The benefit of an implantable cardioverter–defibrillator (ICD) in patients with symptomatic systolic heart failure caused by coronary artery disease has been well documented. However, the evidence for a benefit of prophylactic ICDs in patients with systolic heart failure that is not due to coronary artery disease has been based primarily on subgroup analyses. The management of heart failure has improved since the landmark ICD trials, and many patients now receive cardiac resynchronization therapy (CRT).

Over the past two decades Enterococcus faecalis and Enterococcus faecium have become increasingly important pathogens worldwide, especially due to hospital-acquired infections. Enterococcus spp. are rated as the third leading cause of hospital-acquired bacteraemia in the United States and account for 9.4% of the bacteraemias [ 1 x 1 Wisplinghoff, H, Bischoff, T, Tallent, SM, Seifert, H, Wenzel, RP, Edmond, MB et al. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004; 39: 309–317 Crossref | PubMed | Scopus (2570) | Google Scholar See all References 1 ]. Consistent with this, an Italian multicentre study reported enterococci in 11.4% of all bacteraemias during a 1-year survey [ 2 x 2 Luzzaro, F, Ortisi, G, Larosa, M, Drago, M, Brigante, G, Gesu, G et al. Prevalence and epidemiology of microbial pathogens causing bloodstream infections: results of the OASIS multicenter study. Diagn Microbiol Infect Dis. 2011; 69: 363–369 Abstract | Full Text | Full Text PDF | PubMed | Scopus (41) | Google Scholar See all References 2 ]. Similarly, Danish surveillance data demonstrated rising incidences of E. faecalis and E. faecium bacteraemia, with increases from 2002 to 2009 of 51% and 201%, respectively [ 3 x 3 DANMAP 2009-Use of antimicrobial agents and occurrence af antimicrobial resistance in bacteria from food animals, foods and humans in Denmark. Available at: www.danmap.org; 2010. Google Scholar See all References , 4 x 4 Lester, CH, Sandvang, D, Olsen, SS et al. Emergence of ampicillin-resistant Enterococcus faecium in Danish hospitals. J Antimicrob Chemother. 2008; 62: 1203–1206 Crossref | PubMed | Scopus (45) | Google Scholar See all References ]. Enterococci are generically resistant to all cephalosporins and clinical use of carbapenems and fluoroquinolones is not recommended as first-line treatment. In addition, acquired resistance to penicillins, aminoglycosides and glycopeptides has increased (www.ecdc.europa.eu/en/activities/surveillance/EARS-Net). The 30-day mortality of enterococcal bacteraemia is above 25% for vancomycin-susceptible strains [ 5 x 5 Bhavnani, SM et al. A nationwide, multicenter, case-control study comparing risk factors, treatment, and outcome for vancomycin-resistant and -susceptible enterococcal bacteremia. Diagn Microbiol Infect Dis. 2000; 36: 45–58 Abstract | Full Text | Full Text PDF | Scopus (138) | Google Scholar See all References , 6 x 6 McBride, SJ, Upton, A, Roberts, SA et al. Clinical characteristics and outcomes of patients with vancomycin-susceptible Enterococcus faecalis and Enterococcus faecium bacteraemia – a five-year retrospective review. Eur J Clin Microbiol Infect Dis. 2010; 29: 107–114 Crossref | PubMed | Scopus (34) | Google Scholar See all References , 7 x 7 Suppli, M, Aabenhus, R, Harboe, ZB, Andersen, LP, Tvede, M, Jensen, JU et al. Mortality in enterococcal bloodstream infections increases with inappropriate antimicrobial therapy. Clin Microbiol Infect. 2011; 17: 1078–1083 Abstract | Full Text | Full Text PDF | PubMed | Scopus (31) | Google Scholar See all References ] and above 45% for resistant strains [ 5 x 5 Bhavnani, SM et al. A nationwide, multicenter, case-control study comparing risk factors, treatment, and outcome for vancomycin-resistant and -susceptible enterococcal bacteremia. Diagn Microbiol Infect Dis. 2000; 36: 45–58 Abstract | Full Text | Full Text PDF | Scopus (138) | Google Scholar See all References , 8 x 8 Han, SH, Chin, BS, Lee, HS et al. Vancomycin-resistant enterococci bacteremia: risk factors for mortality and influence of antimicrobial therapy on clinical outcome. J Infect. 2009; 58: 182–190 Abstract | Full Text | Full Text PDF | PubMed | Scopus (27) | Google Scholar See all References ].

Infectious endocarditis remains both a diagnostic and a treatment challenge. A positive outcome depends on a rapid diagnosis, accurate risk stratification, and a thorough follow-up. Imaging plays a key role in each of these steps and echocardiography remains the cornerstone of the methods in use. The technique of both transthoracic echocardiography and transoesophageal echocardiography has been markedly improved across the last decades and most recently three-dimensional real-time echocardiography has been introduced in the management of endocarditis patients. Echocardiography depicts structural changes and abnormalities in the heart, but it does not uncover the underlying pathophysiological processes at the cellular or molecular level. This problem is addressed with introduction of new molecular imaging methods as ¹⁸F-fluorodesoxyglucose (¹⁸F-FDG) PET-CT and single photon emission computed tomography fused with conventional CT (SPECT/CT). Of these methods, ¹⁸F-FDG PET-CT carries the best promise for a future role in endocarditis. But there are distinct limitations with both SPECT/CT and ¹⁸F-FDG PET-CT which should not be neglected. MRI and spiral CT are methods primarily used in the search for extra cardial infectious foci. A flowchart for the use of imaging in both left-sided and right-sided endocarditis is suggested.

Background: The DANISH study (Danish Study to Assess the Efficacy of ICDs [Implantable Cardioverter Defibrillators] in Patients With Non-Ischemic Systolic Heart Failure on Mortality) did not demonstrate an overall effect on all-cause mortality with ICD implantation. However, the prespecified subgroup analysis suggested a possible age-dependent association between ICD implantation and mortality with survival benefit seen only in the youngest patients. The nature of this relationship between age and outcome of a primary prevention ICD in patients with nonischemic systolic heart failure warrants further investigation. Methods: All 1116 patients from the DANISH study were included in this prespecified subgroup analysis. We assessed the relationship between ICD implantation and mortality by age, and an optimal age cutoff was estimated nonparametrically with selection impact curves. Modes of death were divided into sudden cardiac death and nonsudden death and compared between patients younger and older than this age cutoff with the use of χ ² analysis. Results: Median age of the study population was 63 years (range, 21–84 years). There was a linearly decreasing relationship between ICD and mortality with age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.003–1.06; P =0.03). An optimal age cutoff for ICD implantation was present at ≤70 years. There was an association between reduced all-cause mortality and ICD in patients ≤70 years of age (HR, 0.70; 95% CI, 0.51–0.96; P =0.03) but not in patients >70 years of age (HR, 1.05; 95% CI, 0.68–1.62; P =0.84). For patients ≤70 years old, the sudden cardiac death rate was 1.8 (95% CI, 1.3–2.5) and nonsudden death rate was 2.7 (95% CI, 2.1–3.5) events per 100 patient-years, whereas for patients >70 years old, the sudden cardiac death rate was 1.6 (95% CI, 0.8–3.2) and nonsudden death rate was 5.4 (95% CI, 3.7–7.8) events per 100 patient-years. This difference in modes of death between the 2 age groups was statistically significant ( P =0.01). Conclusions: In patients with systolic heart failure not caused by ischemic heart disease, the association between the ICD and survival decreased linearly with increasing age. In this study population, an age cutoff for ICD implantation at ≤70 years yielded the highest survival for the population as a whole. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00542945.