Predictors of hospital mortality in 186 cases of active infective endocarditis treated in a tertiary medical center (1992-2001)

INTRODUCTION AND OBJECTIVES: The aim of this study was to describe the predictors of hospital mortality found in patients admitted for infective endocarditis (IE) to a cardiovascular surgery ward.Patients and method. Prospective study of 186 patients with IE treated in our hospital between 1992 and 2001. RESULTS: One hundred fourteen patients (61.3%) had native valve endocarditis and 72 (38.7%) had prosthetic valve endocarditis (early in 28 patients [up to 12 months after surgery] and late in 44 [later than 12 months]). Blood cultures were positive in 82%. The predominant organism was Streptococcus viridans (36%) in native valve endocarditis and Staphylococcus aureus (33%) in prosthetic valve endocarditis. The hospital mortality was 22.6%. Severe sepsis (4.8%) produced a high mortality rate (88%) and was caused by Staphylococcus aureus in 60%. One hundred nineteen patients (64%) required surgery, 79 (66.4%) of them urgently. Negative blood cultures predicted need for surgery in native valve endocarditis (p < 0.05). The surgical mortality was 21.8% and was related to NYHA III-IV class (p = 0.014) and emergency surgery (p = 0.009) in patients with native valve endocarditis. This last factor also predicted higher surgical mortality in patients with early prosthetic valve endocarditis (p < 0.001). CONCLUSIONS. The hospital mortality of this group of patients with infective endocarditis treated in a tertiary medical center was high. The presence of severe sepsis, although infrequent, had a somber prognosis. Severe heart failure in native valve endocarditis and urgent surgery in native and prosthetic valve endocarditis increased surgical mortality.     

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.     

Short- and long-term prognosis of infective endocarditis in non-injection drug users: improved results over 15 years (1987-2001)

INTRODUCTION AND OBJECTIVES: The treatment of infective endocarditis has undergone significant change within the last few years. The aim of this study was to evaluate the clinical features and prognosis of infective endocarditis over both the short and long term in patients who are not intravenous drug users. PATIENTS AND METHOD: We carried out a prospective study of 222 consecutive patients who were diagnosed with infective endocarditis between 1987 and June 2001 at two centers. RESULTS: Their mean age was 48 (19) years, with 145 (65%) being male. Overall, 154 (69%) had native valve endocarditis and 68 (31%) had prosthetic valve endocarditis. In 61 patients (27%), no predisposing heart disease was found. Staphylococci were the causal microorganisms in 37% of cases (81 patients), and streptococci, in 35% (78 patients). Some 48% of patients underwent surgery during the active disease phase. Overall, inpatient mortality was 17% (39 cases); a significant decrease had occurred in recent years, from 25% in 1989-1995 to 12% in 1996-2001 (P<.01). In addition, the percentage undergoing early elective surgery had increased between the two periods, from 22% to 32% (P<.05). During a follow-up of 60 (48) months, 15 patients (8%) needed late cardiac surgery and 18 (10% of the whole series) died. The 6-year survival rate was 72% overall, and 80% in those who survived the active disease phase. CONCLUSIONS: Short- and long-term prognoses for patients with infective endocarditis appear to have improved over recent years at our hospitals.     

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.     

Late prosthetic valve endocarditis. Immediate and long-term prognosis.

From 1975 to 1989, 307 consecutive episodes of infective endocarditis were diagnosed in our hospital. Of those, 35 were cases of late prosthetic valve endocarditis, defined as those occurring after 12 months of valvular replacement. Blood cultures grew streptococci in 15 patients (43 percent), staphylococci in seven (20 percent), enterococci in five (14 percent), Gram-negative bacilli of HACEK group in four (11.5 percent), and Candida in one. Blood cultures were negative in three cases (prosthetic infection was confirmed at surgery). Heart failure due to prosthetic dysfunction occurred in seven patients (20 percent) and emboli in 12 (34 percent). Early valvular replacement was performed in six patients (17 percent). Complications and mortality were dependent on the infective agent. Overall mortality was 23 percent, no death occurred from streptococcal infection, whereas mortality with endocarditis by organisms of the HACEK group and Staphylococcus was 50 percent and 43 percent, respectively. During a mean follow-up of five years, 11 patients (those with prosthetic leaks diagnosed during the active infection and patients with biologic prostheses) required surgery. There was one relapse in a patient with staphylococcal endocarditis and one recurrence, six years after the initial episode. We conclude that immediate prognosis of late prosthetic valve endocarditis depends on the infective agent. Although the immediate prognosis of streptococcal infections is good, the need for early reoperation during follow-up due to progressive perivalvular leak is high. Also, it appears that deterioration of bioprostheses proceeds swiftly after the cure of infection.     

Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts

INTRODUCTION AND OBJECTIVES: Recurrence of infection is observed in a high proportion of patients who have had infective endocarditis in the past. The aim of our study was to evaluate the possible differences between the first and the recurrent episodes of endocarditis, as well as to assess the outcome and prognosis of patients with recurrent endocarditis. PATIENTS AND METHOD: We reviewed a series of 13 episodes of recurrent endocarditis from among 196 cases of infective endocarditis involving non-drug-addict patients in two hospitals from 1987 to 2000. RESULTS: There were no differences between recurrent and first episodes of endocarditis according to age, sex, heart valve involved or causal microorganisms. Prosthetic valve endocarditis was more common in patients with recurrent endocarditis (86% versus 27%; p < 0.001). Although there were no differences in the rate of complications or early surgery, overall mortality was significantly higher in patients with recurrent endocarditis (53% versus 27%: p < 0.05). When early and late mortality were analysed separately, the differences did not achieve significance. CONCLUSIONS: Recurrent endocarditis was frequent in our series (7% of all cases). The features were similar to those of the first episode except for a higher rate of prosthetic valve endocarditis and a higher overall mortality.     

Outcome of prognostic factors of infectious endocarditis over a 16 year period. Apropos of 471 cases]

Four hundred and seventy one cases of infective endocarditis (IE) were reviewed: 338 native valve IE and 133 prosthetic valve IE (42 early and 91 late IE). Two periods were compared: 1973-1980 (250 cases) and 1981-1988 (221 cases). There was a decrease in native valve IE (78% to 64%) and an increase in late prosthetic valve IE (13% to 27%), little change with respect to age, causal cardiac disease, delay in diagnosis (except in native valve IE, 39 to 29 days), or frequency of complications, especially cardiac (50% and 51%). However, global mortality decreased from 41% to 27% (p < 0.001). The evolution of the frequency of cardiac complications, cardiac surgery and mortality for the two periods was: for native valve IE respectively 53% to 42%, 41% to 37%, 37% to 20% (p < 0.005); for early prosthetic valve IE respectively, 45% to 55%, 41% to 55%, and 82% to 50% (p < 0.05); for late prosthetic IE, respectively 34% to 69%, 34% to 69% and 37% to 36%. The frequency of surgery had therefore little influence on prognosis except in early prosthetic valve IE. The percentage of infections which could not be controlled medically decreased from 17% to 11%. The mortality of unoperated patients decreased from 46% to 28% (p < 0.01), suggesting more effective antibiotherapy, and the mortality of operated patients fell from 34% to 26%. Global surgical mortality was 35% in the acute phase (positive valve culture), 14% after sterilisation (p < 0.001) and the corresponding frequencies of paravalvular leaks was 17% and 4% (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Prosthetic valve endocarditis. A survey.

Fifty eight patients (aged 8-59 years, mean 27) treated for prosthetic valve endocarditis from January 1966 to January 1985 were studied retrospectively by review of case notes. There were 12 cases of early and 46 cases of late prosthetic valve endocarditis. These developed in 28 patients with an isolated aortic valve, in 26 with an isolated mitral valve, and in four with both aortic and mitral prosthetic valves. Streptococci were the most commonly isolated microorganisms, followed by staphylococci, Gram negative bacteria, and fungi. A surgical (34 cases) or a necropsy specimen (10 cases) from 44 cases was examined. Eighty two per cent of the patients had congestive heart failure. Twenty four of the 58 patients were medically treated and 17 died (70% mortality). Combined medical and surgical treatment was used in 34 patients; the main indication for surgery was congestive heart failure. Fourteen patients on combined treatment died (40% mortality). Persistent sepsis and prosthetic valve dehiscence were the most common early and late operative complications. The most important influences on outcome were congestive heart failure, the type of micro-organism, the severity and extent of anatomical lesions, the time of onset of prosthetic valve endocarditis, and the type of treatment. This survey indicates that only patients without congestive heart failure or embolic complications and with sensitive micro-organism should be treated medically. In view of the poor prognosis patients with prosthetic valve endocarditis associated with congestive heart failure, persistent sepsis, and repeat arterial emboli should be treated by early surgical intervention.     

Prosthetic valve endocarditis. A survey

Fifty eight patients (aged 8-59 years, mean 27) treated for prosthetic valve endocarditis from January 1966 to January 1985 were studied retrospectively by review of case notes. There were 12 cases of early and 46 cases of late prosthetic valve endocarditis. These developed in 28 patients with an isolated aortic valve, in 26 with an isolated mitral valve, and in four with both aortic and mitral prosthetic valves. Streptococci were the most commonly isolated microorganisms, followed by staphylococci, Gram negative bacteria, and fungi. A surgical (34 cases) or a necropsy specimen (10 cases) from 44 cases was examined. Eighty two per cent of the patients had congestive heart failure. Twenty four of the 58 patients were medically treated and 17 died (70% mortality). Combined medical and surgical treatment was used in 34 patients; the main indication for surgery was congestive heart failure. Fourteen patients on combined treatment died (40% mortality). Persistent sepsis and prosthetic valve dehiscence were the most common early and late operative complications. The most important influences on outcome were congestive heart failure, the type of micro-organism, the severity and extent of anatomical lesions, the time of onset of prosthetic valve endocarditis, and the type of treatment. This survey indicates that only patients without congestive heart failure or embolic complications and with sensitive micro-organism should be treated medically. In view of the poor prognosis patients with prosthetic valve endocarditis associated with congestive heart failure, persistent sepsis, and repeat arterial emboli should be treated by early surgical intervention.     

Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia

PURPOSE: Staphylococcus aureus is a common cause of bacteremia and of native valve infective endocarditis. However, the risk of endocarditis in patients with a prosthetic valve who develop S. aureus bacteremia is unclear. The aim of this study was to define the risk of prosthetic valve endocarditis in patients with S. aureus bacteremia. SUBJECTS AND METHODS: All patients with a prosthetic valve or ring who developed S. aureus bacteremia during the 94-month study period were prospectively evaluated. The modified Duke criteria were used for the diagnosis of endocarditis. Patients were followed up for 12 weeks after the initial diagnosis of S. aureus bacteremia. RESULTS: The overall rate of definite prosthetic valve endocarditis among the study patients was 26/51 (51%). The risk of endocarditis was similar in patients with late (>or=12 months after valve implantation) vs. early S. aureus bacteremia (<12 months after prosthetic valve implantation) (50% vs. 52%, P=1.0), mitral vs. aortic prostheses (62% vs. 48%, P=0.24), and mechanical vs. bioprosthetic valves (62% vs. 44%, P=0.29). The 12-week mortality was higher among patients with definite vs. possible endocarditis (62% vs. 28%, P=0.019). CONCLUSION: In this investigation, approximately half of all patients with prosthetic valves who developed S. aureus bacteremia had definite endocarditis. The risk of endocarditis was independent of the type, location, or age of the prosthetic valve. The mortality of prosthetic valve endocarditis is high. All patients with a prosthetic valve who develop S. aureus bacteremia should be aggressively screened and followed for endocarditis.     

Role of Surgery in Infective Endocarditis

ABSTRACT. One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (<60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71 % early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.     

Prosthetic valve endocarditis in a multicenter registry of Chinese patients

We evaluated the clinical outcomes of prosthetic valve endocarditis in 2 major tertiary referral centers in Hong Kong. The study population comprised 80 consecutive Chinese patients who fulfilled the modified Duke criteria for prosthetic valve endocarditis from March 2000 to June 2007. The major clinical endpoints analyzed were hospital mortality, need for valve surgery, and relapse of prosthetic endocarditis. The mean age at presentation was 56 ± 13 years, with a slight male preponderance. There were 76 (95%) patients with involvement of a mechanical prosthesis; the majority (69%) had late prosthetic endocarditis. Major hospital complications occurred in 49 (61%) patients. The overall hospital mortality was 28% (22 patients). Thirty-four (42%) patients required valve surgery during index hospitalization, of whom 5 (15%) died due to uncontrolled sepsis. Factors associated with hospital mortality were older age at presentation, Staphylococcus aureus infection, embolic events, severe heart failure, valve surgery, and any major complication. On multivariate analysis, severe heart failure was the only independent predictor of hospital death. Among the 58 hospital survivors followed up for a mean of 48 ± 31 months, 6 (10%) developed late complications related to prosthetic valve endocarditis, with 5 documented cases of relapse.     

Infective endocarditis--analysis of 116 surgically and 26 medically treated patients

We have reviewed 116 cases of bacterial endocarditis treated surgically and 26 cases treated medically since 1973. There were 123 patients with native valve endocarditis and 19 patients with prosthetic valve endocarditis. Overall, the left-sided valves were infected most frequently. There were 10 cases with right-sided valves involved. Multiple valves were infected in 6 patients. There were 6 perioperative deaths in the surgical group. The most common cause of death was multi-organ failure associated with uncontrollable sepsis. The overall operative mortality for active endocarditis was 7.7% (4/55), and for healed endocarditis, 3.3% (2/61). For active native valve endocarditis, the mortality was 4.2% (2/48), for healed native valve endocarditis, 3.6% (2/55), for active prosthetic valve endocarditis, 28.6% (2/7), and for healed prosthetic valve endocarditis, 0%. There was no difference in the operative mortality between active native valve endocarditis and healed native valve endocarditis. The mortality of active prosthetic valve endocarditis was significantly higher than that of active native valve endocarditis (p less than 0.01). Of the 26 patients treated medically, 7 died during the initial hospitalization. The major factor related to mortality in the medically treated patients was persistent sepsis (four patients), and congestive heart failure (three patients). The overall mortality of the medical group for active valve endocarditis was 15% (3/20), and for active prosthetic valve endocarditis, 67% (4/6). We conclude that patients with infective endocarditis with significant valve lesions who are unresponsive to medical therapy should be considered for urgent surgery.     

Infective endocarditis of native cardiac valves: 22 years' surgical experience

BACKGROUND AND AIM OF THE STUDY: Most previous studies on surgery for endocarditis included cases of both prosthetic and native valve endocarditis (NVE), which clearly differ in their course and prognosis. METHODS: Between February 1979 and July 2000, 199 patients underwent surgical treatment for NVE. The native valve was replaced in 185 patients, and repaired in 14. Correlations between previous heart disease and site of NVE, site and etiology, site and embolism, and etiology and extracardiac infection were analyzed. Viability of echocardiography to identify NVE features was compared with surgical inspection. Risk factors for hospital, late mortality and recurrence were assessed by multivariate analysis, including preoperative, operative and postoperative variables. RESULTS: Streptococci were found in 52 cases (26.1%), mostly spreading from splanchnic (n = 10) and cutaneous (n = 9) infections; Staphylococci were found in 43 cases (21.6%), mostly from cutaneous foci (n = 20). Tricuspid valve endocarditis was due to Staphylococcus sp. in all documented cases (11/15; p <0.001), while Streptococcus sp. predominated in the mitral (p = 0.026) position. Echocardiography was reliable in identifying anatomic features of NVE, except for periannular abscess (13 versus 31 found at surgery; p <0.001). Hospital mortality was 6% (n = 12): preoperative NYHA class IV (p = 0.034) and emergency surgery (p = 0.001) were significant predictors of mortality. Average follow up was 57.2+/-4.4 months and was 96.3% complete. There were 27 late deaths (15%). Actuarial survival was 75.7% at 10 years and 60.3% at 20 years. Low social status (p = 0.022), diabetes mellitus (p = 0.003), fever at time of surgery (p = 0.041) and persistent postoperative fever (p = 0.0002) were predictors for late mortality. Endocarditis recurred in 28 patients (15.5%), with 74.1% freedom at 10 years and 68.7% at 20 years. Drug abuse (p = 0.001), mitral endocarditis (p = 0.002), positive blood cultures (p = 0.0003), homograft implantation (p = 0.0012) and persistent postoperative fever (p <0.0001) were significant predictors for recurrence. CONCLUSION: Preoperative conditions of patients with NVE significantly affect early and long-term outcomes. Prognosis is worsened by delayed diagnosis and operation during the active septic process.     

Endocardite infectieuse aortique : intérêt de la chirurgie. À propos de 48 cas

IntroductionInfective endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic location is characterized by its evolution toward myocardial failure and the high number of complications reasons for early surgery.AimTo compare the short- and mid-terms results of surgery for aortic infective endocarditis (IE) in the active phase and the healed phase.Patients and methodsWe analyzed retrospectively the data of 48 consecutive patients operated for aortic infective endocarditis between January 2000 and January 2012. The data on operative mortality, morbidity and major cardiovascular events (mortality, recurrent endocarditis, reintervention, and stroke) were analyzed.ResultsTwenty-three patients (48%) underwent surgery during the active phase (group I), 19 on native and 4 on prosthetic valves, and 25 patients (52%) were operated during healed endocarditis (group II) only on native valve. Mean age was 39 years (12–81) with a male predominance (83%). Rheumatic valvular disease was the main etiology of underlying valvular disease in both groups (85%). The clinical feature was dominated by signs of cardiogenic shock in group I and dyspnea exertion stage III–IV NYHA in group II. Streptococcus and Staphylococcus germs were most frequently encountered. Indication for surgery was heart failure in group I, it was related to the symptoms, the severity of valvular disease and its impact on the left ventricle in group II. An aortic valve replacement with a mechanical prosthesis was performed in the majority of cases (83%). Postoperative mortality concerned only one patient in group I. Twenty-one patients (44%) were followed for a mean of 30 months (1–72). One patient in group II died following cerebral hemorrhagic stroke related to accident with vitamin K antagonist. In both groups, there was an improvement in the functional class. No recurrence of endocarditis was noted in both groups during follow-up.ConclusionThe prognosis of infective endocarditis of the aortic valve is severe due to the fast progression to heart failure. Early medical and surgical approach provides good results on morbidity and mortality in the short- and mid-terms.     

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.     

Endocarditis with Ionescu-Shiley's bioprosthesis. Long-term results

With the aim to attesting the ability of treated pericardial tissue to resist infection we analyzed the incidence of prosthetic valve endocarditis in 541 operative survivors with the Ionescu-Shiley (I-S) valve since January 1977. A total of 580 valves were available for the study, 21 (3.8%) sustained I-S endocarditis or 0.65% patients/annum. The mean age was 53.2 years; male/female ratio was 16/5. Native endocarditis was present in 20 cases (3.6%). There were 13 aortic endocarditis (2 in cases of multiple replacement) and eight mitral. The interval between insertion and endocarditis ranged from 2 weeks to 108 months (means 31); 8 cases were early I-S endocarditis (38%) and 13 late endocarditis (62%). The organisms isolated were: Staphylococcus (epidermidis, aureus) in 10 cases. Streptococcus (viridans, fecalis) in 7 cases, gram negative in three and no organism was cultured in 3 cases. The outcome was as follows: specific medical treatment in 4 cases (one early), valve re-replacement in 11 (four early) from whom eight survived, and 6 patients died with unspecific medical treatment. The total mortality rate 9/21 (43%), in early endocarditis 5/8 (62.5%) and in late endocarditis 5/13 (38%). Operative and necropsy findings in 12/21 showed always periprosthetic abscess but no leaflet perforations. The rate of I-S valve endocarditis compares favourably with other valve substitutes. Early re-replacement combined with adequate antibiotic treatment is mandatory according to our experience.     

Long-term prognosis of early and late prosthetic valve endocarditis

A prospective series of 78 cases of prosthetic valve endocarditis (PVE) was studied (35 cases of early PVE and 43 cases of late PVE). The in-hospital mortality rate was significantly higher in patients with early PVE (31% vs 9%, p <0.01) because the onset of heart failure was more common in these patients (55% vs 37%, p <0.05). However, event-free survival at 4 years in survivors to the active phase was not different (74% and 82%, respectively).     

Surgical therapy of infective endocarditis

Therapy of infective endocarditis (IE) remains a particular challenge due to a relative high morbidity and mortality. Cardiac surgery is established as a cornerstone in therapy for native valve endocarditis (NVE) as well as for prosthetic valve endocarditis (PVE) and is required in 30% of patients with active IE. The basic aim of surgery in IE is the radical debridement of infected tissue and reconstruction of valve function either by reconstructive valve surgery or valve replacement. Indication for surgery depends on several clinical variables, the main indication remains heart failure due to severe heart valve defects or prosthetic valve dysfunction. Surgical therapy of NVE can be performed with good clinical results in the early and late follow-up. Surgical therapy of PVE is still associated with quite high mortality up to 80% in some risk groups. This indicates the particular importance of focus evaluation and antibiotic prophylaxis after primary surgery for infective endocarditis.     

Predictors of mortality in early surgical intervention for active native valve endocarditis and significance of antimicrobial therapy: a single-center experience

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery for active infective endocarditis remains a challenging and high-risk procedure. The outcome from early surgical intervention for active native valve endocarditis (ANVE) was studied, the aim being to identify significant predictors of mortality and the relationship between duration of preoperative antibiotics and outcome. METHODS: Between January 1996 and February 2002, 61 patients with ANVE underwent surgery within four weeks of diagnosis. Preoperatively, 29 patients received antibiotics for <2 weeks (group A), and 32 received antibiotics for 2-4 weeks (group B). The median follow up period was 37.4 months (range: 21-55 months). Data were collected retrospectively and analyzed. To determine factors related to mortality, Kaplan-Meier survival analysis was employed, utilizing log-rank statistics to identify evidence of significant differences between the groups. The relationship between the duration of preoperative antibiotics and morbidity was determined using chi-square and Fisher's Exact tests, as appropriate. RESULTS: Overall operative mortality was 14.8% (group A, 13.8%; group B, 15.6%). Rates of early and late prosthetic valve endocarditis were 1.8% and 1.9% (only in group B) respectively. The overall survival rate for the follow up period was 81.9%. Predictors of mortality were extensive infection (p = 0.01), poor left ventricular function (p <0.0001), progressive cardiac failure as an indication for surgery (p <0.0001), postoperative sepsis (p <0.0001), renal failure after surgery (p = 0.0002) and use of a bioprosthetic valve (p = 0.045). There were no significant inter-group differences for extensive infection (p = 1.00), postoperative sepsis (p = 1.00), reoperation (p = 1.00) and mortality (p = 1.00). CONCLUSION: In patients with ANVE, early aggressive surgical intervention before the onset of cardiac failure and spread of infection is warranted. The present data suggest that, in these patient groups, the duration of preoperative antibiotics had no significant influence on postoperative morbidity and mortality.