BackgroundThere has been an increase in the prevalence of drug abuse (DA) in the national opioid epidemic. With increasing DA, there is an increased risk of infective endocarditis (IE). There are limited recent data evaluating national trends on the incidence and geographical distribution of DA‐IE. We aim to investigate those numbers as well as the determinants of outcome in this patient population.Methods and ResultsHospitalized patients with a primary or secondary diagnosis of IE based on the International Classification of Diseases, Ninth and Tenth Revisions (ICD‐9, ICD‐10) were included. We described the national and geographical trends in DA‐IE. We also compared DA‐IE patients’ characteristics and outcomes to those with IE, but without associated drug abuse (non‐DA‐IE) using Poisson regression models. Incidence of DA‐IE has nearly doubled between 2002 and 2016 All US regions were affected, and the Midwest had the highest increase in DA‐IE hospitalizations (annual percent change=4.9%). Patients with DA‐IE were younger, more commonly white males, poorer, had fewer comorbidities, and were more likely to have human immunodeficiency virus, hepatitis C, concomitant alcohol abuse, and liver disease. Their length of stay was longer (9 versus 7 days; P<0.001) and were more likely to undergo cardiac surgery (7.8% versus 6.2%; P<0.001), but their inpatient mortality was lower (6.4% versus 9.1%; P<0.001).Conclusions DA‐IE is rising at an alarming rate in the United States. All regions of the United States are affected, with the Midwest having the highest increase in rate. Young‐adult, poor, white males were the most affected.

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ObjectivesA substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not.MethodsRetrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes.ResultsAmong a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71).ConclusionAlthough corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

Background Concerns about discordance between echocardiographic and invasive mean gradients after transcatheter aortic valve replacement (TAVR) with balloon‐expandable valves (BEVs) versus self‐expanding valves (SEVs) exist. Methods and Results In a multicenter study, direct‐invasive and echocardiography‐derived transvalvular mean gradients obtained before and after TAVR were compared as well as post‐TAVR and discharge echocardiographic mean gradients in BEVs versus SEVs in 808 patients. Pre‐TAVR, there was good correlation ( R =0.614; P <0.0001) between direct‐invasive and echocardiography‐derived mean gradients and weak correlation ( R =0.138; P <0.0001) post‐TAVR. Compared with post‐TAVR echocardiographic mean gradients, both valves exhibit lower invasive and higher discharge echocardiographic mean gradients. Despite similar invasive mean gradients, a small BEV exhibits higher post‐TAVR and discharge echocardiographic mean gradients than a large BEV, whereas small and large SEVs exhibit similar post‐TAVR and discharge mean gradients. An ejection fraction <50% ( P =0.028) and higher Society of Thoracic Surgeons predicted risk of mortality score ( P =0.007), but not invasive or echocardiographic mean gradient ≥10 mm Hg ( P =0.378 and P =0.341, respectively), nor discharge echocardiographic mean gradient ≥20 mm Hg ( P =0.393), were associated with increased 2‐year mortality. Conclusions Invasively measured and echocardiography‐derived transvalvular mean gradients correlate well in aortic stenosis but weakly post‐TAVR. Post‐TAVR, echocardiography overestimates transvalvular mean gradients compared with invasive measurements, and poor correlation suggests these modalities cannot be used interchangeably. Moreover, echocardiographic mean gradients are higher on discharge than post‐TAVR in all valves. Despite similar invasive mean gradients, a small BEV exhibits higher post‐TAVR and discharge echocardiographic mean gradients than a large BEV, whereas small and large SEVs exhibit similar post‐TAVR and discharge mean gradients. Immediately post‐TAVR, elevated echocardiographic‐derived mean gradients should be assessed with caution and compared with direct‐invasive mean gradients. A low ejection fraction and higher Society of Thoracic Surgeons score, but not elevated mean gradients, are associated with increased 2‐year mortality.