ndocarditis is an infection of the cardiac endothelium and can present as either acute or subacute disease. Acute infective endocarditis advances rapidly, presenting with a sudden onset of high fever, rigors, sepsis, and systemic complications. This presentation alone is indistinguishable from other causes of sepsis, but when there is also a new-onset heart murmur, a diagnosis of acute infective endocarditis should be considered. In contrast, subacute infective endocarditis can be difficult to diagnose. Patients develop nonspecific symptoms such as fatigue, dyspnea, or weight loss over several weeks to months. Fever may or may not be present. Although endocarditis is commonly associated with a heart murmur due to valve regurgitation, new murmurs are present in less than half of cases (Table 1). 1,2 Janeway lesions or Osler nodes are classic diagnostic findings (Figure 1), but they are present in fewer than 5% of cases. Imaging can reveal embolic phenomena such as pulmonary and splenic emboli (Figure 2). Infective endocarditis should be suspected when patients present with either an acute or subacute illness when infective endocarditis risk factors are present (Box 1). In general, Staphylococcus aureus infection causes acute, aggressive infections, and the more indolent pathogens, viridans group streptococci or coagulase-negative staphylococci, cause subacute infective endocarditis. MethodsWe conducted a literature search of the PubMed database from January 2008 through March 2018. The selection, including clinical trials, observational studies, review articles, and society guidelines, was limited to studies published in English. We reviewed the reference articles that were cited in the guidelines IMPORTANCE Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.OBSERVATIONS Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct ro...

Operative mortality for surgically treated infective endocarditis is substantially lower than reported in-hospital mortality rates for infective endocarditis. The described risk scoring system will inform clinical decision-making in these complex patients.

IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011–2012). Patients ≥65 years old with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery ± CABG, aortic valve surgery ± CABG) with and without concomitant S-LAAO were followed until December 31, 2014. EXPOSURE S-LAAO vs. no S-LAAO. MAIN OUTCOME MEASURES Primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years follow-up, as defined by Medicare claims data. Secondary endpoints included hemorrhagic stroke, all-cause mortality, and a composite endpoint (thromboembolism, hemorrhagic stroke, all-cause mortality). RESULTS Among 10,524 patients undergoing surgery (median age of 76 years; 39% female; median CHA2DS2-VASc score of 4), 3,892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, death in 21.5%, and the composite endpoint in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs. 6.2%), all-cause mortality (17.3% vs. 23.9%), and the composite endpoint (20.5% vs. 28.7%), but no significance difference in rates of hemorrhagic stroke (0.9% vs. 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR] 0.67, confidence interval [CI] 0.56–0.81, p<0.0001), death (HR 0.88, CI 0.79–0.97, p=0.001), and the composite endpoint (HR 0.83, CI 0.76–0.91, p<0.001), but not hemorrhagic stroke (subdistribution HR 0.84, 0.53–1.32, p=0.44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among those discharged without anticoagulation (unadjusted rate 4.2% vs. 6.0%, adjusted subdistribution HR 0.26, CI 0.17–0.40, p<0.001), but not among those discharged with anticoagulation (unadjusted rate 4.1% vs. 6.3%, adjusted subdistribution HR 0.88, CI 0.56–1.39, p=0.59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over the three years. These findings are supportive of S-LAAO, but randomized trials are necessary to provide definitive evidence.

Background Cardiac surgery requiring cardiopulmonary bypass is associated with platelet activation. Because platelets are increasingly recognized as important effectors of ischemia and end-organ inflammatory injury, the authors explored whether postoperative nadir platelet counts are associated with acute kidney injury (AKI) and mortality after coronary artery bypass grafting (CABG) surgery. Methods The authors evaluated 4,217 adult patients who underwent CABG surgery. Postoperative nadir platelet counts were defined as the lowest in-hospital values and were used as a continuous predictor of postoperative AKI and mortality. Nadir values in the lowest 10th percentile were also used as a categorical predictor. Multivariable logistic regression and Cox proportional hazard models examined the association between postoperative platelet counts, postoperative AKI, and mortality. Results The median postoperative nadir platelet count was 121 × 109/l. The incidence of postoperative AKI was 54%, including 9.5% (215 patients) and 3.4% (76 patients) who experienced stages II and III AKI, respectively. For every 30 × 109/l decrease in platelet counts, the risk for postoperative AKI increased by 14% (adjusted odds ratio, 1.14; 95% CI, 1.09 to 1.20; P &lt; 0.0001). Patients with platelet counts in the lowest 10th percentile were three times more likely to progress to a higher severity of postoperative AKI (adjusted proportional odds ratio, 3.04; 95% CI, 2.26 to 4.07; P &lt; 0.0001) and had associated increased risk for mortality immediately after surgery (adjusted hazard ratio, 5.46; 95% CI, 3.79 to 7.89; P &lt; 0.0001). Conclusion The authors found a significant association between postoperative nadir platelet counts and AKI and short-term mortality after CABG surgery.