Contemporary Cleveland Clinic experience of fungal infective endocarditis: a focus on imaging and outcomes.

AIMS: Fungal infective endocarditis (IE) is known to carry high morbidity and mortality, yet contemporary literature on the imaging features and prognosis of this patient population remains very limited.

METHODS AND

RESULTS

In this retrospective cohort study, all patients admitted to the Cleveland Clinic between 2009 and 2021 with fungal IE were reviewed. Data were collected on clinical presentation, imaging findings, and patient outcomes. Univariate and multivariate regression analyses for risk factors associated with mortality and with post-surgical re-infection were conducted. A total of 82 patients were included. The mean age was 51 ± 16 years, 77% had prosthetic valves, 29% had aortic grafts, and the rate of intravenous drug use history was 39%. Echocardiographic features differed between organisms, with no Histoplasma patients demonstrating infectious annular involvement. The rate of patients with large vegetations (>1 cm) was 70%. In all, 43% had severe valvular dysfunction, 30% had paravalvular abscess, and 21% had aortic graft infections. Of the four patients undergoing nuclear studies, none of them had intracardiac uptake. Inpatient and 1-year mortality rates were 15% and 30%, respectively. Patients who received medical therapy without surgery had worse mortality than those who underwent surgery (P = 0.015).

CONCLUSION

We present the largest contemporary cohort study of fungal IE to date. Rates of complicated infection in fungal IE were high. Multimodality imaging with transesophageal echocardiography and computed tomography was critical in diagnosis. Although useful in identifying peripheral complications, nuclear studies may have lower sensitivity in identifying fungal IE, and further research is warranted in this population. While still elevated, 1-year mortality rates (30%) were significantly lower in our patient cohort than previously reported.