Infective Endocarditis in Children: The Changing Profile

This article discusses the principles for diagnosis and treatment of infective endocarditis in children. There has generally been a consistent volume of streptococcus endocarditis, the major lesion in pediatric endocarditis, but there has been an increase in Staphylococcus aureus endocarditis as well as neonatal endocarditis. Neonatal endocarditis is a severe form of the disease.     

Surgical management of infective endocarditis

We reviewed fourty-six patients who had undergone surgery for infective endocarditis in the past fifteen years and identified risk factors affecting the outcome. Twenty-nine patients had infection of the native valve only, 11 had infective endocarditis associated with congenital heart disease, and 6 had prosthetic valve endocarditis. Overall hospital mortality was 6.5%. Prosthetic valve endocarditis carried a higher mortality (33%) than native valve endocarditis (3.4% or congenital heart disease with infective endocarditis (0%). For the patients with active endocarditis, the early mortality rate was higher (13%) than with inactive endocarditis (3.2%). Staphylococcal infections were more likely to cause severe valve destruction and residual infection than streptococcal infection. Our results indicated that surgical management of infective endocarditis should be done after the completion of adequate antibiotic therapy. Early diagnosis should reduce the mortality, prevent fatal complications, and lead to qualitative improvement of infective endocarditis.     

Performance of the fontan procedure using extra-cardiac direct anastomosis on patients treated for penicillin-resistant Streptococcus pneumoniae endocarditis

Streptococcus pneumoniae is now a rare cause of endocarditis in humans. We report a patient with a double outlet right ventricle and mitral atresia, who underwent the Fontan procedure without prosthetic materials after treatment for penicillin-resistant Streptococcus pneumoniae endocarditis. Postoperative infectious endocarditis was not found. In patients with a history of infectious endocarditis, direct anastomosis of the main pulmonary artery and inferior vena cava would reduce the risk of recurrent infectious endocarditis.     

Performance of the fontan procedure using extra-cardiac direct anastomosis on patients treated for penicillin-resistant <Emphasis Type="Italic">Streptococcus pneumoniae</Emphasis> endocarditis

Streptococcus pneumoniae is now a rare cause of endocarditis in humans. We report a patient with a double outlet right ventricle and mitral atresia, who underwent the Fontan procedure without prosthetic materials after treatment for penicillin-resistant Streptococcus pneumoniae endocarditis. Postoperative infectious endocarditis was not found. In patients with a history of infectious endocarditis, direct anastomosis of the main pulmonary artery and inferior vena cava would reduce the risk of recurrent infectious endocarditis.     

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.     

Prosthetic valve endocarditis. Analysis of factors affecting outcome of therapy

We analyzed the outcome of 116 patients with prosthetic valve endocarditis treated between 1975 and 1983 and used multivariate analysis to identify risk factors for in-hospital mortality and bad outcome during follow-up. Complicated prosthetic valve endocarditis was defined as the presence of a new or changing heart murmur, new or worsening heart failure, new or progressive cardiac conduction abnormalities, or prolonged fever during therapy. Complicated prosthetic valve endocarditis was present in 64% of patients; factors associated with complicated prosthetic valve endocarditis included aortic valve infection (odds ratio 4.3, p = 0.002) and onset of endocarditis within 12 months of the cardiac operation (odds ratio 5.5, p = 0.0001). The in-hospital mortality rate for prosthetic valve endocarditis was 23%; patients with complicated prosthetic valve endocarditis had a higher mortality than patients with uncomplicated infection (odds ratio 6.4, p = 0.0009). Combined medical-surgical therapy was used in 39% of patients; surgical therapy was more common in patients with complicated prosthetic valve endocarditis (odds ratio 16, p less than 0.0001) and in patients infected with coagulase-negative staphylococci (odds ratio 3.9, p = 0.003). Survival after initially successful therapy for prosthetic valve endocarditis was adversely affected by the presence of moderate or severe congestive heart failure at hospital discharge (p = 0.03). Bad outcome during follow-up (death, relapse of prosthetic valve endocarditis, or subsequent cardiac operation related to sequelae of the original infection) was more common in the medical than the medical-surgical therapy group (p = 0.02). The difference in long-term outcome between patients treated initially with medical or with medical-surgical therapy was particularly evident in those with complicated prosthetic valve endocarditis (p = 0.008). The presence of complicated prosthetic valve endocarditis is a central variable in assessing prognosis and planning therapy; the majority of patients with complicated prosthetic valve endocarditis are best treated with medical-surgical therapy. Those who are not treated surgically during their initial hospitalization are at high risk for progressive prosthesis dysfunction and require careful follow-up.     

Is There an Advantage to Repairing Infected Mitral Valves?

Background. The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment.

Methods. Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis.

Results. There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance.

Conclusions. We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.     

Successful management of iliac mycotic aneurysm secondary to Klebsiella endocarditis--report of a case

A case of common iliac mycotic aneurysm that presumably developed secondary to Klebsiella endocarditis was described. Recently, reports on gram negative septicemia and endocarditis have been on the increase. However, mycotic aneurysms secondary to bacterial endocarditis and particularly to Klebsiella endocarditis are rare. Inadequately treated serious gram negative septicemias have a high mortality rate. Early diagnosis and adequate combination chemotherapy with prompt surgical intervention were proven to be important factors in the successful management of such a complication.     

Septic peripheral embolization from bacterial and fungal endocarditis

Arterial embolization is second only to cardiac failure as a potentially lethal complication of acute infectious endocarditis. Embolization may be encountered with increasing frequency due to the prolongation of life afforded by antibiotics and cardiac valve replacement surgery. While distal organs are more often affected, peripheral embolization of the lower extremities is by no means rare. Over a two-year period, we have treated six patients with acute infectious endocarditis who developed lower extremity ischemia. Four patients had Gram positive bacterial endocarditis while two immunosuppressed patients developed fungal endocarditis. Treatment of all six patients included lower extremity embolectomy or bypass grafting and long-term intravenous antimicrobial or antifungal therapy. Cardiac valve replacement was required in all six patients. All lower extremities were successfully reperfused, and no patient required amputation. Although the four patients with bacterial endocarditis survived, the two patients with fungal endocarditis eventually died. In conclusion, aggressive use of arteriography, embolectomy, antimicrobial drugs, and cardiac valve replacement appear to offer the best chance for survival and limb salvage for arterial embolism related to endocarditis.     

Successful management of iliac mycotic aneurysm secondary to klebsiella endocarditis —Report of a case

A case of common iliac mycotic aneurysm that presumably developed secondary to Klebsiella endocarditis was described. Recently, reports on gram negative septicemia and endocarditis have been on the increase. However, mycotic aneurysms secondary to bacterial endocarditis and particularly to Klebsiella endocarditis are rare. Inadequately treated serious gram negative septicemias have a high mortality rate. Early diagnosis and adequate combination chemotherapy with prompt surgical intervention were proven to be important factors in the successful management of such a complication.     

Spondylodiscitis and infective endocarditis: case studies and review of the literature

STUDY DESIGN: This study evaluated the association between infective endocarditis and infective spondylodiscitis and its clinical features. OBJECTIVES: To report case studies of patients with spondylodiscitis complicating infective endocarditis. SUMMARY OF BACKGROUND DATA: Early diagnosis of infective endocarditis as the source of the spondylodiscitis is often difficult because clinical and radiologic patterns are similar to those present in spondylodiscitis alone. METHODS: The case records of the patients with infective endocarditis admitted to our Department from 1991-1998 were reviewed. The diagnosis of spondylodiscitis was made on the basis of clinical features and of typical radiologic signs. RESULTS: Among 30 patients affected by infective endocarditis, three also were affected by spondylodiscitis. All patients fully recovered after appropriate antibiotic therapy. CONCLUSIONS: In all patients with spondylodiscitis, infective endocarditis should be excluded, particularly in patients with a history of heart valve disease.     

Bartonella haenselae infective endocarditis following transcatheter edge‐to‐edge mitral valve repair: A case report

Infective endocarditis following a Mitraclip procedure might be an under‐recognized complication. We describe the case of infective endocarditis by Bartonella henselae as a late complication in a patient with a previously implanted MitraClip system for mitral valve repair. Due to the severity of infection, surgical treatment was performed despite the high preoperative surgical risk, but recurrence of endocarditis of the biological valve implanted occurred. Although infection with Bartonella is known as a possible source of endocarditis, it has never been described before in relation to failed MitraClip therapy.     

Endocarditis after transcatheter aortic valve replacement; a new nightmare in cardiac surgery

Treatment of prosthetic valve endocarditis after transcatheter aortic valve replacement (TAVR) remains challenging. An increase in TAVR endocarditis is inevitable, especially with the extension of indications and implantation in low‐risk patients. We present a case of complex surgical treatment of prosthetic valve endocarditis after TAVR.     

Comparison of bioprosthetic and mechanical valve replacement for active endocarditis

The choice between bioprosthetic or mechanical prosthetic valve replacement for active valvular endocarditis has been controversial. To establish the role of each, we reviewed the case histories of 185 patients who underwent valve replacement for active valvular endocarditis during the past 5 years. All patients had life-threatening, active bacterial endocarditis of a native or prosthetic valve. Group I (88 patients) had replacement with the Ionescu-Shiley pericardial valve and Group II (97 patients) with the St. Jude Medical valve. The male/female distribution, age range, and functional classification were the same in the two groups. Mean follow-up was approximately 20 months for both groups. Valve replacement was done because of native valve endocarditis in 76 patients in Group I and 49 patients in Group II. Of the remainder of the Group I patients, six had endocarditis of a bioprosthesis and six of a mechanical valve; of the remainder of Group II patients, 30 had endocarditis of a bioprosthesis and 18 of a mechanical valve. Early mortality was not significantly different between the two groups (14 deaths in each group). Of the 74 survivors in Group I, 15 underwent valve reoperation, 10 because of recurrent endocarditis and five because of sterile perivalvular leakage. The frequency of reoperation was significantly different (p less than 0.01) from that in Group II, in which only five patients underwent valve reoperation, four for recurrent endocarditis and one for sterile perivalvular leakage. The actuarial rate for freedom from reoperation was also significantly higher in Group II patients; 94.6% were free from reoperation at 4 years compared to 75% at 4 years in Group I patients (p less than 0.01). The actuarial survival rate, which also differed significantly between groups, was 78.7% at 4 years in Group I and 87.4% at 4 years in Group II (p less than 0.05). Patients receiving a bioprosthesis for active endocarditis had a significantly higher reoperation rate and a significantly greater incidence of recurrent endocarditis (p less than 0.01). Therefore, we prefer to use a mechanical valve for valve replacement in most patients who have active endocarditis.     

Surgical intervention of infective endocarditis]

33 patients with infective endocarditis were treated from 1980 to 1989. 31 of them were operated on for primary endocarditis complicated by congenital heart disease (5 patients) and valvular heart disease (26 patients). Two patients (6.5%) died postoperatively and 2 patients with primary endocarditis complicated by aortic insufficiency died without operation. In 10 patients with endocarditis secondary to open-heart surgery, 6 were reoperated upon but 5 of them died; in the remaining 4 who were not reoperated on died. We consider that surgical intervention for endocarditis, either primary or postoperative, should be taken as early as possible after a short period of ineffectiveness of antibiotic therapy.     

Early and late outcomes after reoperation for prosthetic valve endocarditis

OBJECTIVE: Prosthetic valve endocarditis remains a challenging complication after heart valve replacement. To identify predictive risk factors, we have reviewed 30 patients who underwent surgery for prosthetic valve endocarditis between March 1986 and May 1999. METHODS: There were 15 men and 15 women (mean age 51 years). Prosthetic valve endocarditis was classified as early (< or = 1 year after operation) in 10 cases, and as late in the other 20 cases. The most common indication for surgery was moderate to severe congestive heart failure due to prosthetic valve dysfunction in 21 (70%) patients. The average follow-up period was 6.5 years, with a range of 0.3 to 14.1 years. RESULTS: The most common microorganism was Staphylococcus epidermidis in both patients with early (50%) and late prosthetic valve endocarditis (25%). The in-hospital mortality was 13.3% (4/30). There were six late deaths. The actuarial survival at 5 years was 78% and 66% at 10 years. An early onset of prosthetic valve endocarditis was the only significant determinant of both in-hospital mortality (p = 0.005) and overall mortality (p = 0.021). Emergency surgery had a statistically significant relationship with in-hospital mortality (p = 0.045). No significant influence on mortality after reoperation for prosthetic valve endocarditis was found in age, sex, valve position, antecedent native valve endocarditis, or in the type of pathological findings (ring abscess, valve dehiscence, and vegetation). CONCLUSION: Early onset of prosthetic valve endocarditis and emergency surgery were important risk factors for mortality due to prosthetic valve endocarditis.     

Stentless Porcine Bioprostheses in the Treatment of Aortic Valve Infective Endocarditis

Between January 1992 and June 1994, 23 patients underwent surgery for aortic valve endocarditis at the Department of Cardiovascular Surgery of the University of Verona; a subgroup of 10 patients underwent aortic valve replacement with a porcine stentless valve (Biocor LTDA n = 8; Toronto SPV n = 2). There were 7 males and 3 females with a mean age of 56.3 years (range, 36 to 73 years). Eight patients had active endocarditis and two had healed endocarditis. Nine patients had native valve in endocarditis, the presence of a bicuspid aortic valve in 2, and 1 patient had recurrent prosthetic valve endocarditis (PVE), 7 of whom were in New York Heart Association (NYHA) Functional Class IV. The main indications for operation were congestive cardiac failure, active sepsis, and presence of large and mobile vegetations by echo and arrhythmias. There were no operative or late mortalities in this subgroup of patients. Short-term survival is 100% at a mean follow-up time of 11.2 months (range, 4 to 18 months), with no recurrent endocarditis or valve-related complications.     

Pulmonary valve neocuspidization and tricuspid valve replacement in intravenous drug abusers with infective endocarditis: Report of two cases

Right-sided infective endocarditis accounts for 5–10% of endocarditis cases. It occurs predominantly among intravenous drug abusers. The pulmonary valve is involved in fewer than 2% of patients with endocarditis. Literature data are limited and optimal medical strategy, including surgical technique, remains non-standardized in this clinical situation. We present 2 patients treated surgically for tricuspid and pulmonary valve endocarditis and discuss a method of pulmonary valve neocuspidization based on the Ozaki technique.     

Deep sternal wire infection resulting in severe pulmonary valve endocarditis

Right-sided infective endocarditis is uncommon, comprising less than 5% of all cases of endocarditis. This is primarily seen in patients with drug abuse, long-term intravenous catheters, and congenital malformations, or a combination of these. Isolated pulmonary valve endocarditis is difficult to recognize due to its rarity, minimal cardiac manifestations, and predominance of pulmonary infections secondary to embolization of the vegetations. We describe an unusual case of chronic sternal wound infection and migration of an infected braided sternal wire causing right ventricular outflow tract and pulmonary valve endocarditis, which necessitated a complicated reoperation including pulmonary valve replacement with a homograft.     

Can leg pain be the sole presenting symptom of infective endocarditis? A case report

Infective endocarditis is a serious septic disease that can be life threatening unless effective therapy is instituted following the correct diagnosis. The complication of septic embolism and mycotic aneurysm in patients with infective endocarditis may increase morbidity and mortality. We present a case of peroneal artery aneurysm with coincident double native heart valve endocarditis in a patient.