Sabbagh, Abdallah El

Abstract Background Cardiovascular implantable electronic device (CIED)-associated infective endocarditis with large vegetations carries substantial morbidity and a high risk of embolization during transvenous lead extraction (TLE). Purpose To evaluate procedural outcomes, microbiological clearance, and embolic risk in patients undergoing percutaneous aspiration of vegetations in the setting of CIED-associated infective endocarditis prior to TLE. Methods Between January 2023 and October 2025, patients with confirmed CIED-associated infective endocarditis and echocardiographic evidence of vegetations on transvenous leads or cardiac valves were included. Mechanical aspiration was performed at the operator’s discretion for vegetation size > 20 mm, multiple vegetations, prior or potential embolization risk, or ongoing sepsis. All patients underwent percutaneous aspiration using the AngioVac or Penumbra system, followed by TLE either during the same session or in a staged procedure. Baseline clinical characteristics, microbiologic data, procedural details, and outcomes were reviewed. Results Our cohort comprised five patients (60% male) with a median age of 56.8 years (IQR 49.4–66.1). Median lead dwell time was 6.1 years (IQR 3.9–14.8). Median vegetation size was 12.5 mm (IQR 8–17). Two patients had prior septic pulmonary emboli. Microbiology identified Staphylococcus aureus in 2, Streptococcus spp. in 2, and Salmonella spp. in 1. The tricuspid valve and lead were involved in 4 patients, the mitral valve in 2, and the aortic valve in 1. The AngioVac system was used in 4 cases and Penumbra in 1. Successful aspiration (≥70% reduction in vegetation size of the targeted valve) was achieved in all cases. Two patients underwent staged extraction and three underwent concomitant TLE with complete removal of the transvenous system. A total of 8 leads were extracted (median 1, IQR 1–2.5); 4 patients had ICD leads, 2 with dual coil. No clinically significant embolic events occurred during the procedures. Among two patients with persistent infection, blood cultures cleared within 24 hours in one and 96 hours in the other. There were no major procedural complications or in-hospital or 30-day mortality. One patient with multivalvular involvement (aortic, mitral, tricuspid) subsequently underwent valve replacement surgery after blood cultures became sterile post-aspiration and TLE. Conclusion Percutaneous mechanical aspiration of vegetations prior to TLE was feasible and safe, resulting in effective microbiological clearance without periprocedural embolic events or major complications. This approach provides a viable alternative to surgical extraction in selected high-risk patients with large vegetations and device-related infective endocarditis and helps control sepsis.TEE images of the TV vegetationMacroscopic image of the vegetation

Isolated pulmonary valve endocarditis (PV-IE) is a rare condition. Its epidemiology, clinical profile, and management remain poorly characterized. A systematic review was conducted to provide a contemporary characterization (2020–2025) of adult cases with isolated PV-IE. Individuals with previous cardiac surgeries, cardiac implantable electronic devices (CIEDs), or long-term venous catheters were excluded. Of 1902 citations identified, 72 studies were selected with 79 eligible cases, mostly case reports. Patients were predominantly male (78.5%) with a median age of 43 years. Congenital heart disease (CHD) and injection drug use (IDU) were risk factors in 30.4% and 27.8% of cases, respectively, while 41.8% had neither (No-CHD/IDU group). Staphylococcus aureus was the leading pathogen (39%), followed by streptococci (16.5%) and Enterococcus faecalis (8.9%). Vegetations were large (median, 19.5 mm), and pulmonary septic emboli highly prevalent (~93% of cases). More than half (54.4%) of patients underwent surgery. Hospital mortality was low (7.6%). Differences across risk factor subgroups were observed, with higher median age in No-CHD/IDU patients and more staphylococcal etiology in patients with IDU, although treatment approaches and mortality did not differ. This review highlights distinct characteristics and the overall favorable short-term prognosis of isolated PV-IE, underscoring the need for larger, systematically collected datasets.

Abstract Background Knowing the prevalence of patent foramen ovale (PFO) and the increasing number of people who inject drugs (PWID) with right-sided infective endocarditis (RSIE), we aimed to better characterize the syndrome of injection drug use, RSIE, and PFO with systemic embolic events. Method A systematic search across multiple databases was independently screened using predefined criteria (from inception until September 2025). Published cases of adult PWID diagnosed with RSIE and ischemic stroke or other systemic embolic event were included, provided they had PFO assessment. Individuals were excluded if they had cardiac implantable electronic device (CIED) infections or any other conditions associated with systemic or paradoxical embolism. Results The review identified 13 studies with 14 young patients, mostly without comorbidities, predominantly infected with Staphylococcus aureus. In most cases, echocardiography revealed large tricuspid valve vegetations. Neuroimaging confirmed multiple ischemic infarcts, while 5 patients showed emboli outside the central nervous system (4 of them as the only systemic embolism). At least 11 (79%) patients had echocardiographic evidence of right-to-left shunting. Management included cardiac surgery in 6 cases that involved valve replacement or repair, percutaneous PFO closure in 2 cases, and percutaneous mechanical aspiration in 1 case. Three patients (21%) died during hospitalization, and only 27.3% patients had outpatient follow-up. Conclusions RSIE with systemic embolism in PWID with PFO has rarely been reported, affects younger patients without sex predominance, and was usually due to S. aureus with large tricuspid vegetations. Right-to-left shunting was characteristic, and outcomes were poor despite combined medical, surgical, and interventional therapies.

Background: Older adults with severe aortic stenosis (AS) are at high risk of mortality unless treated by aortic valve replacement (AVR). The Society of Thoracic Surgery (STS) score is primarily used clinically to determine mortality risk from surgical AVR. Due to geriatric comorbidities unique to older adults, traditional methods of risk stratification with STS may have significant shortcomings. Administratively derived risk scores that have prognostic significance in the geriatric population may prove valuable. Methods: We reviewed patients at our hospital system with AS undergoing AVR (surgical and transcatheter) and administratively derived an Elder Risk Assessment (ERA) score from the health record. The ERA score is a composite of age, marital status, number of hospitalized days in previous 2 years, and comorbidities (diabetes, coronary artery disease (CAD), heart failure, stroke, pulmonary disease, cancer, and dementia). Kaplan-Meier method was used to estimate survival by ERA score tertile. Cox regression was used to determine association between ERA and survival after accounting for STS predicted risk. Results: There were a total of 228 patients that underwent AVR (TAVR: 59 (26.1 %); SAVR 167 (73.9%) and had ERA scores derived. The average age was 79.6 (SD 7.6) years) and there were 93 (40.8%) women. Patients were stratified by ERA score tertiles: low (≤6), mid (6-13), or high (≥14). Over a mean follow up of 5.8 (SD 3.1) years, lower ERA scores were associated with better long-term survival (p<0.001). After accounting for age, sex, and STS score, mid ERA (HR 1.61; 95% CI 1.00-2.59; p<0.001) and high (HR 2.90; 95% CI 1.79-4.69; p<0.001) were associated with mortality (reference: low ERA). For every 10-point increase in the ERA, there was a 2-fold increase in adjusted mortality risk (HR 2.14; 95% CI 1.58-2.90; p<0.001). Conclusions: Older adults undergoing AVR for severe AS have specific geriatric comorbidities that may be better characterized using the ERA score. This administratively derived score was independently associated with survival after accounting for the widely used STS risk score.

Background: Coronary artery disease (CAD) is common among liver transplantation (LT) candidates, yet whether pre-transplant percutaneous coronary intervention (PCI) improves post-LT outcomes remains uncertain. Methods: We conducted a single-center, Institutional Review Board-approved cohort study of adults undergoing LT from 2005 to 2025. Asymptomatic candidates with significant stenosis on invasive angiography were included; prior coronary artery bypass grafting was excluded. The primary endpoint was major adverse cardiovascular events (MACE: myocardial infarction [MI], stroke/transient ischemic attack, new systolic dysfunction, post-LT coronary revascularization, or all-cause death). Results: Among 111 patients (median age 65 years; 84% male), 66 (59%) underwent PCI and 45 (41%) were managed medically. Over a median 32 months of follow-up, 61 patients (55%) experienced MACE. Composite MACE did not differ between PCI and non-PCI groups (52% vs. 60%, p = 0.40; log-rank p = 0.59). Fine–Gray modeling showed no association of PCI with MACE; independent predictors were prior MI (HR 1.81, 95% CI 1.01–3.24) and pre-transplant dialysis (HR 2.13, 95% CI 1.07–4.24). Major bleeding occurred in 7%. Matched and era-stratified analyses were concordant. Conclusions: In asymptomatic LT candidates with angiographically severe CAD, pre-LT PCI was not associated with a lower incidence of post-LT MACE.

Background We tested whether biologic age, as estimated by deficits, functional impairments, or Age‐Gap or their combination, provide improved estimation of cause‐specific death as compared with chronological age. Methods Cardiovascular and noncardiovascular deficits, functional impairments, and Age‐Gap were prospectively collected in 535 patients aged ≥55 years undergoing percutaneous coronary interventions between August 1, 2014, and March 31, 2018. Age‐Gap was calculated as the difference between chronological age and age estimated by artificial intelligence ECG using a convolutional neural network. The full biological age model included deficits, functional impairments, and Age‐Gap >2 SD. A multivariable reduced model with the least number of variables was also created to provide a comparable C index to the full model. Results The average chronological age was 72.1±9.5 years, and there were 68% of men. During a median follow‐up of 2.61 years, 124 (23%) patients died. There was a modest correlation between Age‐Gap and biological age ( r =0.28 [95% CI, 0.20–0.35]; P <0.001). When modeled with chronologic age as a covariate, Age‐Gap predicted all‐cause (hazard ratio [HR], 1.07 [95% CI, 1.04–1.10]; P <0.001) and cardiovascular (HR, 1.07 [95% CI, 1.04–1.11]; P <0.001) mortality. As compared with chronological age, the full biological age model noted significant improvement in the prediction of long‐term overall (95% CI, 0.65–0.78), cardiovascular (95% CI, 0.69–0.77), and noncardiovascular (95% CI, 0.55–0.86) mortality. In the reduced models, most prognostic information for noncardiovascular mortality (C index: 0.79) was obtained by subjective difficulty in performing tasks, whereas the deficit‐based estimation predicted cardiovascular mortality (C index: 0.72). Conclusions Estimated biological age from deficits and functional impairments was superior to chronological age in predicting long‐term cause‐specific mortality following percutaneous coronary interventions.

Background: Conduction abnormality post-transcatheter aortic valve implantation (TAVI) remains clinically significant and usually requires chronic pacing. The effect of right ventricular (RV) pacing post-TAVI on clinical outcomes warrants further studies. Methods: We identified 147 consecutive patients who required chronic RV pacing after a successful TAVI procedure and propensity-matched these patients according to the Society of Thoracic Surgeons (STS) risk score to a control group of patients that did not require RV pacing post-TAVI. We evaluated routine echocardiographic measurements and performed offline speckle-tracking strain analysis for the purpose of this study on transthoracic echocardiographic (TTE) images performed at 9 to 18 months post-TAVI. Results: The final study population comprised 294 patients (pacing group n = 147 and non-pacing group n = 147), with a mean age of 81 ± 7 years, 59% male; median follow-up was 354 days. There were more baseline conduction abnormalities in the pacing group compared to the non-pacing group (56.5% vs. 41.5%. p = 0.01). Eighty-eight patients (61.6%) in the pacing group required RV pacing due to atrioventricular (AV) conduction block post-TAVI. The mean RV pacing burden was 44% in the pacing group. Left ventricular ejection fraction (LVEF) was similar at follow-up in the pacing vs. non-pacing groups (57 ± 13.0%, 59 ± 11% p = 0.31); however, LV global longitudinal strain (−12.7 ± 3.5% vs. −18.8 ± 2.7%, p < 0.0001), LV apical strain (−12.9 ± 5.5% vs. 23.2 ± 9.2%, p < 0.0001), and mid-LV strain (−12.7 ± 4.6% vs. −18.7 ± 3.4%, p < 0.0001) were significantly worse in the pacing vs. non-pacing groups. Conclusions: Chronic RV pacing after the TAVI procedure is associated with subclinical LV systolic dysfunction within 1.5 years of follow-up.