Infective endocarditis in patients with chronic liver disease: clinical and prognostic assessment

INTRODUCTION AND OBJECTIVES: Chronic liver disease increases the susceptibility to bacterial infections and infective endocarditis. Our aim was to determine the clinical and microbiological features and the prognosis in patients with chronic liver disease who also had infective endocarditis. PATIENTS AND METHOD: One hundred and seventy-four consecutive inpatients at our institution were recruited and followed. Thirty of them had chronic liver disease. Clinical, microbiological and echocardiographic variables were analyzed and, in some cases, histological variables were also recorded. RESULTS: Patients with chronic liver disease were younger (36 11 vs 54 18 years; p < 0.01) and had a larger proportion of intravenous drug users (73 vs 16%; p < 0.01), HIV infection (47 vs 10%; p < 0.01), right valve involvement and spleen enlargement, but heart failure appeared less often (7 vs 34%; p = 0.003). Thirty percent of the patients with and 51% of patients without chronic liver disease underwent surgery for infective endocarditis. Total mortality among patients with and without chronic liver disease was 40% and 31%, respectively. After adjustment for age and for the incidence of congestive heart failure, chronic liver disease doubled mid-term mortality with a RR = 2.45 (p = 0.015). CONCLUSIONS: Chronic liver disease has a significant impact on the prognosis in patients with infective endocarditis, and these patients should therefore be considered a high risk group.     

Multiple-valve infective endocarditis: clinical, microbiologic, echocardiographic, and prognostic profile

Whether infection in more than 1 valve worsens the prognosis for endocarditis remains untested. We conducted the current study to determine the profile of multiple-valve endocarditis, compare multiple-valve endocarditis with single-valve endocarditis, and determine predictors of outcome. We conducted a prospective and observational study including 680 episodes of infective endocarditis consecutively diagnosed at 3 tertiary centers. Multiple valve involvement was present in 115 episodes (17%), and single valve involvement in 530 (78%). In the remaining 35 cases, valvular involvement could not be documented. Mean age of patients with multiple valve endocarditis was 58 years. Clinical complications were frequent (heart failure 65%, renal failure 44%, systemic embolisms 24%). The microorganism most frequently isolated was Staphylococcus aureus (22%).Factors predictive of in-hospital mortality in the univariate analysis were septic shock, prosthetic endocarditis, heart failure, and persistent infection. In the multivariate analysis, we detected heart failure (odds ratios [OR], 4.7; 95% confidence interval [CI], 1.6-13.8) and persistent infection (OR, 4.3; 95% CI, 1.7-10.8) as predictors of in-hospital mortality. Compared to single-valve endocarditis, multiple-valve disease was associated more frequently with heart failure (65% vs. 50%, p = 0.03), perivalvular complications (41% vs. 21%, p < 0.001), and heart surgery (70% vs. 54%, p = 0.002). Despite these differences, in-hospital mortality was similar (28% vs. 30%, p = 0.647). In conclusion, multiple-valve endocarditis has a poor clinical course. Mortality is similar to that of single-valve endocarditis, probably in relation with aggressive therapy including surgery in many patients. Heart failure and persistent infection are independent predictors of death.     

Influence of diabetes mellitus on the clinical manifestations and prognosis of infective endocarditis: a report from the International Collaboration on Endocarditis-Merged Database

The purpose of this investigation was to study the influence of diabetes mellitus (DM) on outcomes of infective endocarditis (IE). Outcomes were compared between 150 diabetic and 905 non-diabetic patients with IE from the International Collaboration on Endocarditis Merged Database. Compared to non-diabetic patients, diabetic patients were older (median age 63 vs 57 y, p<0.001), were more often female (42.0% vs 31.9%, p=0.01), more often had comorbidities (41.5% vs 26.7%, p<0.001), and were more likely to be dialysis dependent (12.7% vs 4.0%, p<0.001). S. aureus was isolated more often (30.7% vs 21.7%, p=0.02), and microorganisms from the viridans Streptococcus group less often (16.7% vs 28.2%, p = 0.001) in the diabetic group. There was no difference with respect to the presence of congestive heart failure, embolism, intra-cardiac abscess, new valvular regurgitation, or valvular vegetation. Diabetic patients underwent surgical intervention less frequently (32.0% vs 44.9%, p = 0.003), and had higher overall in-hospital mortality (30.3% vs 18.6%, p = 0.001). On multivariable analysis, DM was an independent predictor of mortality (odds ratio (OR) = 1.71, 95% confidence interval (CI) 1.08-2.70), especially in male patients, as diabetic males had higher mortality than non-diabetic males (OR 2.18, CI 1.08-4.35). DM is an independent predictor of in-hospital mortality among patients hospitalized with IE.     

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990s

Prosthetic valve endocarditis is considered to be associatedwith a more severe prognosis than native valve endocarditis.Among other factors, inappropriate visualization of vegetationsin prosthetic valve endocarditis by transthoracic echocardiographyis responsible for this observation. Since the introductionof transoesophageal echocardiography into clinical practicethe diagnostic sensitivity and specificity of the detectionof vegetations located on prosthetic valves have been enhanced.Therefore we aimed to determine and compare the prognosis ofprosthetic valve endocarditis and native valve endocarditisin the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104patients were seen at our institution between 1989 and 1993.Eighty patients (77%) had native valve endocarditis and 24 (23%)had late prosthetic valve endocarditis. In the latter grouptwo patients had recurrent infective endocarditis. Patientswith prosthetic valve endocarditis were older (mean age 64 vs54 years in native valve endocarditis; P<0.00l) and the majoritywas female (62% vs 38% in native valve endocarditis; P<0.001In prosthetic valve endocarditis, infection of a valve in themitral position predominated (65% vs 30% in native valve endocarditis;P<0.0l), whereas in native valve endocarditis more than halfthe cases had isolated aortic valve endocarditis (51% vs 27%in prosthetic valve endocarditis; P<0.01). In prostheticvalve endocarditis more cases were caused by Staphylococcusaureus (31% vs 14% in native valve endocarditis; P<0.08),whereas in native valve endocarditis the most frequent organismswere streptococci (29% vs l9% in prosthetic valve endocarditis;P<0.12). Differences in the clinical features of native valveendocarditis and prosthetic valve endocarditis could not befound except for a higher rate of embolism in native valve endocarditis(40% vs l9% in prosthetic valve endocarditis; P<0.05). Vegetationscould be detected by transthoracic echocardiography more frequentlyin native valve endocarditis (71% vs 15% in prosthetic valveendocarditis; P<0.0001). Transoesophageal echocardiographyvisualized vegetations in 95% of the episodes of native valveendocarditis and in 80% of the episodes of prosthetic valveendocarditis (P<0.09). Thus, the diagnostic gain by transoesophagealechocardiography was greatest in prosthetic valve endocarditis.Patients with native valve endocarditis had significantly largervegetations than patients with prosthetic valve endocarditis(P<0.05 for length, P<0.00l for width). The median timeto diagnosis was similar in native valve endocarditis and prostheticvalve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditisand in 58% of those with prosthetic valve endocarditis; themedian time delay between the diagnosis of infective endocarditisand surgery tended to be shorter in prosthetic valve endocarditisthan in native valve endocarditis (45 vs 60 days). The in-hospitalmortality and the mortality during a follow-up of 22±10 months did not significantly differ between native valveendocarditis and prosthetic valve endocarditis (21% vs 17% 28%vs 25%). In summary in the era of transoesophageal echocardiography,late prosthetic valve endocarditis does not seem to carry aworse prognosis than native valve endocarditis. This can beattributed in part to the improved diagnostic accuracy achievedby transoesophageal echocardiography leading to comparable diagnosticlatency periods in both patient groups. Finally, better characterizationof vegetations on prosthetic valves by transoesophageal echocardiographyallows early lifesaving surgery in patients with prostheticvalve endocarditis.     

心脏瓣膜术后感染性心内膜炎再次手术后临床预后的分析

目的:分析心脏瓣膜置换或成形术后感染性心内膜炎再次进行外科手术后的近期及远期预后情况。方法:分析了2007年01月至2017年12月,在安贞医院就诊的心脏瓣膜术后感染性心内膜炎患者,以单纯感染性心内膜手术患者为对照组,并根据年龄、性别按1∶1的比例配对,每组67例。结果:与单纯感染性心内膜炎的患者相比,瓣膜术后感染性心内膜炎患者术前LVEF和心功能分级均明显较低[(61.2±7.5)%vs.(56.9±10.1)%,P=0.003;(2.9±0.9)vs.(2.4±0.7), P=0.006],其它基线资料无明显差异。瓣膜术后感染性心内膜炎患者再次手术后住院时间[12.0(19.5,20.5)vs. 7.5 (6.0,10.8)d,P=0.03]、体外循环时间[145.0 (118.5,203.0)vs.100.0 (81.0,132.0)min,P<0.001]均明显延长。经过平均(87.9±42.5)个月的随访,心脏瓣膜术后感染性心内膜炎患者总体不良心血管事件(26.9%vs.11.9%,P=0.03)发生率和远期死亡率(19.4%vs.7.5%,P=0.04)均明显增加,但术后30 d内病死率、再次手术率以及心律失常等不良事件的发生,两组并没有明显区别。Kaplan-Meier生存分析结果显示,心脏瓣膜术后感染性心内膜炎再手术后10年预期生存率约为59.4%,而单纯感染性心内膜炎进行手术后的10年生存率约为86.4%。结论:与单纯感染性心内膜炎患者相比,两组患者早期死亡率没有区别,但心脏瓣膜术后感染性心内膜炎患者远期死亡率明显较高。     

Relation between the presence of echocardiographic vegetations and the complication rate in infective endocarditis

M-mode and two-dimensional echocardiograms of 77 patients with infective endocarditis were examined to determine if presence and/or size of vegetations on echocardiogram were predictive of morbidity and mortality. Patients with (n = 43) or without (n = 34) vegetations on echocardiogram did not differ significantly in the proportions developing congestive heart failure (23 of 43 or 53% vs 12 of 34 or 35%) or emboli (11 of 43 or 24% vs 6 of 34 or 18%), whereas a slightly lower proportion of those with vegetations required surgery (5 of 43 or 12% vs 7 of 34 or 21%) or died (3 of 43 or 7% vs 4 of 34 or 12%). No significant relationship was found between vegetation size and the frequency of complications, the need for surgery, or death. In contrast, patients whose echocardiograms demonstrated premature mitral valve closure or chordal or cusp rupture had a significantly higher incidence of heart failure (10 of 13 or 77% vs 22 of 60 or 37%, p less than 0.003) and surgery (3 of 13 or 23% vs 7 of 60 or 12%, p less than 0.05). We conclude that: the presence of vegetation on the initial echocardiogram is not predictive of the clinical course in infective endocarditis; vegetation size does not predict complications, need for surgery, or death; but valve cusp or chordal rupture and/or premature mitral valve closure are associated with congestive heart failure and the need for surgery.     

Surgical treatment of infective mitral valve endocarditis: predictors of early and late outcome

BACKGROUND AND AIMS OF THE STUDY: The study aim was to review our experience in surgical treatment of infective mitral valve endocarditis, and to identify predictors of early and late outcome. METHODS: Ninety-one consecutive patients (52 males, 39 females, mean age 55.6 years) underwent surgery between 1973 and 1997 for endocarditis of isolated mitral (n = 65, 71%), mitral and aortic (n = 25, 28%) and mitral, aortic and tricuspid valves (n = 1, 1%). Native valve endocarditis (NVE) was present in 60 patients (66%) and prosthetic valve endocarditis (PVE) in 31 (34%). The main indications for surgery were heart failure in 32 patients, valve dysfunction in 23, vegetations in 21, and persistent sepsis in 11. Eighty-six patients (95%) were in NYHA classes III-IV, and 58 (64%) had active culture-positive endocarditis at surgery. Mechanical valves were implanted in 73 patients and bioprosthetic valves in 13; valves were repaired in five patients. The impact of 46 parameters on early and late outcome was defined by means of univariate and multivariate statistical analysis. Follow up was complete (mean 5.5 years; range: 0-23.1 years; total 507.3 patient-years). RESULTS: Operative mortality rate was 11% (n = 10). Recurrent infection was recorded in five patients (6%), and reoperation was required in eight (9%). Freedom from recurrent infection and reoperation at 10 years was 89.1% and 87.8% respectively. There were 22 late deaths, 15 from cardiac causes. Actuarial survival rates for all patients at 5, 10 and 15 years were 73.0%, 62.7% and 58.7% (for hospital survivors, the corresponding rates were 81.9%, 69.7% and 66.0%). On multiple logistic regression and Cox proportional hazards models, the following were independent predictors: preoperative pulmonary edema (p = 0.01) for operative mortality; PVE (p = 0.02) for recurrence; younger age (p = 0.02) and PVE (p = 0.02) for reoperation; male gender (p = 0.004) and longer ITU stay for survival (if all patients were included); male gender (p = 0.01) and myocardial invasion by infection (p = 0.02) for survival (if only the hospital survivors were analyzed). CONCLUSION: Surgery for infective mitral valve endocarditis carries a relatively high, though acceptable, risk but provides satisfactory freedom from recurrent infection, reoperation and improved long-term survival. Analysis of these data demonstrated that the preoperative hemodynamic status was the major predictor of in-hospital outcome, PVE increased the risk for recurrent infection and reoperation, whereas male gender and myocardial invasion by the infective process critically reduced the probability of long-term survival. The type of offending pathogen, the activity of infection and the involvement of more than one valve did not appear to influence early and/or late outcome.     

Value of echocardiographic findings in predicting cardiovascular complications in infective endocarditis.

Echocardiography allows the detection of vegetations and estimation of valvular dysfunction in patients with infective endocarditis. The value of echocardiographic findings in predicting cardiac and other vascular complications in infective endocarditis is not well understood. Identification of high-risk patients and early surgery may improve their prognosis. The authors reviewed echocardiographic findings and related them to the development of congestive heart failure, systemic embolism, and the need for surgery or the risk of death without surgery in patients with infective endocarditis. There were 125 episodes of endocarditis in 114 patients (84 episodes [67%] in men) with a mean age +/- standard deviation of 37 +/- 7 years. Vegetations were detected by echocardiography on at least 1 valve in 87 episodes (70%); on the mitral valve in 36 episodes (29%); on the aortic valve in 21 episodes (17%); and on the tricuspid valve in 45 episodes (36%). Severe aortic regurgitation was present in 9 episodes (7%) and severe mitral regurgitation in 4 instances (3%). In 12 of 21 episodes (57%) of vegetations on the aortic valve compared with 15 of 104 patients (14%) without vegetations on the aortic valve (p < 0.001), and in 8 of 9 instances (89%) of severe aortic regurgitation compared with 19 of 116 episodes (16%) without severe aortic regurgitation (p<0.00001), the patients developed congestive heart failure. In 18 of 55 episodes (33%) of vegetations on the aortic/mitral valve compared with 17 of 70 episodes (25%) without vegetations on the aortic valve/mitral valve (p = NS), the patients developed systemic embolism. In 13 of 21 episodes (62%) of vegetations on the aortic valve compared with 19 of 104 episodes (19%) without vegetations on the aortic valve (p < 0.001), and in 8 of 9 episodes (89%) of severe aortic regurgitation compared with 24 of 116 episodes (21%) without severe aortic regurgitation (p < 0.00001), the patients either had surgery or died without surgery. Echocardiographic findings do not reliably predict the risk of systemic embolism in patients with infective endocarditis. Vegetations on the aortic valve and severe aortic regurgitation detected by echocardiography predict a high risk of developing congestive heart failure, and for the combined outcome of requiring surgery, or dying without surgery in infective endocarditis. Early surgery may improve the outlook for survival of these patients.     

Analysis of surgical versus medical therapy in active complicated native valve infective endocarditis

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p < 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p < 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p < 0.005) and long-term (p < 0.005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation.

Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.     

Prognostic Implications of Diabetes in Patients With Left-Sided Endocarditis: Findings From a Large Cohort Study

Patients with diabetes mellitus (DM) have a higher incidence of infections, and those with bacteremia are more prone to develop sepsis and infective endocarditis (IE). Nevertheless, data concerning the impact of DM on the prognosis of patients with IE are limited and sometimes contradictory. We examined the impact of DM on the inhospital outcome of left-sided IE in a large cohort of patients. We studied 594 consecutive episodes of left-sided IE diagnosed at 3 tertiary care centers. They were divided into 2 groups: episodes in patients with DM (n = 114) and episodes in patients without DM (n = 480). We retrospectively analyzed the influence of DM therapy on patient outcome. Compared to patients without DM, patients with DM were older (67 ± 10 vs. 60 ± 15 yr; p < 0.001), less frequently male (53.5% vs. 67.9%; p = 0.004), and more commonly had chronic renal failure (23.9% vs. 6.9%; p < 0.001) and chronic obstructive pulmonary disease (14.6% vs. 7.8%; p = 0.019). Enterococcus (14.9% vs. 7.4%; p = 0.011) and Streptococcus bovis (8.8% vs. 3.8%; p = 0.024) were isolated more frequently. In the univariable analysis, septic shock (29.2% vs. 16.4%; p = 0.005) and mortality (43.5% vs. 30.0%; p = 0.008) were more common among patients with DM than in those without. Considering the different treatments for DM, septic shock (33.3%; p = 0.011) and death (50.8%; p = 0.012) were more frequent in patients receiving oral medication to treat diabetes than in patients with the other treatment modalities. However, multivariable analysis showed that DM had an independent association with development of septic shock (OR 2.282; 95% CI 1.186–4.393), but it was not a predictor of inhospital mortality.Staphylococci were the most frequently involved microorganisms in all patients; however, Enterococcus and Streptococcus bovis were more frequently isolated from individuals with DM and left-sided IE, whereas viridans group streptococci were more commonly isolated from those with left-sided IE who did not have DM. DM was independently associated with the development of septic shock, but it was not an independent predictor of inhospital mortality in patients with left-sided IE.Abbreviations: CI = confidence interval, COPD = chronic obstructive pulmonary disease, DM = diabetes mellitus, IE = infective endocarditis, OR = odds ratio     

Surgical treatment of active infective endocarditis: analysis of 20 years' experience

OBJECTIVES: Changes in perioperative condition and outcomes of surgically treated patients with active infective endocarditis were evaluated during the last 20 years. METHODS: Between 1983 and 2002, 132 patients with active infective endocarditis underwent surgery at Saitama Medical School. Changes in frequency, pathogens, clinical features, surgical results, and perioperative treatment were compared between four periods of 5 years. RESULTS: The percentage of surgery for infective endocarditis remained almost the same among all cardiovascular procedures. Staphylococcal infective endocarditis increased significantly (p < 0.01), and prosthetic valve infective endocarditis and periannular abscess became more common. Surgery tended to be performed in severely ill patients significantly more frequently (p < 0.01). If all patients were included, hospital mortality did not decrease significantly, at 1.7% in stable patients, but 50% in critically ill patients. Intensive care unit stay became relatively longer. Recurrent infection was observed significantly more frequently in critically ill patients and in patients with prosthetic valve infective endocarditis. Patients were referred for surgery following diagnosis and underwent surgery at increasingly more appropriate timing. However, the diagnosis of infective endocarditis took 1.5 months to establish regardless of the patient's condition or the clinical outcome. Moreover, antibiotics were administered orally in around 90% and intravenously in nearly 70% of the patients without microbiological tests, and negative cultures remained very frequent. CONCLUSIONS: Critically ill patients underwent surgery increasingly more frequently, and surgical outcomes remained unsatisfactory over the last 20 years. Early diagnosis and avoidance of premature antibiotic therapy may be important for future improvement.     

Infective endocarditis in the elderly]

To elucidate clinical features of infective endocarditis in the elderly, 20 elderly patients aged > or = 60 years were compared in detail with 30 others aged < 60 years retrospectively. Twelve of the 20 elderly patients had a calcific aortic valve or an artificial device as a predisposing heart disease, whereas 16 middle-aged patients had mitral valve prolapse or congenital heart disease (p = 0.001). The prevalence of major extracardiac disorders such as neurological disease were higher in the elderly than in the middle (9/20 vs 3/30; p < 0.01). The frequency of infected valve was similar; mitral in 8, aortic in 11 and other valves or congenital defect in 2 in the elderly versus 14, 11 and 6, respectively in the middle. Among 39 patients in whom causative microorganisms were identified, staphylococcus epidermidis was most frequently identified in the elderly (5/20), whereas streptococcus species was found in the middle (12/30). Time from the onset of symptoms to correct diagnosis was usually delayed in the entire group; the delay was longer particularly in the elderly than in the middle-aged patients (72 +/- 87 vs 36 +/- 32 days; p < 0.1). Maximal body temperature was less in the elderly than in the middle-aged patients (38.5 +/- 0.7 vs 39.3 +/- 1.1 degrees C; p < 0.01), whereas peak level of C-reactive protein (10.4 +/- 6.1 vs 13.0 +/- 7.9 mg/dL), the incidences of heart failure (9/20 vs 10/30), and embolic complications (7/20 vs 10/20) were similar in the 2 groups. Cardiac operation was performed less in the elderly than in the middle-aged patients (9/20 vs 21/30; p < 0.08). Five elderly patients had disease-related mortality, whereas only one middle-aged patient died (p = 0.02). These results suggest that although predisposing heart disease and causative microorganism in infective endocarditis are different between the elderly and middle-aged patients, the incidence of major complications are similar. However, due to the delay of correct diagnosis in the elderly who usually have major extracardiac disorders, the prognosis of infective endocarditis in the elderly is poor.     

Trend and contributing factors of in-hospital deaths in patients with infective endocarditis over the last twenty years

OBJECTIVES: To evaluate the changes in the clinical background to infective endocarditis and identify the contributing factors to in-hospital deaths over the last 20 years. METHODS: Seventy-five patients (mean age 48.2 +/- 24.0 years) with infective endocarditis treated between January 1984 and December 2003 at our hospital were evaluated retrospectively. The patients were divided into two groups (first decade, n = 26 and second decade, n = 49). RESULTS: The infection route was unknown in 65% of the patients, but the oral route was the most common known route (16.0%). Congenital heart disease (24.0%)was the most common background disease, followed by valvular heart disease (22.7%), and post prosthetic valve replacement (22.7%). The mitral valve was most frequently infected(56.0%), followed by the aortic valve (34.7%). Multi-valve infection was present in 13.3% of the patients. Although the frequency of streptococcal endocarditis reduced, that of staphylococcal endocarditis increased in the second decade. The overall in-hospital mortality was 26.7%, but slightly improved in the second decade (34.6% vs 22.4%, p = 0.26). The overall in-hospital mortality was similar between the surgically treated group and the non-surgically treated group (25.0% vs 27.3%, NS). In the surgically treated group, in-hospital mortality was lower in the second decade than the first decade, but higher in the group treated for active infective endocarditis. Multivariate analysis found age > or = 51 years, renal insufficiency, neurological abnormality, and culture negative as predictors of in-hospital mortality. CONCLUSIONS: Rapid and appropriate primary medical treatment are important in the active phase of infective endocarditis. Age > or = 51 years was the strongest predictor of in-hospital infective endocarditis death.     

The advantage of repair of mitral valve in acute endocarditis

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair offers a survival benefit compared with valve replacement in surgery for non-infectious mitral regurgitation. It is unclear whether repair offers an advantage for patients undergoing mitral valve surgery for active endocarditis. Morbidity and mortality (early and late) and event-free survival were compared between the repair and replacement groups. METHODS: Between September 1986 and July 1999, 44 patients with acute native mitral valve endocarditis underwent surgery; 28 patients had valve replacement, and 16 underwent repair. Nine patients had complex repairs including replacement of a portion of the leaflet with prosthetic patch, placement of artificial chordae, resection of a portion of both leaflets, and/or reconstruction of a commissure. The remainder had simple repairs. RESULTS: Preoperative characteristics and indications for surgery between the two groups were similar. There were six in-hospital (21%) and six late cardiac deaths (21%) in the valve replacement group, but no early deaths or late cardiac deaths in the repair group (p <0.05). Independent risk factors for early and late death were need for associated procedures (p <0.03) and mitral valve replacement (p <0.05). Additional risk factors for late death were diabetes mellitus (p = 0.005) and hemodynamic instability as an indication for surgery (p = 0.047). Five patients undergoing valve replacement required reoperation due to recurrent endocarditis, compared with none in the repair group (p = 0.065). Mean follow up was 39+/-33 months in the repair group, and 57+/-51 months in the replacement group. CONCLUSION: Early and late mortality and event-free survival were better in patients undergoing mitral valve repair compared with replacement for acute endocarditis. Valve repair should be carried out whenever possible in this patient group.     

Tailored surgical therapy for acute native mitral valve endocarditis

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has been shown superior to valve replacement for the treatment of non-infectious valve disease. The criteria and results of valve repair for native valve endocarditis are still being defined. The study aim was to examine the short- and long-term results of mitral valve repair and replacement for acute infective endocarditis and to define criteria for the use of each technique. METHODS: A total of 53 consecutive patients who presented with acute native mitral valve infective endocarditis (diagnosed less than six weeks before surgery) between January 1992 and June 2002 was retrospectively analyzed. RESULTS: Twenty-one patients (40%) underwent mitral valve repair, and 32 (60%) underwent valve replacement. Operative mortality was 0% for the repair group and 13% (4/32) for the replacement group (p = 0.14). Median follow up was 4 years (range: 6-108 months). At five years follow up, a median ejection fraction (EF) of 60% and mitral regurgitation (MR) grade of 1/4 was observed, with an overall late survival of 85% (19/21), in the repair group, while the replacement group had a median EF of 55% and an overall late survival of 73% (p = 0.73). Recurrent endocarditis occurred in 2/21 (10%) in the repair group and 1/32 (3%) in the replacement group (p = 0.34). CONCLUSION: Mitral valve repair is a safe and effective technique to treat acute native mitral valve infective endocarditis with favorable short- and long-term morbidity and mortality. Patients with advanced endocarditis and annular destruction require valve replacement. Mitral valve repair should be performed when technically feasible.     

Surgical treatment of infective mitral valve endocarditis

BACKGROUND AND AIM OF THE STUDY: The approach to mitral valve endocarditis is a surgical challenge, and the optimal procedure remains a matter of debate. In this condition, mitral valve repair appears feasible, but its long-term effects--as opposed to more often practiced valve replacement--have not yet been determined. Herein, the authors' experience of surgical treatment of infective mitral valve endocarditis is presented, with reference to surgical replacement or reconstruction. METHODS: A retrospective analysis was performed of all patients with infective native mitral valve endocarditis treated surgically at the University Hospital Zurich and the City Hospital Triemli Zurich between 1980 and 1996. Of 154 patients, 97 (63%) underwent mitral valve replacement, and 57 (37%) mitral valve reconstruction. RESULTS: The 30-day mortality was 3.2% (5/154); 4% (4/97) after replacement and 1.7% (1/57) after reconstruction (p = 0.67). Survival (Kaplan-Meier) was 93%, 81% and 61% after one, five and 10 years, respectively. There was no significant difference between valve replacement and reconstruction in terms of long-term survival (p = 0.15), but there was a trend towards better survival after reconstruction than replacement if only cardiac deaths were considered (p = 0.1). At follow up, reconstruction patients were significantly less frequently symptomatic (NYHA class III/IV) than replacement patients (0% versus 29%; p = 0.002), had a lower incidence of atrial fibrillation and need for pacemaker implantation (29% versus 47%; p = 0.04), and tended to have less dyspnea in daily life (20% versus 38%; p = 0.07). Reoperation in patients surviving more than 30 days was more common in replacement than in reconstruction patients. CONCLUSION: The present data suggest a trend for better clinical outcome after mitral valve reconstruction than after replacement when treating mitral valve endocarditis. These results encourage mitral valve reconstruction in mitral valve endocarditis, but recommendations to clinicians undertaking surgery on mitral valve endocarditis must be made with caution.     

Prognostic significance of valvular regurgitation in patients with infective endocarditis

PURPOSE: Doppler ultrasound is a sensitive modality for detecting and quantitating valvular regurgitation in patients with infective endocarditis. Because valvular regurgitation leads to heart failure, we evaluated the prognostic significance of Doppler-detected valvular regurgitation in patients with endocarditis who had not yet developed clinical heart failure. PATIENTS AND METHODS: We reviewed the medical records of 65 patients with a clinical diagnosis of infective endocarditis from May 1985 to March 1990. A total of 49 patients were included in the study: 33 patients with native valve endocarditis and 16 patients with prosthetic valve endocarditis. The initial Doppler echocardiogram was examined in these patients to determine the presence and degree of valvular regurgitation. RESULTS: Significant (moderate to severe) valvular regurgitation was detected in 23 (47%) patients. The presence or absence of significant valvular regurgitation did not predict the development of congestive heart failure, the need for surgery, or death (p = NS). The development of congestive heart failure was significantly associated with the need for surgery (p less than 0.0001) and death (p less than 0.05). CONCLUSION: We conclude that the detection of significant valvular regurgitation in patients with infective endocarditis who have not yet developed heart failure is not predictive of future complications nor does the absence of significant valvular regurgitation identify a group of patients with a more favorable prognosis. In our series, patients who developed congestive heart failure had a significantly higher incidence of surgery and death. Therefore, decisions regarding clinical management in patients with infective endocarditis should not be made solely on the presence or absence of echocardiographically detected valvular regurgitation.     

The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts

INTRODUCTION AND OBJECTIVES: Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms. PATIENTS AND METHODS: A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997. RESULTS: The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical). CONCLUSIONS: A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.     

Cardiac complications of infectious endocarditis

Factors predisposing to cardiac complications and influencing hospital survival, were analysed in a retrospective study of 101 cases of infective endocarditis. Heart failure occurred in 52 p. 100 of our patients. A significantly greater incidence of heart failure was observed in endocarditis with no preexisting heart disease (p less than 0.01), aortic and mitral valve involvement (p less than 0.01), staphylococcus aureus infections (p less than 0.05), arrhythmias (p less than 0.001), and conduction disturbances (p less than 0.01). Significantly more patients with congestive cardiac failure died in hospital (51 p. 100) than those without congestive cardiac failure (17 p. 100) (p less than 0.001). Severe heart failure before treatment (p less than 0.05), streptococcus D endocarditis (p = 0.05), supraventricular arrhythmias (p less than 0.05), and intracardiac conduction disturbances (p less than 0.05), significantly increased the hospital mortality in patients with congestive heart failure. Electrocardiographic findings revealed arrhythmias in 34 p. 100 of cases, more commonly with mitral valve involvement (71 p. 100) and 52 p. 100 died in hospital. The development of intracardiac conduction disturbance during the course of 18 cases of endocarditis (aortic valve in 11 cases) was associated with a hospital mortality rate of 60 p. 100. The incidence of pericarditis and pulmonary embolism was 4 and 7 p. 100 respectively, and all patients died in hospital. Acute inferior myocardial infarction compatible with coronary embolism was suspected in one patient. Early cardiac valve replacement improved the hospital survival in patients with cardiac complications of infective endocarditis.     

雷帕霉素洗脱支架对糖尿病患者经皮冠状动脉介入治疗的远期影响

目的分析雷帕霉素洗脱支架(SES)对糖尿病患经皮冠状动脉介入治疗后的远期影响。方法采用回顾性研究方法,在1004．例接受冠状动脉内支架术治疗的冠心病患中,84例糖尿病和250例非糖尿病患置入SES;168例糖尿病和502例非糖尿病患置入普通支架。记录并比较一般临床资料、冠状动脉造影及冠状动脉内支架术情况、远期心脏事件发生率和1年无心脏事件生存率。结果随访期间(平均16．2个月),SES组中糖尿病亚组和非糖尿病亚组的远期心脏事件发生率为4．8％比3．6％,P=0．744;1年无心脏事件生存率为95．0％比96．7％,P=0．602,两亚组差异均无统计学意义。但BMS组中,糖尿病亚组的远期心脏事件发生率显高于非糖尿病组(31.0%比21．7％,P=0．015);两亚组的1年无心脏事件生存率分别为74．2％比86．8％(P=0．001)。结论SES能显改善糖尿病患冠状动脉支架术的远期疗效,降低靶病变再狭窄和远期心脏事件的发生率,提高1年无心脏事件生存率。