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12.8 Infective endocarditis in rheumatic

heart disease Infective endocarditis is a known complication of RHD,766 and acute rheumatic fever (the antecedent of RHD) may even present with concomitant IE.767 Of the 3343 participants enrolled in The Global Rheumatic Heart Disease Registry (REMEDY),768 133 (2.4%) had a history of IE at enrolment,769 and 20 (0.7%; 3.65 per 1000 patient-years) developed IE during the 27-month follow-up.770 These participants were young with a median age of 28 years (interquartile range 18–40 years), 66.2% were women, and over 30% were children. The majority of the over 40 million patients with RHD771 live in low- and middle-income countries and face socioeconomic and health-system barriers772 to adequate prevention, early diagnosis, and advanced care and, therefore, are at particular risk of IE.773 Global access to surgery for RHD and RHD-associated complications is extremely limited.774 RHD patients presenting with fever, changing or new murmurs should be investigated for IE. In studies from RHDendemic regions, RHD is the most common underlying cardiac condition, with significant mortality and morbidity.775–784 In those affected with oral bacteria-related IE linked to RHD, oral Streptococcus spp. was the main cause of IE associated with poor oral health status.785 In RHD-endemic countries, IE in children is strongly linked to RHD,786–788 and when causing HF, carries the highest case fatality rate.789 IE is associated with enhanced risk of death among patients with RHD undergoing isolated mitral valve replacement (odds ratio 5.22, 95% confidence interval [CI], 1368–19 915; P = 0.008).790 Pregnancy is a particularly high-risk period for women with RHD, with an increased risk of developing IE.791,792 However, high-income countries or countries with emerging economies are seeing less IE linked to RHD, as the incidence rates of RHD in these regions decrease.793–796

12.9 Infective endocarditis during

pregnancy Infective endocarditis in pregnancy is a rare but extremely serious condition with high maternal and foetal morbidity and mortality, and is estimated to complicate ∼1 in 100 000 pregnancies.797–799 Maternal mortality approaches 18%, with most deaths relating to HF or an embolic event, while pre-term birth is reported at 55.7% and foetal mortality at 29%.800 Recurrent infective complications can occur in up to 27% of women post-partum.801 The diagnosis must be considered in pregnant women with unexplained fever and cardiac signs (especially tachycardia), new or changing cardiac murmurs, and peripheral signs of septic emboli.802 Women with CHD, RHD,803 and structural heart disease, together with those with prosthetic heart valves and with PWID are at particular risk.800,804–807 The gravity of the condition requires the inclusion of gynaecologists, obstetricians, and neonatologists in the Endocarditis Team in any suspected cases, and a diagnosis and treatment plan should be formulated without delay, as this is key to saving the lives of mothers and infants.799,808,809 Management can be challenging, especially when the pregnant patient warrants a cardiac operation under CPB. Although this poses a considerable risk to the foetus, urgent surgery when indicated should not be delayed.799,810

12.10 Infective endocarditis in

immunocompromised patients 12.10.1. Solid organ transplant recipients The incidence of IE in recipients of solid organ transplantation (SOT) ranges between 1% and 2%.107 SOT recipients with IE are younger and have higher prevalence of co-morbidities (particularly renal and liver disease) compared with non-SOT patients with IE. Among the SOT patients with IE, the most common transplanted organ is the kidney (72%), followed by liver (17%), and pancreas (8%).811 Similar to non-SOT patients, aortic followed by mitral IE are the most common forms of IE while right-sided IE is uncommon. Interestingly, SOT patients with IE more frequently have atrial or ventricular vegetations without valve involvement (mural IE).107 In-hospital and healthcare-related IE are the most frequent causes of IE in recipients of SOT and the most frequent microorganism involved is S. aureus (34%), followed by Enterococcus spp. (17%), and Streptococcus spp. (11%).107,811

Surgical valve repair/replacement is less frequently performed in SOT patients with IE as compared with non-SOT patients. Interestingly, the outcomes of IE in patients with SOT do not differ from those of non-SOT with IE.107,811 The reasons for the similar outcomes may rely on the younger age of the SOT patients, the frequent contact with the healthcare system which may lead to early diagnosis and treatment of IE, and the frequent involvement of infectious disease specialists in the care of hospitalized SOT patients. However, compared with SOT patients without IE, those who develop IE during the index transplant hospitalization have worse outcomes.811 The high levels of immunosuppression probably negatively impact the IE course in these patients. Heart transplant recipients represent 10% of SOT with IE patients.811 Among 57 heart transplant recipients who developed IE, the most frequent organism was S. aureus (26%), followed by A. fumigatus (19%), and E. faecalis (12%).105 The median time to IE presentation after heart transplant was 8 years and the mitral valve was the most frequently affected, followed by mural and tricuspid valve IE. All-cause mortality in this group of patients is high (45%), and fungal aetiology is associated with worse outcomes. Similar to other SOT recipients, heart transplant recipients were not frequently referred to surgery (35%).105

12.10.2 Patients with human immunodeficiency virus

The advent of combined antiretroviral treatment has led to a reduction in the risk of developing acquired immune deficiency syndrome (AIDS) but people living with HIV remain a vulnerable population for IE.812 The incidence of IE in people living with HIV has decreased over the last two decades. A retrospective study from Spain has shown a reduction in the incidence of IE from 18.2 per 100 000 patient-years between 1997 and 1999 to 2.9 events per 100 000 patient-years between 2000 and 2014.813 Similarly, a registry from the United States of America reported a reduction in the incidence of IE from 148 in 2007 to 112 in 2017.141 Patients living with HIV and presenting with IE are becoming older, and have a higher percentage of substance abuse and comorbidities.141,813 Of importance, the number of patients living with HIV who are admitted with IE have higher frequency of CHD, prior valve surgery, CIED infection, and haemodialysis.141,813 The most frequent microorganisms causing IE are Staphylococcus spp. (the majority of which is S. aureus), followed by Streptococcus spp., Gram-negative bacilli, and enterococci. It is important to note that over the last two decades, the frequency of CoNS as a cause of IE has decreased whereas the frequency of streptococci, Gram-negative bacilli, enterococci, and fungus has increased.813 Community-acquired IE has become the most frequent form while healthcare-associated IE rates have significantly decreased over time. The outcomes of IE in people living with HIV have improved over the years (from 23.9 to 5.5 deaths per 100 000 patient-years) and surgical Downloaded from academic.oup.com/eurheartj/article/44/39/3948/7243107 by guest on 07 October 2026