Distant embolisation in infective endocarditis: characteristics and outcomes

Original Article Neth Heart J https://doi.org/10.1007/s12471-023-01771-6 Distant embolisation in infective endocarditis: characteristics and outcomes Mariëlle G. J. Duffels · Tjeerd Germans · Annet Bos-Schaap · Olivier Drexhage · Jiri F. P. Wagenaar · Friso M. van der Zant · Martine Hoogewerf · Remco J. J. Knol · Victor A. W. M. Umans Accepted: 2 February 2023 © The Author(s) 2023 Abstract Background Infective endocarditis is a severe and potentially lethal cardiac disease. Recognition of the clinical features of endocarditis, such as distant embolisation, and adequate treatment should be initiated promptly given the grim perspective of upcoming virulent pathogens. Methods We report on our registry-based experience with outcomes of consecutive patients with infective endocarditis with distant embolisation. We aimed to describe the patient characteristics of infective endocarditis complicated by distant organ embolisation and the safety aspects of continuing endocarditis treatment at home in these patients. Results From November 2018 through April 2022, 157 consecutive patients were diagnosed with infective endocarditis. Of them, 38 patients (24%) experienced distant embolisation, either in the cerebrum (n = 18), a visceral organ (n = 5), the lungs (n = 7) or the myocardium (n = 8). Pathogens identified in blood cultures were predominantly streptococcal variants (43%), with only one culture-negative endocarditis case. Of the 18 patients with cerebral embolisation, M. G. J. Duffels · T. Germans · A. Bos-Schaap · O. Drexhage · V. A. W. M. Umans () Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands J. F. P. Wagenaar Department of Infectious Diseases, Northwest Clinics, Alkmaar, The Netherlands F. M. van der Zant · R. J. J. Knol Department of Nuclear Medicine, Northwest Clinics, Alkmaar, The Netherlands M. Hoogewerf Department of Medical Microbiology, Northwest Clinics, Alkmaar, The Netherlands 12 had neurological complaints and most often discrete abnormal findings on neurological examination. Six of the 8 cardiac embolism patients experienced chest pain before admission. Visceral organ and pulmonary embolism occurred silently. Of the 38 patients with distant embolisation, 17 could be discharged earlier by providing antibiotic treatment at home without complications. Conclusion This registry-based single-centre experience showed an incidence of distant embolisation in daily care of 24%. Cerebral and coronary embolisation provoked symptoms, while visceral emboli remained silent. Pulmonary emboli may present with inflammatory signs. Distant embolisation was not in itself a contra-indication for outpatient endocarditis@home treatment. What’s new? This registry-based, single-centre experience showed an incidence of distant embolisation in a non-referral hospital of 24%.  With regard to the occurrence of distant embolisation, there are three important aspects: it may establish the diagnosis of endocarditis, impact clinical decision-making and affect the clinical and inflammatory course of the disease.  Patients with distant organ embolic events may be seen at the internal medicine, orthopaedics or neurology department with localised symptoms and a common denominator of positive blood cultures while being febrile or septic.  Outpatient intravenous antibiotic treatment is also feasible for recovering patients with distant organ embolisation and may warrant adjustment of the guidelines.  Distant embolisation in infective endocarditis Original Article Keywords Infective endocarditis · Embolisation · Imaging · Clinical cardiology Introduction Infective endocarditis is a common cardiac disease with a potential fatal clinical course [1, 2]. The natural course of endocarditis has changed, with different pathogens and patient characteristics [1, 3–5]. The incidence has been reported to increase over time, with a rise in more virulent microorganisms in earlier studies [3–5]. The prevalence of infective endocarditis is estimated to be 3–10 per 100,000 inhabitants. Although several patient groups at risk have been identified, i.e. patients with mechanical cardiac valves or cardiovascular implantable devices, the majority of endocarditis patients are non-high-risk patients [3, 6]. However, recognition and treatment of endocarditis have become more sophisticated, and adequate treatment should be initiated promptly given the grim perspective of upcoming virulent pathogens. This is even more apparent in patients with distant embolic events either at presentation or during the course of their treatment because this requires more sophisticated recognition and treatment [5–9]. Such patients may be seen, for example, at the internal medicine, orthopaedics or neurology department with localised symptoms and a common denominator of positive blood cultures while being febrile [10–13]. A multidisciplinary approach should entail an imminent multiimaging workup and the start of effective and culturedriven antibiotic therapy. We aimed to describe the patient characteristics of infective endocarditis complicated by distant organ embolisation in a non-surgical hospital. Additionally, we provide information on the safety aspects of continuing endocarditis treatment at home in these patients. Methods Patient population From November 2018 through April 2022, all patients with suspected endocarditis were presented at the weekly Endocarditis Team meeting at Northwest Clinics in Alkmaar, the Netherlands. Confirmation or rejection of the diagnosis of infective endocarditis was based on clinical presentation, blood culture sampling and multimodality imaging. All consecutive patients with a confirmed diagnosis were prospectively followed and constituted the patient cohort. Infective endocarditis was defined according to the 2015 European Society for Cardiology (ESC) modified diagnostic criteria [1]. Multimodality imaging included transthoracic echocardiography and/or transoesophageal echocardiography. When indicated, 18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) (n = 91) Distant embolisation in infective endocarditis or cardiac magnetic resonance imaging (MRI) (n = 8) was performed. Embolic events were defined as (sub)clinical wedgeshaped lesions shown on any imaging modality. These were subdivided into cardiac, pulmonal, visceral organ and cerebral embolisms. Endocarditis team Endocarditis presentations may result in admissions and treatments by medical specialists from diverse disciplines, which often delays the diagnosis and the initiation of optimal therapy. We therefore formed the Alkmaar Endocarditis Team in accordance with the ESC Guidelines [1]. In Endocarditis Team meetings, we discuss the following patient groups: (a) patients in whom the diagnosis is not yet confirmed and (b) patients with a stable clinical course while on appropriate antibiotic treatment. The team, with in-person expertise of (imaging) cardiologists, in (...truncated)