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Background Transcatheter edge-to-edge mitral valve repair using the MitraClip device is increasingly used for high surgical risk patients with severe mitral regurgitation (MR). Previous guidelines for infective endocarditis prophylaxis prior to dental procedures focused on high-risk patients, but without explicit recommendation for MitraClip recipients. We believe this could be the first reported case to identify Streptococcus oralis as the causative organism. Case presentation An 87-year-old male with severe MR treated with two MitraClip devices three months prior to index admission, presented with worsening malaise and intermittent chills on a background of multiple comorbid conditions. The patient had dental work a month prior to presentation, including a root canal procedure, without antibiotic prophylaxis. Vitals were significant for fever and hypotension. On physical examination, there was a holosystolic murmur at the apex radiating to the axilla, bilateral pitting edema in the lower extremities, and elevated jugular venous pulsation. A transthoracic echocardiogram showed severe MR with a possible echodensity on the mitral valve, prompting a transesophageal echocardiogram, which demonstrated a pedunculated, mobile mass on the posterior leaflet of the mitral valve. Five blood cultures grew gram positive cocci in pairs and chains, later identified as Streptococcus oralis, with minimum inhibitory concentration to penicillin 0.06 mg/L. Initial empiric antibiotics were switched to ceftriaxone 2 gr daily and subsequent blood cultures remained negative. However, the patient developed pulmonary edema and worsening hemodynamic instability requiring vasopressors. As surgical risk for re-operation was considered prohibitive, the decision was made to continue medical management and comfort-directed care. The patient died a week later. Conclusions Despite low incidence, infective endocarditis should be included in the differential among MitraClip recipients. The explicit inclusion of this growing patient population in the group requiring prophylaxis prior to dental procedures in the 2020 ACC/AHA valvular heart disease guidelines is an important step forward.

Funding Acknowledgements Type of funding sources: None. Background Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent literature suggests that surgery during index hospitalization may be performed safely without increased risk of mortality. However, the risk of post-operative complications remains unclear. Purpose The purpose of this meta-analysis is to assess the association of early surgery with post-operative complications as compared to delayed surgery in patients with IE. Methods We performed a literature search for studies reporting an association between early surgery and study endpoints. The primary endpoint was post-operative neurological complications. The secondary endpoints were post-operative systemic embolic events, recurrence of IE, and need for reoperation. Early surgery was defined as surgery within 14 days of admission. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Results A total of 11 studies with 1857 participants (634 with early surgery vs 1223 with delayed surgery) were included. The mean duration of follow-up was 39 months (ranging between 6 to 66 months). Early surgery compared to delayed surgery was not associated with increased risk of post-operative neurological complications (OR 1.01, 95% CI 0.55, 1.85; P=0.98). Heterogeneity was low: Chi2 = 2.93, I2 = 0%. Early surgery compared to delayed surgery was not associated with increased risk for post-operative systemic embolic events, recurrence of IE, or need for reoperation (OR 0.98, 95% CI 0.6, 1.61; p=0.94; OR 1.66, 95% CI 0.83, 3.33; p=0.15; OR 2.18, 95% CI 0.41, 11.69; p=0.36). Conclusions Early surgery performed within 14 days of initial hospitalization is not associated with increased risk of post-operative complications compared to delayed surgery.

We report chip-integrated Kerr optical parametric oscillators with emission wavelengths between 590 nm and 1150 nm and conversion efficiencies reaching 15%. We further demonstrate photonic-crystal-mediated devices with >99.7% as-fabricated output wavelength accuracy.