Echocardiographic and clinical correlates in drug addicts with infective endocarditis. Implications of vegetation size

Thirty-four drug addicts with endocarditis were studied to evaluate the prognostic significance of vegetation size and its short-term changes, as determined by two-dimensional echocardiography. Among 43 episodes of endocarditis, vegetations were detected in 27 (63%), confined to the tricuspid valve in 20 patients, mitral valve in one, aortic valve in two, and both tricuspid and mitral valves in four. All vegetations were large (greater than or equal to 1 cm) (mean maximal dimension, 1.7 +/- 0.5 cm). Medical cure was achieved in all 16 patients without vegetations and in 18 (90%) of 20 patients with tricuspid valve vegetations. One patient with tricuspid vegetation and polymicrobial infection died of respiratory failure. Surgery was required for one patient with tricuspid vegetation, all three patients with isolated left-sided endocarditis, and two of four patients with multivalve involvement. Short-term changes of tricuspid valve vegetations during therapy (one to eight weeks) did not correlate with clinical outcome. Although large tricuspid vegetations may occasionally identify a subset at risk for complications, most patients with isolated tricuspid valve endocarditis have a benign prognosis.     

Tricuspid endocarditis. Value of echocardiography. Developmental data. Apropos of 11 cases

Clinical and echocardiographic data of 11 patients with tricuspid valve endocarditis (TE) were analysed to determine diagnostic criteria and to study the outcome of this condition. The study population comprised 6 men and 5 women (average age 38.4 +/- 18 years). TE was the only lesion in 9 cases; there was 1 case of associated pulmonary and aortic valve endocarditis, and in the other patient mitral and aortic valve endocarditis was also present. Five patients were heroin addicts. In 5 cases, the causative organism was Staphylococcus aureus. The clinical presentation was usually atypical with a systolic murmur rarely characteristic in 9 patients and signs of right ventricular failure in only 3 patients. On the other hand, 8 patients had one or more episodes of acute pneumonia or typical pulmonary embolism. The diagnosis was established by echocardiography which demonstrated the valvular vegetations. The outcome was favourable in 10 patients, only one of whom required surgical intervention. Two dimensional echocardiography provided valuable information about the evolution of the valvular vegetations, frequently showing regression after medical therapy.     

生物瓣应用于老年心脏瓣膜置换术的临床总结

目的 探讨老年心脏瓣膜病患者应用生物瓣置换的价值.方法 对36例老年患者施行生物瓣膜置换术,其中行二尖瓣置换18例,主动脉瓣置换10例,二尖瓣及主动脉瓣置换8例;同期行三尖瓣成形术12例,冠脉搭桥术6例.结果 本组围手术期死亡2例.出院后随访1～48个月,心功能恢复至Ⅰ级9例、Ⅱ级21例、Ⅲ级2例.结论 老年患者应用生物瓣具有良好的耐久性,并可避免因抗凝治疗出现的各种并发症,临床应用值得推广。     

Endocarditis: epidemiology, diagnosis and treatment

The current incidence of infective endocarditis (IE) is estimated as seven cases per 100,000 population per year and continues to increase. The prognosis is significantly influenced by proper diagnosis and adequate therapy. In cases with unconfirmed IE, besides careful clinical examination, transesophageal echocardiography is the imaging technique of choice. Culture-negative endocarditis requires either termination of antimicrobial treatment initiated without microbiological test results and reevaluation of blood samples or serological/molecular biological techniques to identify the causative organism. Antimicrobial therapy should established only after quantitative sensitivity tests of antibiotics, including evaluation of the minimal bactericidal concentrations (MBC) of established combinations of antibiotics. Concomitant kidney involvement, a significant impairment of the hepatic function or the combination therapy with oto- and/or nephrotoxic antibiotics, requires drug monitoring. Large (> 10 mm) vegetations attached to the mitral valve are linked with a high incidence of thromboembolic complications. In most of these cases, the indication for surgical intervention is given, especially if the MBC of the optimal combination of antibiotics is high (> 2 micrograms/ml). In the first three weeks after primary manifestation of signs and symptoms of IE, an index embolism is frequently followed by recurrences. If vegetations can still be demonstrated by echocardiography after an embolic event, surgical intervention should seriously be considered. Cerebral embolic events are no contraindication for surgery with use of the heart-lung machine, as long as cerebral bleeding has been excluded by cranial computed tomography immediately preoperatively and the operation is performed before a significant disturbance of the blood-brain barrier (< 72 hours) has manifested. A significant prognostic improvement has also been demonstrated for patients with early surgical intervention, after their clinical course was complicated by myocardial failure due to acute valve incompetence, acute renal failure, mitral kissing vegetations in primary aortic valve IE, and in patients with sepsis persisting for more than 48 hours despite adequate antimicrobial therapy.     

Natural history of tricuspid valve endocarditis: A two dimensional echocardiographic study

Sixteen patients with tricuspid valve endocarditis were studied to define (1) what clinical or echocardiographic subsets are at risk for complications or need for tricuspid valve surgery, and (2) the long-term two dimensional echocardiographic course of tricuspid vegetations. There were 18 episodes of tricuspid endocarditis in the 16 patients; 12 patients had a history of intravenous drug abuse. Staphytococcus aureus was the most common infecting organism (11 patients). Persistent infection, cardiomegaly or radiography and right-sided heart failure were present in all patients undergoing tricuspid valve surgery and in none of the medically treated patients.

Echocardiographic studies demonstrated tricuspid vegetations in 10 patients by M mode and in all 16 by two dimensional technique. Vegetation size, right ventricular enlargement and abnormal septal motion were not of prognostic significance. Two dimensional echocardiographic measurements of vegetation size correlated with surgical pathologic measurements in the four patients who underwent surgery. Serial two dimensional echocardiographic studies were available in eight patients a mean of 10.6 (range 2 to 19.5) months after the initial study: Vegetations had decreased in size or disappeared in seven patients and were essentially unchanged in one patient.

It is concluded that (1) two dimensional echocardiography increases the detection of tricuspid valve vegetations and accurately estimates their size; (2) persistent Infection, cardlomegaly and right-sided heart failure identify a subgroup of patients with tricuspid endocarditis who may have increased risk; (3) no M mode or two dimensional echocardiographic feature is a predictor of outcome; and (4) tricuspid valve vegetations tend to resolve with time.     

New aspects of infective endocarditis

The current incidence of infective endocarditis (IE) is estimated as 7 cases per 100,000 population per year and continues to increase. The prognosis is significantly influenced by proper diagnosis and adequate therapy. In cases with unconfirmed IE, transesophageal echocardiography is the imaging technique of choice. Culture-negative endocarditis requires either termination of antimicrobial treatment initiated without mircobiological test results and reevaluation of blood samples or serological/molecular biological techniques to identify the causative organism. Antimicrobial therapy should be established only after quantitative sensitivity tests of antibiotics (minimal inhibitory concentrations, MIC) and guided by drug monitoring. In the first 3 weeks after primary manifestation, an index embolism is frequently followed by recurrencies. If vegetations can still be demonstrated by echocardiography after an embolic event, a surgical intervention should seriously be considered. Cerebral embolic events are no contraindication for cardiac surgery, as long as a cerebral bleeding has been excluded by cranial computed tomography immediately preoperatively and the operation is performed before a significant disturbance of the blood-brain barrier (<72 hours) has manifested. A significant prognostic improvement has also been demonstrated for patients with early surgical intervention suffering from myocardial failure due to acute valve incompetence, acute renal failure, mitral kissing vegetations in primary aortic valve IE, and in patients with sepsis persisting for more than 48 hours despite adequate antimicrobial therapy.     

Candida endocarditis: retrospective study in 12 patients

PURPOSE: Candida endocarditis are rare, with a poor prognosis. Actually, the principal problem concerns the growing incidence of nosocomial fungal infections. The objective of the present investigation is to assess a disease which risks becoming more pronounced in the future. METHODS: We have collected observations of Candida sp. endocarditis between 1985 to 1997 from three French university hospitals. RESULTS: Twelve of the observations fit the Duke criteria of acute endocarditis. Patients were eight men and four women, with a mean age of 46 years. An immunodepression was found in seven cases, and four patients were active drug addicts. Six had an underlying heart disease at risk to acute endocarditis. Candidemia risk factors were found in nine cases, with an average of 2.7 risk factors per patient. The fungal agents detected were Candida albicans (eight cases), C. tropicalis (one case), C. parapsilosis (two cases), and C. glabrata (one case). These vegetations were on aortic (seven cases), mitral (three cases), tricuspid valves (two cases) or in other areas (three cases), with multiple localizations (two cases). In three observations, vegetations were associated with myocardium abscesses. Eight patients had embolic complications, two had a cardiac insufficiency leading to death. The treatment was medical in all of the cases and combined with a surgical treatment in ten cases. The surgery was performed, on an average, 17 days after diagnosis, allowing seven surviving patients. Among them, five received a secondary prophylaxis and no recurrence was recorded. CONCLUSIONS: Prognosis remains severe because of the voluminous, friable and necrotic vegetations, which favor embolic migrations and which are not easily accessible to antifungals, which penetrate poorly into these vegetations. Therapy is based on a medical treatment combined with a valve replacement which needs to be done early on, and is followed by a relapse prevention which can occur several years after the initial episode.     

Influence of vegetation size on clinical outcome of right-sided infective endocarditis

Endocarditis involving right-sided valvular structures is largely a disease of intravenous drug abusers. The majority of these patients respond to antibiotic therapy with clearing of their bacteremia and preservation of their hemodynamic status. This study evaluated the prognostic value of echocardiographically determined vegetation size in 23 episodes of right-sided valvular endocarditis in 21 patients. Right-sided vegetations were visualized in 19 of 23 episodes (83 percent). Of these, a vegetation of 1.0 cm or greater was found in 11. No patient with an echocardiographically determined vegetation size of less than 1.0 cm required surgery, whereas four of 11 (36 percent) of those episodes in which the vegetation size was 1.0 cm or greater required surgery for persistent pyrexia (p less than 0.05). In all patients requiring surgery, a bioprosthetic tricuspid valve was placed at the time of initial surgery and in no patient did early reinfection occur. This study reconfirms the benign prognosis of right-sided valvular endocarditis. Further, although vegetations of less than 1.0 cm identify those patients who will respond to medical therapy, echocardiographically documented vegetations of 1.0 cm or greater are associated with a significantly lower response rate to appropriate medical therapy. The association of fever that persists for more than three weeks in the absence of another source of infection with an echocardiographically demonstrable right-sided vegetation of 1 cm or more identifies those patients who will require surgical intervention. Finally, tricuspid valve replacement can be performed at the time of initial surgery without undue concern for early reinfection or valve dysfunction.     

Viridans streptococcal endocarditis: clinical, microbiological, and echocardiographic correlations

Infections caused by species within the viridans streptococci have been associated with different clinical characteristics. We studied 36 patients with viridans streptococcal endocarditis. Complications were seen in 10 (32%) of 31 patients with native valve endocarditis and four (80%) of five with prosthetic valve endocarditis and included death in two, valve replacement in six, persistent infection in three, emboli in two, and congestive heart failure in nine. Two-dimensional echocardiograms demonstrated vegetations in 26 (72%) of 36, flail mitral valves in seven, disruption of aortic valve prosthesis in one, and perivalvular abscesses in three (two Streptococcus sanguis I and one Streptococcus intermedius I). All twelve patients with native valve endocarditis who suffered complications had vegetations detected by two-dimensional echocardiography, whereas seven patients with native valve endocarditis without vegetations, as detected by two-dimensional echocardiography, had no complications (P = .03). We found no significant correlation between streptococcal species and clinical outcome. To confirm our identifications, we sent 16 identical viridans streptococcal endocarditis isolates to five institutions; only three of 16 were identified as the same species by all five institutions. We conclude that viridans streptococcal endocarditis can be associated with a virulent clinical course and that there is marked variability in species designations of individual strains by different laboratories.     

Isolated gonococcal pulmonary valve endocarditis: diagnosis by echocardiography.

The perplexing clinical course of a 23-year-old black male with isolated gonococcal pulmonary valvular endocarditis is presented. M-mode echocardiography provided the first clue to the presence of pulmonary valvular vegetations and the proper diagnosis. Since Neisseria gonorrhea appears to have a particular affinity for the pulmonary valve, the presence of isolated pulmonary valvular endocarditis should raise the strong possibility that Neisseria gonorrhea is the offending organism. This case report of pulmonary valvular vegetations detected by echocardiography strongly emphasizes that all four cardiac valves must be visualized in order to rule out the presence of echocardiographically detectable valvular vegetations.     

Spectrum of echocardiographic findings in bacterial endocarditis.

Forty-seven echocardiograms were obtained in 32 patients with bacterial endocarditis. Preexistent abnormalities were found in 14 patients. In five of them thought to have bacterial endocarditis on normal valves, echocardiography showed mitral stenosis (one), bicuspid aortic valve (two), and prolapse of mitral valve (two). Definite vegetations were seen in 22 patients--on the aortic valve in seven, the mitral valve in 12, and both valves in three. Ten patients had milder changes suggestive but not diagnostic of vegetations. In 12 patients, surgery confirmed the echocardiographic findings. Fourteen had systemic embolic episodes and all had echocardiographic evidence of vegetations. Abnormalities secondary to bacterial endocarditis, other than vegetations, were common. Twenty-one patients had left ventricular volume overload. Ten had a flail posterior leaflet of the mitral valve, three of which were confirmed surgically. Eight had abnormal coarsely fluttering echoes in the left ventricular outflow tract consistent with a prolapsing aortic valve or underlying aortic vegetations; four were confirmed by surgery. Five had signs of severe aortic regurgitation of recent onset (premature mitral valve closure) and all had confirmation by surgery. Echocardiographic abnormalities persisted after successful medical treatment. We conclude that echocardiography is helpful in patients with bacterial endocarditis. It permits recognition of unsuspected preexistent lesions and the characteristic vegetations, as well as the extent and nature of valvular damage secondary to bacterial endocarditis. However, echocardiography does not differentiate between active and healed lesions.     

Evaluation of prosthetic valve endocarditis by 64-row multidetector computed tomography

Two patients with prosthetic aortic valves--one bioprosthetic and one mechanical--presented with bacteremia and underwent evaluation for infective prosthetic valve endocarditis. Multidetector computed tomography (MDCT) imaging demonstrated vegetations on both prosthetic valves confirmed by transesophageal echocardiography. Based on the MDCT coronary artery assessment, neither patient underwent pre-operative invasive coronary angiography. Both patients underwent surgical treatment without complication. In conclusion, this report demonstrates that MDCT can, in some cases, accurately image vegetations on prosthetic aortic valves in infective endocarditis.     

Comparison of two-dimensional and M-mode echocardiography in the evaluation of patients with infective endocarditis.

M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. In 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one sinus on Valsalva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.     

ECHOCARDIOGRAPHIC HEMODYNAMIC ASSESSMENT OF STENTLESS AND SUPERSTENTLESS AORTIC BIOPROSTHESES IN TERMS OF SURVIVAL ADVANTAGE

Porcine xenografts as stentless and recently superstentless bioprosthetic aortic valves are anticipated to cause improved hemodynamics and increase longevity over stented bioprostheses. Stentless valves showed extremely good flow characteristics. Durability has been reported to be better than in stented xenografts accompanied by low gradients, rare and only trivial aortic valve regurgitation. As during the last years the well‐known and attractive aortic bioprostheses stentless St. Jude Toronto SPV and superstentless Shelhigh were often used all over the world including in our institute, we will present their morphologic and functional assessment. Toronto SPV prosthesis requires two suture lines to be implanted. The first row of sutures is between the left ventricular outflow tract and inflow of the valve and the second between the aortic sinuses and the valve. The subcoronary technique of the implantation is intraannular with aortic root as a stent. The diameter of sinotubular junction during diastole is crucial for valve competence and when it exceeds the diameter of the aortic annulus by more than 3 mm, the root is dilated and this valve should not be used. At the completion of the implantation of the valve, the sinotubular junction should not exceed the diameter of the valve. On the contrary, Shelhigh superstentless bioprosthetic aortic valves require one suture line and no sutures are needed in the vicinitiy of the coronary arteries (which might also distort the base of the valve). A composite valve mounted on a superflexible ring has three separate cusps, which allow the best hemodynamic characteristics. Valve implantation is easy with mini or total root replacement and with the possibillity of oversizing the valve conduit by one to three sizes enhancing the hemodynamic advantages. A complete echocardiographic examination included the estimation of maximal and mean transvalvular gradients from transthoracic 5‐chamber view or transesophageal transgaastric view, as well as calculations of effective orifice area by the continuity equation or with planimetry in transesophageal short axis view, especially in the cases of aortic regurgitation. Effective orifice area index, a predictable measure of patient–prosthesis mismatch was calculated at the time of operation or postopertively. Aortic prosthesis valve regurgitation was recorded by pulsed and color Doppler. Left ventricular size, systolic and diastolic function are important clues regarding the severity of regurgitation. Transesophageal assessment of the structure and function of the bioprosthetic stentless valves in short and longitudinal axis provides the evaluation of clinical performance. Measurement of left ventricular mass after aortic valve replacement with both bioprosthetic stentless valves has been done by the truncated ellipse method. Twenty‐eight patients undergoing aortic valve replacement were assigned to receive either Toronto stentless or Shelhigh superstentles aortic valve. Transthoracic and transesophageal echocardiograms were performed after 1 week, 3 months and 6 months, postoperatively. We found maximal systolic transvalvular gradients ranged from 18 to 26 mmHg and mean systolic transvalvular gradients from 8.5 to 12 mmHg with effective orifice area from 1.5 to 2.1cm² without significantly changes in both groups. Thesegradients after 3 and 6 months postoperatively dropped more in the Toronto stentless group, but not significantly hemodinamicly in relation to Shelhigh superstentles group, and the effective orifice area ranged in both groups from 2.4 to 2.8 cm². Left ventricular mass had fallen in both groups but the degree of mass reduction was comparable. Diastolic function has significantly improved in both groups. In conclusion,we had only trivial regurgitation in two cases of Toronto stentless group. Stentless bioprostheses convey hemodynamically and possibly survival benefit through a low incidence of valve‐related complications. Owing to more recent developments of stentless technology with the most advanced anticalcification treatment and superior hemodynamic performance due to maintenance of the normal aortic physiology and flexibility of the aortic root, it is felt that these valves could last 15 years or longer.They will probably provide a useful alternative to aortic homografts in the future.     

Infective endocarditis following percutaneous pulmonary valve replacement: Diagnostic challenges and application of intra-cardiac echocardiography

Background

Infective endocarditis (IE) following percutaneous pulmonary valve replacement (PPVR) with the Melody valve is rarely reported. Furthermore, there are challenges in this diagnosis; especially echocardiographic evidence of vegetation within the prosthesis may be difficult.

Method and result

This study is a retrospective review of all patients with Melody valve implantation in a tertiary centre. Between November 2006 and November 2012, 43 procedures were performed in 42 patients (mean age 25 years, 6–67 years). At a median follow-up of 27 months (2–66 months), six patients were suspected for IE. However, repeated transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed no evidence of IE and the patients were diagnosed as possible cases according to the modified Duke's criteria. Two patients did not respond to antibiotic treatment and underwent intra-cardiac echocardiography (ICE), which clearly demonstrated vegetations. These two cases required surgical explantation, while the other four patients were treated medically without complications.

Conclusion

IE after Melody valve implantation is uncommon, but difficult to verify since TTE and TEE often cannot demonstrate vegetations inside the stent. ICE should be considered in suspected cases of IE following PPVR with negative TTE and TEE examinations in order to early tailor the best treatment for the individual patient suspected for IE.     

Two-dimensional echocardiographic assessment of bioprosthetic valve dysfunction and infective endocarditis

Two-dimensional echocardiography of Hancock porcine heterograft valves was evaluated by correlation with clinical, hemodynamic, angiographic and pathologic findings in 80 patients. Ninety-five aortic and mitral bioprostheses were categorized by the type of valvular abnormality: group I, dysfunction due to primary tissue failure (41 valves); group II, dysfunction due to paravalvular leakage without infection (5 valves); group III, infective endocarditis with or without hemodynamic dysfunction (28 valves); and group IV, control cases without dysfunction or infection (21 valves). Increased size of a bioprosthetic leaflet image (minimal dimensions 3 x 5 mm) was observed in 46% (19 of 41) of cases with primary tissue failure and in 62% (10 of 16) of cases with leaflet vegetations due to endocarditis. Prolapse of leaflet echoes to below the level of the bioprosthetic sewing ring occurred in 76% (28 of 37) of cases with torn leaflets and also in 46% (6 of 13) of valves with vegetations on intact leaflets. Antegrade extension of leaflet echoes to beyond the level of the stents, observed in 4 of 16 cases with leaflet vegetations, was the only echocardiographic sign distinguishing leaflet infection from leaflet degeneration. Aortic bioprostheses with ring dehiscence affecting 40 to 90% of the anular circumference showed motion discordant with the motion of the adjacent aortic root and native anulus. Although echocardiographic abnormalities are frequently observed with bioprosthetic leaflet degeneration or infection, the echocardiographic appearance often does not distinguish between these two major complications and is best interpreted concurrently with other clinical and laboratory assessment.     

Infective endocarditis

Opinion statement Despite improvements in antibiotic regimens, patients with infective endocarditis (IE) have a high risk of valve replacement and death. Effective initial treatment depends on two steps: 1) diagnosis of the infecting organism, enabling specific antibiotic therapy, and 2) complete characterization of the anatomic extent of infection. Identification of the infecting organism requires culturing of blood prior to the initiation of antibiotics. Whenever possible, at least three sets of blood cultures should be obtained over 6 to 24 hours and held for 4 weeks if necessary to detect unusual or fastidious organisms. Transesophageal echocardiography (TEE) is usually necessary either to confirm the diagnosis or, most importantly, to identify the local complications of infection, many of which mandate surgery. Despite widespread availability, TEE remains under-used, both for the prevention of unnecessary antibiotic therapy in patients at very low risk for the disease and for the recognition of patients likely to benefit from early surgery. The selection of optimal antibiotic therapy depends on microbiologic data to establish the sensitivities of the specific causative organism. Short courses of antibiotic therapy and outpatient administration of intravenous antibiotics are useful in selected cases.     

INCIDENCE OF VERRUCOUS VEGETATIONS IN SYSTEMIC LUPUS ERYTHEMATOSUS. THE ASSOCIATION WITH ANTIPHOSPHOLIPID ANTIBODIES

Background: Valvular heart disease is prevalent in systemic lupus erythematosus (SLE) and is a common cause of morbidity and mortality. Valvular thickening and verrucous valvular vegetations (Libman–Sacks) are the most common lesions. The purpose of this prospective study was to analyze the incidence of Libman–Sacks vegetations in patients with SLE. Methods: Two hundred and seventeen consecutive patients (196 females, 21 males, aged 53 ± 11 years) with SLE were evaluated with M‐mode, 2D, and Doppler echocardiography. Libman–Sacks vegetations were defined as distinct localized masses of varying size and shape on the surface of the valve leaflets and exhibiting no independent motion. In 76 (35%) patients with SLE there were antiphospholipid antibodies (APL) present. Results: Thirty‐two (14.7%) patients with SLE had Libman–Sacks vegetations and in 21 (65.6%) of them there was a presence of antiphospholipid antibodies. In 22 patients the location of the masses was in the mitral, in 9 in the aortic, and in 1 in the tricuspid valve, whereas in 4 cases in BOTH valves. Valvular regurgitation was the predominant lesion in 18 mitral, 9 aortic, and 1 tricuspid, but only 2 cases had severe mitral regurgitation. Valvular stenosis was detected in 5 cases. Three patients had severe mitral stenosis and one of them died, while in the other two patients mitral stenosis was reversed with treatment of the underlying disease. The remaining two cases had severe aortic stenosis but one of them, also having severe mitral regurgitation, died suddenly. Conclusion: Our results show that Libman–Sacks vegetations are quite frequent in patients with SLE and are related to the presence of antiphospholipid antibodies. The most common lesion is valvular regurgitation and rarely valvular stenosis.     

Surgical treatment of high-risk valvular endocarditis

The authors have studied the short and long term results of surgical treatment of acute phase of infectious endocarditis in a group of 33 high risk patients with valvular heart disease. The age varied from 2 to 68 years; 18 patients were male and 22 were of the white race. The aortic valve was most frequently involved (18/54.5%), followed by the mitral valve (13/39.3%) and tricuspid valve (2/6.0%). Twenty four patients (72.7%) were in functional class III and seven (21%) in functional class IV. The noninvasive studies in those patients revealed 13 cases (39.4%) with normal cardiac size. The ECG was abnormal in 27 cases (81.8%) mostly with left atrial and ventricular hypertrophy. The echocardiogram revealed the presence of vegetations in 27 patients (81.8%) and blood cultures were positive in 22 cases (66.6%). All patients were treated with antibiotics. The pathologic analysis revealed the presence of vegetations in 94% and structural alterations in 16.5%. Twenty-one patients had heart valve replacement with mechanical prosthesis (63.6%), 11(33.3%) had bioprosthesis and one had tricuspid excision without replacement (3.0%). The hospital mortality was 12% and the late mortality 3%. Three deaths occurred in patients who had prolonged clinical treatment (more than 65 days) and one patient died of severe fungal endocarditis. The follow-up of the remaining 26 patients varied from 01 to 448 weeks (mean 183) demonstrating important clinical improvement and a normally functioning valve prostheses. All patients are in functional class I and II. The analysis of our data indicates that surgical treatments is the best option for high risk endocarditis and should be undertaken earlier in all patients in this risk group.     

Clinical relevance of vegetations in infective endocarditis.

Two-dimensional echocardiograms of 58 patients with infective endocarditis were examined to determine if presence and/or size of vegetations on echocardiogram were predictive of morbidity and mortality. Group 1 (38 patients) with one or more vegetations, had a significantly higher rate of complications (emboli, congestive heart failure, need for surgery and death) than group 2 (20 patients) without vegetations (p less than 0.001). Analysis of morphologic characteristics of the vegetations in group 1 was of no predictive value for complications in individual patients. In contrast, patients whose echocardiograms demonstrated vegetations on aortic valve had a significantly higher incidence of heart failure, embolisation, surgery and death than those with vegetations on mitral valve. Thus, the detection of vegetations on initial echocardiogram clearly identifies a subgroup at risk for complications, more so if vegetations are present on the aortic valve, but the vegetations size does not predict an adverse clinical outcome.