs in 58 (1.7%) of 3476 controls. The incidence of BSIs was significantly higher in AAV patients (34.5/1000 person-years against 4.8/1000 person-years). One-year hazard ratio (HR) for first-time BSIs was significantly elevated in AAV patients (HR 10.5, [95% CI 5.58-11.9]), and those receiving haemodialysis (HR 34.8, 95% CI 3.35-360.8) or plasma exchange (HR 14.6, 95% CI 3.79-56.6) faced even higher infection rates. Following first-time BSI, one-year mortality rates were equally high in AAV patients (36.3%) and controls (34.5%). Most common microbial agents-Escherichia coli, Staphylococcus aureus, enterococci and streptococci-were similar between the two groups. However, AAV patients exhibited higher microbial diversity, with 48.6% attributed to other pathogens like coagulase-negative staphylococci, Klebsiella pneumoniae, Pseudomonas aeruginosa and fungi. CONCLUSION:AAV patients face high BSI risk, diverse microbiology and increased one-year mortality, with CVC-related interventions as solitary risk factors.

Infective endocarditis (IE) is a significant clinical challenge with abysmal morbidity and mortality for those who are affected. Diagnostics remain difficult and outcomes have only improved slightly over the past decades, yet & horbar;and encouraging & horbar;more high-level evidence is emerging with meaningful improvements for patients. The European Society of Cardiology (ESC) recently published their updated endocarditis guidelines,1 and the major change was on the basis of the Partial Oral versus Intravenous Antibiotic Treatment of Endocarditis (POET) study.2 The POET study lays the ground for switching patients with stable left-sided IE from intravenous (I.V.) to oral antibiotic treatment.

Infective endocarditis (IE) has been associated with severe outcomes when complicated by diabetes mellitus (DM). We aimed to report characteristics, microbial etiology, and mortality for patients with IE stratified by DM from a nationwide cohort. We used Danish registries, and patients with first-time IE (2010–2020) were stratified by DM. We computed inverse Kaplan-Meier estimates for one-year mortality from admission. We computed multivariable adjusted Cox regression for the adjusted one-year mortality from admission and discharge. We identified 6,211 patients with first-time IE; 1,503 (24.2

BACKGROUND/AIMS:Mitral valve surgery (MVS) is recommended in severe mitral valve regurgitation (MR). Contemporary data on national surgical patterns and patient characteristics are lacking and are essential for the continuous epidemiologic monitoring of the disease. METHODS:Using Danish nationwide registries, patients undergoing MVS for MR between 1996 and 2022 were identified. Temporal trends in patient characteristics and annual incidence rates per 100,000 person years (PY) were computed. One-year cumulative mortality and mortality rates over calendar time were computed using the Kaplan-Meier estimator and multivariable adjusted Cox-analysis respectively. RESULTS:8098 patients were included. Median age increased from 65.5 (1996-2001) to 69.4 years (2018-2022). Patients became less comorbid regarding ischemic heart disease and heart failure. The overall incidence rate of MVS increased from 4.09 to 8.66/100,000 PY (1996-2022), with significantly increasing incidences of mitral repair, biological replacement, and transcatheter-edge-to-edge repair (TEER), and significantly decreased incidence of mechanical replacement. The overall cumulative one-year mortalities were: TEER 18.9 %, biological replacement 15.5 %, mechanical replacement 10.2 %, mitral repair 4.8 %. Adjusted analysis showed a significant decrease in one-year mortality across time for mitral repair (HR 0.27 [95 % CI 0.15-0.49], p < 0.001) and TEER (HR 0.55 [95 % CI 0.31-0.97], p = 0.04). No significant mortality differences were observed for other interventions. CONCLUSIONS:From 1996 to 2022, more patients underwent mitral valve surgery driven by increasing incidence rates of mitral repair, biological replacement, and TEER. Patients got older but less comorbid regarding major cardiovascular comorbidities. Mortality significantly improved over time for patients undergoing mitral repair and TEER. Results could reflect earlier diagnosis and increased echocardiographic surveillance.