Aims Transcatheter aortic valve replacement-related infective endocarditis (TAVR-IE) is associated with a poor prognosis. TAVR-IE diagnosis is challenging, and benefits of the most recent classifications [European Society of Cardiology (ESC)-2015, International Society for Cardiovascular Infectious Diseases (ISCVID)-2023, and ESC-2023] have not been compared with the conventional Duke criteria on this population. The primary objective was to compare the diagnostic value of the Duke, ESC-2015, ISCVID-2023, and ESC-2023 criteria for the diagnosis of TAVR-IE. The secondary objectives were to determine which criteria increase the diagnostic accuracy of each classification and to evaluate in-hospital and 1-year mortality of TAVR-IE. Methods and results From January 2015 to May 2022, 92 patients with suspected TAVR-IE were retrospectively included in two French centres, including 82 patients with definite TAVR-IE and 10 patients with rejected TAVR-IE as defined by expert consensus. Duke classification yielded a sensitivity of 65% [95% confidence interval (CI): 53-75%] and a specificity of 100% (95% CI: 69-100%) for the diagnosis of TAVR-IE. ESC-2015 classification increased Duke criterion sensitivity from 65 to 73% (P = 0.016) but decreased specificity from 100 to 90%. ISCVID-2023 and ESC-2023 also increased Duke criterion sensitivity from 65 to 76% (P = 0.004) and 77% (P = 0.002), respectively, but also decreased specificity from 100 to 90%. A positive 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was the most helpful criterion, as 10 patients (11%) were correctly reclassified. In-hospital mortality after TAVR-IE was 21% and 1-year mortality was 38%. Conclusion A multimodality imaging approach, including 18F-FDG PET/CT and gated cardiac CT, is the cornerstone of TAVR-IE diagnosis and explains the higher sensitivity of ESC-2015 and recent classifications compared with Duke criteria.

OBJECTIVES:Acute infective endocarditis after aortic root replacement is challenging. Peri-annular complications are often present and worsen the prognosis due to the risk of aortic root dehiscence. We perform a modified Bentall procedure with a tension-free proximal suturing technique. The aim of this study was to describe the results of this technique in terms of mortality, reintervention and endocarditis recurrence. METHODS:We retrospectively analysed the data of 20 patients undergoing surgery for acute infective endocarditis on aortic root replacement between 2014 and 2021. The surgical technique involved a graft with pseudosinuses and an aortic valve prosthesis sutured to this tube, keeping 5 mm of the tube under the prosthesis, allowing tension-free suturing between the reconstructed aortic annulus and the graft. Primary end-points were overall mortality and reintervention at 1 year. RESULTS:The median age was 57.9 years (26.0-77.0), 80.0% patients were men, and mean EuroSCORE II was 36.0% (± 17.7). Thirteen patients (65.0%) had periannular complications, 5 patients (25.0%) had severe aortic regurgitation. At 30 days, the overall mortality rate was 10.0% (2 patients). The Kaplan-Meier survival estimates at 1-year and 6-years were 90.0% and 85.0%, respectively. During a mean 42-month (± 44.5) follow-up period, no recurrence of endocarditis or reintervention was observed. Two patients experienced Bentall dehiscence without need for reintervention. CONCLUSIONS:The use of a modified Bentall technique with tension-free proximal suturing yields encouraging outcomes for patients undergoing redo aortic root replacement for acute infective endocarditis.

Background: Infective endocarditis (IE) is a serious condition which is difficult to diagnose and to treat, both medically and surgically. Objectives: The objective of this study was to evaluate the impact of the SARS-CoV-2 pandemic on the management of patients with IE. Methods: We conducted a single-centre retrospective study including patients hospitalized for IE during the pandemic (Group 2) compared with the same period the year before (Group 1). We compared clinical, laboratory, imagery, therapeutic, and patient outcomes between the two groups. Results: A total of 283 patients were managed for possible or definite IE (164 in Group 1 and 119 in Group 2). There were more intravenous drug-related IE patients in Group 2 (p = 0.009). There was no significant difference in surgery including intra-cardiac device extraction (p = 0.412) or time to surgery (p = 0.894). The one-year mortality was similar in both groups (16% versus 17.7%, p = 0.704). The recurrence rate was not significantly different between the two groups (5.9% in Group 2 versus 9.1% in Group 1, p = 0.311). Conclusions: The SARS-CoV-2 pandemic did not appear to have had a negative impact on the management of patients with IE. Maintenance of the activities of the endocarditis team within the referral centre probably contributed to this result. Nevertheless, the high proportion of intravenous drug-addicted patients in the pandemic cohort suggests that the SARS-CoV-2 pandemic had a major psychosocial impact.

Background. - Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases. Aim. - To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis. Methods. - Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year. Results. - High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P = 0.015), periannular complication on echocardiography (odds ratio 6.9; P < 0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90 mg/L; P = 0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P = 0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up. Conclusions. - High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk. (c) 2024 L'Auteur(s). Publie par Elsevier Masson SAS. Cet article est publie en Open Access sous licence CC BY-NC (http://creativecommons.org/licenses/by-nc/4.0/).

IntroductionLes entérocoques sont des pathogènes fréquemment responsables d'endocardites infectieuses (EI), en particulier sur les valves prothétiques, avec une augmentation d'incidence récemment décrite chez les patients qui ont bénéficié d'une implantation de valve aortique par voie percutanée (TAVI). Le pronostic est sombre et reste mal connu sur le long terme chez les patients traités par antibiotiques seuls malgré une indication chirurgicale théorique.Matériels et méthodesNous avons réalisé une étude rétrospective en incluant les patients traités pour une EI à Enterococcus spp. sur valve prothétique hospitalisés dans notre centre hospitalier universitaire entre janvier 2012 et décembre 2022.RésultatsAu total 95 patients ont été inclus. Les patients étaient principalement de sexe masculin, avec un âge médian de 76 ans. Les EI touchaient majoritairement les valves prothétiques biologiques (62,1%) et les TAVI (21,1%). E. faecalis était l'agent étiologique principalement retrouvé (86,2%). La plupart des patients ont reçu une antibiothérapie associant amoxicilline et ceftriaxone. Un traitement chirurgical était indiqué chez 62,1 % des patients, mais seulement la moitié d'entre eux ont finalement été opérés. Un traitement antibiotique prolongé d'un an a été proposé pour 39 patients non opérés. 55,3 % d'entre eux ont poursuivi le traitement jusqu'à un an. Une seule rechute a été rapportée. Le taux de mortalité global à un an était de 41,1 %. La mortalité était statistiquement plus élevée lorsque la chirurgie n'était pas réalisée malgré son indication (P<.001), et lorsque l'amoxicilline n'était pas poursuivie sur du plus long terme après un traitement médical initial complet (P<.001).ConclusionL'EI à entérocoque sur valve prothétique est une affection grave, avec des taux de mortalité élevés attribués principalement aux caractéristiques des patients. Lorsqu'elle est indiquée, l'intervention chirurgicale semble être un facteur de survie majeur. Pour les patients non opérés, un traitement antibiotique prolongé pourrait être envisagé, dont la durée pourrait être guidée par 18F-FDG-PET/CT.Aucun lien d'intérêt

The aim of this study was to provide insight into high-energy phosphate compound concentration dynamics under realistic clinical cold-storage conditions using the Celsior solution in seven heart grafts discarded from transplantation. The hearts of seven local donors (three males, four females, age 37 ± 17 years, height 175 ± 5 cm, weight 75 ± 9 kg) initially considered for transplantation and eventually discarded were submitted to a Magnetic Resonance Spectroscopy observation in a clinical Magnetic Resonance Imaging scanner over at least 9 h. The grafts remained in their sterile container at 4°C during the entire examination. Hence, Phosphocreatine (PCr), adenosine triphosphate (ATP), inorganic phosphate (Pi) and intracellular pH were recorded non-destructively at a 30-minute interval. With the ischemic time Ti, the concentration ratios decreased at PCr/ATP = 1.68−0.0028·Tis, Pi/ATP = 1.38 + 0.0029·Tis, and intracellular pH at 7.43–0.0012·Tis. ATP concentration remained stable for at least 9 h and did not decrease as long as phosphocreatine was detectable. Acidosis remained moderate. In addition to the standard parameters assessed at the time of retrieval, Magnetic Resonance Spectroscopy can provide an assesment of the metabolic status of heart grafts before transplantation. These results show how HEPC metabolites deplete during cold storage. Although many parameters determine graft quality during cold storage, the dynamics of HEPC and intracellular pH may be helpful in the development of strategies aiming at extending the ischemic time.

Plasma creatinine phosphokinase (CPK) elevation is frequent after heart transplantation. In the present study, we tested the hypothesis that this CPK elevation is related to idiopathic cardiomyopathy as primary cardiac disease. We included 203 patients who survived >1 year after heart transplantation. Plasma CPK was measured every 4 months during a 15.1 +/- 7.7-year follow-up. In univariate analysis, CPK elevation was significantly associated with age at transplantation, length of follow-up, treatment with everolimus, and idiopathic cardiomyopathy as primary cardiac disease. In multivariate analysis, idiopathic cardiomyopathy and length of follow-up were the only significant predictors of CPK elevation (p = 0.002 and p = 0.0001, respectively). A subgroup of 19 patients had frequent CPK elevation (>20% of the dosages). All these patients but 1 had an idiopathic cardiomyopathy as primary disease. In 5 of these 19 patients, we identified a syndrome known to affect both cardiac and skeletal muscles. In conclusion, underlying idiopathic cardiomyopathy is a major determinant of plasma CPK elevation after heart transplantation. Our results show that besides well-described syndromes associating skeletal and cardiac muscle disease, idiopathic cardiomyopathy may be associated with subclinical skeletal muscle myopathy. (c) 2023 Elsevier Inc. All rights reserved. (Am J Cardiol 2024;213:50-54)

Introduction:The use of an aortic bioprosthesis is on the rise in younger patients with severe aortic stenosis despite the risk of accelerated structural valve degeneration (SVD). In the search for an optimal valve substitute that would not be prone to SVD, the INSPIRIS bioprosthesis represents a promising solution to lowering the risk of SVD. Here, we report the 1-year outcomes of the INSPIRIS RESILIA aortic bioprosthesis in a population of young patients who underwent aortic valve replacement.Methods:In this prospective single-center study, we included all consecutive patients receiving INSPIRIS RESILIA bioprosthesis between June 2017 and July 2021. Patients with isolated severe aortic regurgitation were excluded. Clinical assessment and transthoracic echocardiography were performed preoperatively and at 1 year post-operatively. The primary outcome was overall mortality at one year.Results:A total of 487 patients were included. The mean age was 58.2 ± 11.5 years, 75.2% were men. Most of the interventions were elective, with a mean EuroSCORE II of 4.8 ± 7.9. The valve annulus size in most cases was either 23 mm or 25 mm. Overall mortality at 1-year was 4.1%. At 1-year, 7 patients (1.4%) had a stroke, 4 patients (0.8%) had a myocardial infarction, and 20 patients (4.1%) were hospitalized for congestive heart failure. The Kaplan-Meier estimated survival rates and survival without major adverse cardiac events at 1-year were 96.4% and 96.7%, respectively. At 1-year follow-up, 10 patients (2.1%) had endocarditis and 1 patient (0.2%) had partial prosthetic thrombosis. Pacemaker implantation at 1-year post-operative was necessary in 27 patients (5.5%). Severe patient prosthesis mismatch and severe intra valvular regurgitation were 1.2% and 0.6%, respectively. The Kaplan-Meier estimated survival rates at 1-year of no infective endocarditis preoperative and infective endocarditis preoperative were 97.9 ± 0.7% and 89.5 ± 3.3%, respectively (P < 0.001). Excluding endocarditis-related complication, no structural valve deterioration and no valve failure requiring redo surgery were reported.Conclusion:This is the largest single-center descriptive study of the 1-year outcomes after INSPIRIS RESILIA bioprosthesis implantation. The EDWARDS INSPIRIS RESILIA bioprosthesis provides encouraging clinical outcomes with an excellent 1- year survival rates and good hemodynamic performance. Long-term studies are mandatory to assess valve durability.

Background: The influence of different bicuspid aortic valve (BAV) morphology in the clinical course of infective endocarditis (IE) has not yet been investigated. This study aimed to describe the clinical and echocardiographic features of IE in patients with BAV (BAVIE) according to valve morphology.Methods: Patients with definite BAVIE prospectively enrolled in 4 high-volume referral centers from 2000 to 2019 were evaluated and divided into 2 groups according to the echocardiographic definition of fused BAV morphology: right-left coronary (RL type) and right noncoronary or left noncoronary (non-RL type) cusp fusion. All patients were followed up for 1 year.Results: One hundred thirty-eight patients with BAVIE were included (77.7% male; median age, 52 [36.8361.00] years): 112 patients with RL type (81%) and 26 patients with non-RL type BAV (19%), with no significant differences in age, sex, and comorbidities between groups. Although 43% of the cohort had known BAV, the referral was late after symptom onset, particularly for the RL phenotype; time from symptom onset to hospitalization >30 days (31.3% vs 11.5%; P = .032) and New York Heart Association class $ II (64.3% vs 42.3%; P = .039) were more frequent in patients with RL type BAV than in patients with non-RL type BAV. Conversely, patients with non-RL type BAV had a higher incidence of hemorrhagic stroke (19.2% vs 5.4%; P = .034) and high-grade atrioventricular block (11.5% vs 0.9%; P = .021). Streptococcus viridans was more frequently isolated in patients with non-RL type BAV than in patients with RL type BAV (44% vs 24.1%; P = .045). No difference in short-and intermediate-term mortality was observed between groups.Conclusions: Clinical profile and echocardiographic features in BAVIE patients may differ according to valve morphology, and patients with BAVIE appear to be referred late, even when BAV disease is previously known. (J Am Soc Echocardiogr 2023;36:760-8.)

Aims To determine the prognosis of patients treated for infective endocarditis (IE) according to their healthcare pathway. To assess how the ESC guidelines are implemented concerning the performance of transoesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centres in which the patients are hospitalized. Methods and results In a prospective multicentric study including 22 hospitals in the South-East of France, 342 patients were classified into three groups according to their healthcare pathway: 119 patients diagnosed and taken care entirely in a reference centre or hospital with cardiac surgery [Referral Center (RC) group], 111 patients diagnosed and initially taken care in a non-RC (NRC), then referred in a centre including cardiac surgery [transferred to the Referral Center (TRC) group] and 112 patients totally taken care in the NRC (NRC group). One-year mortality was 26% (88 deaths) and was not significantly different between Groups 1 and 2 (20 vs. 21%, P = 0.83). Patients in the NRC group had a higher mortality (37%) compared with patients in the RC and TRC groups (P < 0.001). ESC guidelines were not implemented similarly depending on the healthcare pathway (P = 0.04). Patients in the NRC group were significantly older (P < 0.001) and had more comorbidities (P < 0.001) than patients treated in referral centres. Conclusion Prognosis of patients with IE is influenced by their healthcare pathway. Patients treated exclusively in NRC have a worse prognosis than patients treated in referral or surgical centres.

Whipple’s disease (WD) is a chronic multisystemic infection caused by Tropheryma whipplei. If this bacterium presents an intracellular localization, associated with rare diseases and without pathognomonic signs, it is often subject to a misunderstanding of its physiopathology, often a misdiagnosis or simply an oversight. Here, we report the case of a patient treated for presumed rheumatoid arthritis. Recently, this patient presented to the hospital with infectious endocarditis. After surgery and histological analysis, we discovered the presence of T. whipplei. Electron microscopy allowed us to discover an atypical bacterial organization with a very large number of bacteria present in the extracellular medium in vegetation and valvular tissue. This atypical presentation we report here might be explained by the anti-inflammatory treatment administrated for our patient’s initial diagnosis of rheumatoid arthritis.

Background. - In native mitral valve infective endocarditis (NMIE), the respective values of mitral valve repair (MVRep) and replacement (MVR) are still debated. Aim. - To compare MVRep and MVR in a large prospective matched cohort. Methods. - Between 2010 and 2017, all consecutive patients operated on for NMIE in our centre were included prospectively. Clinical and outcome features were compared between the two groups. Primary endpoint was event-free survival, including death, reoperation and relapse. Univariate and multivariable survival analyses and a propensity score analysis were performed. Results. - Among 152 patients, 115 (75.7%) underwent MVRep, and 37 (24.3%) MVR. Median follow-up was 28 +/- 22 months. Surgery was performed during the active phase in 75.0% of patients (25.7% on an urgent basis). Compared with the MVRep group, patients in the MVR group were more frequently intravenous drug abusers (10.8% vs. 0.9%; P = 0.016), had a more frequent history of rheumatic fever (13.5% vs. 0%; P = 0.001), more aortic abscesses (16.7% vs. 3.5%; P = 0.018), larger vegetations (16.6 +/- 8.1 mm vs. 12.6 +/- 9.9 mm; P = 0.042) and poorer New York Heart Association status (P = 0.006). Overall mortality was lower in the MVRep group than in MVR group (11.3% vs. 29.3%; P = 0.018). Event-free survival was better in the MVRep group than in the MVR group in univariate analysis (hazard ratio: 2.72, 95% confidence interval: 1.34-5.52; P = 0.004). Survival analysis in the propensity-matched cohort showed that MVRep was safer than MVR (log rank test: P = 0.018). Multivariable analysis using the Cox proportional hazard model confirmed this finding (hazard ratio: 3.48, 95% confidence interval: 1.15-10.61; P = 0.03). Conclusions. - MVRep is feasible in most cases of NMIE and, when technically possible, should be preferred, even in urgent surgery. (c) 2022 Elsevier Masson SAS. All rights reserved.

A 35-year-old man, with a deep pectus excavatum due to a Marfan syndrome treated 9 years before for an acute type A dissection involving only the aortic arch, by a Bentall surgery, was admitted for acute chest pain. Computed tomography (CT) scan showed an acute type non-A non-B dissection extending to the iliac. After 5 days with strict arterial blood pressure management, the patient had recurrent refractory chest pain and a hybrid technique associating full supra-aortic vessels debranching and STABILISE technique during the same procedure was performed. The patient had an uneventful recovery with CT scan showing complete aortic arch aneurysm exclusion.

Methods. - In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death. Results. - Between April 2014 and January 2018, 351 patients with a definite diagnosis of left sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P = 0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61-33.67; P = 0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22-121.17; P = 0.006). Conclusions. - Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration. (c) 2021 Elsevier Masson SAS. All rights reserved.

BACKGROUND:18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE).AIMS:Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake).METHODS:Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected.RESULTS:Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P<0.001), without a change in specificity. Diffuse splenic uptake was observed in 39 (52.0%) patients, including 37 (58.7%) with a final diagnosis of NVE (specificity 83.3%).CONCLUSIONS:18F-FDG PET/CT has poor sensitivity but high specificity in the diagnosis of NVE. The usefulness of 18F-FDG PET/CT is high for embolic detection. Diffuse splenic uptake represents a possible new diagnostic criterion for NVE.

Moderate and severe TR is a prognostic marker of mortality independently from right ventricular dysfunction, pulmonary hypertension and left ventricular dysfunction. The survival benefit of ITVS is controversial. The aim of this study is to define the clinical and paraclinical criteria associated with morbidity-mortality of ITVS. We conducted a single-centre, retrospective study of 69 patients who underwent an ITVS at Marseille University Hospital from 2008 to 2018. Combined left-heart surgery and congenital cardiopathy were excluded. The primary outcome (PO) is composite including death and rehospitalization for acute decompensated heart failure within a year after surgery. Nineteen patients were treated for secondary tricuspid regurgitation (TR) (15 TR following left-sided valvulopathy and 4 TR caused by chronic atrial fibrillation (AF)). Forty-four had an operation for primary TR (36.5% of total TR were endocarditis). Mean patient follow-up was 44.5 months. Thirty-seven % of patients with secondary TR met the PO versus 9% of others (P = 0.011). Preoperative signs of chronic right heart failure (NYHA, congestive signs, anaemia and hyponatremia) were significantly linked with our PO. Right ventricular systolic pressure collected by preoperative right heart catheterization was a marker of unfavourable postoperative prognosis, confirmed by multivariate analysis (P = 0.006). Survival was worse for secondary TR (two years after surgery, 50% of patients with secondary TR were still alive and had not been readmitted versus 75% of others, P = 0.01). Isolated surgery of functional TR, whether caused by pulmonary hypertension secondary to left heart disease or due to right atrial dilatation (linked to AF) without a downstream obstacle, had a high morbidity-mortality risk in the short-term. Right heart catheterization may help in targeting high-risk surgical patients with secondary TR for percutaneous treatment.

We evaluated the feasibility and outcomes of immediate preoperative renal artery embolization (IPRAE) before complex nephrectomy for locally advanced RCC ± inferior vena cava thrombus (IVCT). A comparative retrospective (2007–2017) multicenter study which included 145 patients with locally advanced RCC ± IVCT: 99 radical nephrectomies vs. 46 radical nephrectomies with IPRAE identified in the prospective UroCCR national database (CNIL DR 2013–206; NCT03293563). IPRAE was performed under local anesthesia the day of nephrectomy (< 4 h prior to nephrectomy). The primary endpoint was peroperative blood loss (mL). Secondary outcomes were: tolerance of embolization (pain visual scale), success rate of IPRAE defined by complete devascularization of the kidney, perioperative complications according to Clavien score and postoperative GFR. The baseline characteristics of IPRAE and the control groups were similar. Tumor staging was 14% T2b, 41% T3a, 27% T3b, 13% T3c, 6% T4. The success rate of IPRAE was 98%. Median artery embolizated per patient was 2 (Agochukwu and Shuch in World J Urol 32:581–589, 2014; Marshall et al. in J Urol 139:1166–1172, 1988; Yap et al. in BJU Int 110:1283–1288, 2012;Gill et al. in J Urol. 194:929–938, 2015; Wang et al. in Eur Urol 69:1112–1119, 2016). No severe complications occurred after IPRAE. Postembolization syndrome was reported in 7% (Clavien I-II). Mean peroperative blood losses in the IPRAE and control groups were: 726 ± 118 ml and 1083 ± 114 ml (P = 0.03). In a multivariate analysis that included: age, Karnofsky index, IPRAE (yes vs. no), IVCT (yes vs. no), tumor size and synchronous metastasis, no IPRAE and IVCT were significantly associated with increased peroperative bleeding. IPRAE before nephrectomy for locally advanced and/or IVCT tumors was well tolerated, was associated with lower peroperative bleeding and did not increase the incidence or severity of postoperative complications.

OBJECTIVES The primary objective was to assess the value of the European Society of Cardiology (ESC) criteria, including F-18-fluorodeoxyglucose positron emission tomography/computed tomography (F-18-FDG-PET/CT) in prosthetic valve infective endocarditis (PVE). Secondary objectives were: 1) to assess the reproducibility of F-18-FDG-PET/CT; 2) to compare its diagnostic value with that of echocardiography; and 3) to assess the diagnostic value of the presence of a diffuse splenic uptake BACKGROUND F-18-FDG PET/CT has been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the benefit of the ESC criteria has not been prospectively compared with the conventional Duke criteria. METHODS Between 2014 and 2017, 175 patients with suspected PVE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable F-18-FDG PET/CT, 115 patients were evaluated, including 91 definite and 24 rejected IE, as defined by an expert consensus. RESULTS Cardiac uptake by F-18-FDG PET/CT was observed in 67 of 91 patients with definite PVE and 6 with rejected IE (sensitivity 73.6% [95% confidence interval (CI): 63.3% to 82.3%], specificity 75% [95% CI: 53.3% to 90.2%]). The ESC 2015 classification increased the sensitivity of Duke criteria from 57.1% (95% CI: 46.3% to 67.5%) to 83.5% (95% CI: 74.3% to 90.5%) (p < 0.001), but decreased its specificity from 95.8% (95% CI: 78.9% to 99.9%) to 70.8% (95% CI: 48.9% to 87.4%). Intraobserver reproducibility of F-18-FDG PET/CT was good (kappa = 0.84) but interobserver reproducibility was less satisfactory (kappa = 0.63). A diffuse splenic uptake was observed in 24 (20.3%) patients, including 23 (25.3%) of definite PVE, and only 1 (4.2%) rejected PVE (p = 0.024). CONCLUSIONS F-18-FDG PET/CT is a useful diagnostic tool in suspected PVE, and explains the greater sensitivity of ESC criteria than Duke criteria. However, F-18-FDG PET/CT also presents with important limitations concerning its feasibility, specificity, and reproducibility. Our study describes for the first time a new endocarditis criterion, that is, the presence of a diffuse splenic uptake on F-18-FDG PET/CT. (C) 2020 by the American College of Cardiology Foundation.

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

Mycotic aneurysm (MA) is rare but is a serious complication of infective endocarditis (IE). To evaluate the epidemiological, microbiological, diagnostic, therapeutic and prognostic data of patients with this complication. In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1988 to 2017 ( n = 2483), 101 (4%) presented MA. Patients with MA were younger (56 vs. 67y, P < 0.001), more often male (83% vs. 71%, P = 0.007), intravenous drug users (13% vs. 5%, P < 0.001). Diabetes (5% vs. 15%, P = 0.004), neoplasia (9% vs. 16%, P = 0.049), history of valve replacement (31% vs. 21%, P = 0.031) and cardiac device (5% vs. 20%, P < 0.001) were less frequent in MA group. Positive blood cultures were more frequent in MA group (97% vs. 81%). MA group had more aortic and mitral location (63% vs. 48%, p = 0.006 and 53% vs. 42%, P = 0,034, respectively) with more aortic perforation (25% vs. 14%, P = 0.002). Septic emboli were more frequents in MA group (81% vs. 41%, P < 0.001) regarding cerebral septic emboli (57% vs. 17%, P < 0.001), non-cerebral emboli (39% vs. 22%, p < 0.001) and multiple septic emboli (25% vs. 8%, P < 0.001). MA group had more cerebral events: ischemic stroke (33% vs. 12%, P < 0.001), intracranial hemorrhage (33% vs. 3%, P < 0.001). The indication of cardiac surgery was more frequent in the MA group (83% vs. 70%, P = 0.007) but the delay to surgery was longer (20 vs. 13 days, P = 0.029). Regarding the evolution, MA group had higher in-hospital mortality (22% vs. 13%, p0.014) and poorer 1-month survival (65% vs. 80%, P = 0.045) but the one-year mortality did not differ (52% vs. 49%, P = 0.79). Our data highlight that MA in IE is associated with poor short-term prognosis, mainly due to neurological complications in his younger population. One of the future challenges should be the improvement of the diagnostic of MA in IE.