Periannular complications in infective endocarditis involving prosthetic aortic valves

The periannular extension of infection in prosthetic valve endocarditis (PVE) is a serious complication of infective endocarditis associated with high mortality. Periannular lesions in PVE occasionally rupture into adjacent cardiac chambers, leading to aortocavitary fistulae and intracardiac shunting. It is unknown whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinctive clinical characteristics of patients with PVE and either aortocavitary fistulization or nonruptured abscesses. In a retrospective multicenter study of >872 PVE episodes, 150 patients (17%) with periannular complications in PVE in the aortic position were identified (29 with aortocavitary fistulization and 121 with nonruptured abscesses). Early-onset PVE was present in 73 patients (49%). Rates of heart failure (p = 0.09), ventricular septal defect (p <0.01), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 128 patients (83%). In-hospital mortality in the overall population was 39%. Multivariate analysis identified heart failure (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6 to 6.8), renal failure (OR 2.5, 95% CI 1.2 to 5.2), and co-morbidity (OR 2.4, 95% CI 1.1 to 5.1) as independent risk factors for death. Fistulous tract formation was not associated with increased in-hospital mortality (OR 1.6, 95% CI 0.7 to 3.7). The actuarial 5-year survival rate in surgical survivors was 100% in patients with fistulae and 78% in patients with nonruptured abscesses (log-rank p = 0.14). In conclusion, aortocavitary fistulous tract formation in PVE complicated with periannular complications is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscesses. Despite the frequent complications, fistulous tract formation in the current era of infective endocarditis is not an independent risk factor for mortality.     

Epidemiologic features of infective endocarditis in Taiwanese adults involving native valves

Little is known about the incidence and clinical outcomes of infective endocarditis (IE) involving native valves in Asian countries. This nationwide study investigated epidemiologic features and in-hospital mortality associated with IE in adults (age > or =18 years) based on Taiwan's National Health Insurance database from 1997 through 2002. Of 7,240 enrolled patients with IE involving native valves, the mean age was 53 +/- 19 years and 70% were men. The mean annual crude incidence was 7.6 per 100,000 inhabitants. The incidence was significantly higher in men than in women (10.4 vs 4.6 per 100,000; p <0.001). The incidence of IE increased steadily with age, ranging from 3.8 per 100,000 persons in patients <30 years of age to 33 per 100,000 persons in patients > or =80 years of age (p <0.001). Staphylococcal (32%) and streptococcal species (61%) were the most common causative pathogens. The mean in-hospital mortality rate was 18%. Multivariate analysis showed that male gender, older age (> or =50 years), diabetes mellitus, heart failure, neurologic complications, renal insufficiency, respiratory failure, shock, and Staphylococcus species as the causative microorganism were independent predictors of in-hospital mortality. In conclusion, this Taiwanese study revealed a high incidence of IE in men and elderly subjects. The in-hospital mortality rate remained high. Patients with IE who also developed shock and respiratory failure were the most likely to have a poor outcome.     

Periannular extension of infective endocarditis

OBJECTIVES: This prospective study was designed to assess the current clinical course, risk factors, microbiologic profile and echocardiographic findings of patients with left-sided endocarditis and perivalvular complications. BACKGROUND: Periannular complications worsen the prognosis of patients with endocarditis. The relation between these complications and the clinical and microbiologic data has not been clearly defined. METHODS: In this clinical cohort study, 211 patients with left-sided endocarditis, according to the Duke criteria, were prospectively recruited. All patients underwent conventional and transesophageal echocardiography. The mean follow-up interval was 151 days. RESULTS: Perivalvular complications were detected in 78 patients (37%). The incidence of periannular extension of infection in native and prosthetic valves was 29% and 55%, respectively. The presence of prosthesis (relative risk [RR] 1.88, 95% confidence interval [CI] 1.35 to 2.64) and previous endocarditis (RR 1.78, 95% CI 1.16 to 2.7) were the only pre-existing heart conditions associated with perivalvular complications. Aortic infection (RR 1.8, 95% CI 1.23 to 2.66) and the development of atrioventricular (AV) block (RR 2.55, 95% CI 1.91 to 3.41) were related with the existence of these complications. Coagulase-negative staphylococci were very common in patients with perivalvular complications (RR 1.77, 95% CI 1.21 to 2.59), and small vegetations were more frequent in these patients (RR l.45, 95% CI 0.95 to 2.22). An operation was more frequently performed in patients with perivalvular complications, but mortality was similar in patients with and without these complications. CONCLUSIONS: Aortic infection, prosthetic endocarditis, new AV block and coagulase-negative staphylococci were independent risk factors of periannular complications. The period between symptom onset and diagnosis, the incidence of pericardial effusion and persistent signs of infection were similar between patients with and without perivalvular complications. Patients with perivalvular complications did not demonstrate a difference in the presence or size of vegetations or the frequency of embolism. An operation was more frequently performed in these patients, but mortality was similar in both groups.     

Usefulness of cytokines interleukin-6 and interleukin-2R concentrations in diagnosing active infective endocarditis involving native valves

The most important diagnostic value in infective endocarditis (IE) is isolation of the causative microorganism. Because premature antibiotic treatment is commonly administered before the assessment of blood cultures, the percentages of isolated microorganisms has decreased significantly within the last decades. Therefore, additional criteria for the diagnosis of IE may be helpful. It was hypothesized that assessment of interleukin-6 (IL-6) and interleukin-2R (IL-2R) may provide new diagnostic criteria for inflammation in IE. IL-6 and IL-2R serum concentrations, white blood cell count (WBC), and C-reactive protein (CRP) were measured in the blood of 47 patients with IE at the time of diagnosis and during treatment. WBC and CRP were elevated in patients with IE at the time of diagnosis. Both parameters were higher (p <0.05) in patients with positive blood cultures when compared with negative cultures. The differences persisted during the first week of treatment (p <0.01). In contrast, IL-6 and IL-2R concentrations were elevated (p <0.001) independently of the status of blood cultures. Serum concentrations of IL-6 and IL-2R decreased continuously during antibiotic treatment. Assessment of IL-6 and IL-2R could thus provide new diagnostic criteria for inflammation in IE, and these interleukins could also be suitable for monitoring the course of inflammation during treatment.     

二叶式主动脉瓣畸形合并感染性心内膜炎的临床及预后分析

目的:总结二叶式主动脉瓣畸形合并感染性心内膜炎的临床特点及治疗,明确影响主动脉瓣感染性心内膜炎预后的因素。方法:将2001-01-2010-12期间我院收治的符合DUKE诊断标准的自体主动脉瓣感染性心内膜炎患者98例,分为二叶式主动脉瓣畸形组和三叶式主动脉瓣畸形组,评价临床表现、实验室检查、超声心动图、瓣膜形态、手术治疗与死亡率的相关性。结果:31例(31.6%)二叶式主动脉瓣感染性心内膜炎患者更年轻,易发生瓣周脓肿(35.5%)。二叶式主动脉瓣是瓣周脓肿的独立预测因素(OR=4.015,95%CI 1.307～12.335,P<0.05)。二叶式主动脉瓣畸形组与三叶式主动脉瓣畸形组的早期手术及院内死亡率均差异无统计学意义。严重心力衰竭(OR=8.955,95%CI1.811～44.687,P<0.01)及未控制的感染(OR=0.170,95%CI0.041～0.697,P<0.05)是主动脉瓣感染性心内膜炎死亡的独立预测因素。瓣膜手术可以降低主动脉瓣(OR=0.222,95%CI0.006～0.822,P<0.05)及二叶式主动脉瓣(OR=0.320,95%CI0.090～1.140,P<0.05)感染性心内膜炎的死亡率。结论:二叶式主动脉瓣畸形是主动脉瓣感染性心内膜炎常见的瓣膜异常。二叶式主动脉瓣感染性心内膜炎的患者更年轻,易发生瓣周脓肿。手术治疗可降低二叶式主动脉瓣感染性心内膜炎的死亡率。     

Infective endocarditis caused by Erysipelothrix rhusiopathiae involving three native valves

Human infection with Erysipelothrix rhusiopathiae is extremely rare and occupationally related. This paper presents for the first time a case of a 47 year-old male with endocarditis involving three valves simultaneously.     

Nonbacterial thrombotic endocarditis involving both the tricuspid and aortic valves

A 71‐year‐old male presented after sudden onset of confusion and expressive aphasia. MRI head revealed multiple ischemic lesions consistent with cardio‐embolic pathophysiology. A computed tomography angiography of lung showed peripheral pulmonary emboli. He underwent a transesophageal echocardiogram as a part of the stroke workup and was found to have vegetations on both aortic and tricuspid valves. The blood cultures did not show any growth, and the patient remained afebrile during the course of hospitalization. A diagnosis of nonbacterial thrombotic embolism was made, and he was discharged on anticoagulation therapy with subcutaneous low molecular heparin.     

Severe infective endocarditis of native valves caused by Weissella confusa detected incidentally on echocardiography

Weissella confusa is gram-positive, catalase-negative, short rod or coccobacillus that has been isolated from a wide variety of habitats. We describe a rare, severe infective endocarditis of native valves caused by W. confusa that was detected incidentally on echocardiography. The patient recovered completely with valvular replacement plus antibiotic therapy.     

Cardiac complications of infective endocarditis

Cardiac complications caused by infective endocarditis (IE) are varied and frequently life-threatening. This article focuses on new data related to several complications, and summarizes the indications, timing, and type of valve surgery recommended in the management of IE. Several recent studies using propensity score techniques have resulted in disparate conclusions and underscore the need for randomized prospective studies to better address whether and when surgery should be performed in patients with IE. Mitral valve repair is an exciting new development in surgical methodology and probably will have increased application over the next two decades. Excellent reviews related to periannular abscesses, fistulae, acute coronary syndrome, and pericarditis have been published recently and are also summarized.     

Immunofluorescence studies of cardiac valves in infective endocarditis

Mitral and aortic valves removed at emergency cardiac surgery from a patient with infective endocarditis caused by Streptococcus viridans were studied by immunofluorescence to ascertain the extent and pattern of various immune reactants within the large valvular vegetations. Heavy intravalvular deposits of IgG as well as bacterial antigen were present. Much more focal interstitial IgM and C3 deposits were noted within vegetations and valve substance. Diffuse endocardial and subendocardial deposition of C5b-C9 and C9 complement neoantigens was present. Direct staining of valvular tissues and vegetations for rheumatoid factor showed extensive interstitial tissue deposition. These findings emphasize the large amounts of immune reactants and constituents of immune complexes present in valves and vegetations of patients with infective endocarditis.     

Changing epidemiology of native valve infective endocarditis

Introduction and objectives

The aim of our study is to assess changes in the epidemiologic features of patients with native valve infective endocarditis.

Methods

We analyzed a prospective series of 228 cases of native valve infective endocarditis in non-intravenous drug users attending our center between 1987 and 2009. We compared three subperiods: 1987-1994 (67 cases), 1995-2002 (74 cases) and 2003-2009 (87 cases).

Results

The mean age of patients has progressively increased (38±22 years in the first subperiod vs 60±16 years in the third; P<.001), as has the proportion of cases without predisposing heart disease (25%, 46% and 67%; P<.001). Incidence of mitral valve prolapse remained stable (12%, 18% and 11%). Percentages of patients with predisposing heart disease and who were aware of their condition have fallen in recent years (45%, 27% and 21%; P<.001). A portal of entry for the infection could not be identified in 64%. Overall, Staphylococcus aureus is the most frequent causative organism (26%) whereas the percentage of cases caused by Streptococcus viridans remains unaltered (22%, 20% and 24%).

Conclusions

We found significant changes in the epidemiology of native valve infective endocarditis. The incidence of patients without predisposing heart disease has increased significantly and staphylococci are the most frequent causative organisms.Full English text available from: www.revespcardiol.org     

Pericardial effusion in prosthetic and native valve infective endocarditis

Background

Pericardial effusion (PE) is widely believed to signify more advanced infective endocarditis (IE) and a generally worse outcome.

Long-term complications of native valve infective endocarditis in non-addicts. A 15-year follow-up study.

OBJECTIVE: To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis. DESIGN: Cohort study. SETTING: University-affiliated tertiary medical center. PATIENTS: One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone. MEASUREMENTS: Relapse, recurrence, need for late cardiac surgery, and cardiac mortality. RESULTS: Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years. CONCLUSIONS: Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).     

Diagnostic value of intraoperative swabs of heart valves in infective endocarditis

BACKGROUND AND AIM OF THE STUDY: Intraoperative swabs of heart valves are obtained regularly from patients undergoing heart valve surgery for infective endocarditis (IE) in order to confirm the preoperative diagnosis and to adjust the antibiotic regimen. The study aim was to assess the diagnostic value of intraoperative swabs of heart valves in IE. METHODS: A total of 83 patients was referred for surgical treatment of active IE between October 1994 and May 1999. Preoperatively, microorganisms were isolated using a minimum of two positive blood cultures; results were compared with those obtained from intraoperative heart valve swab cultures. RESULTS: Preoperatively, 73 patients (88%) had a positive blood culture, and 10 (12%) had culture-negative endocarditis. The intraoperative swab confirmed the preoperative diagnosis in 31 cases (37%). Bacteria were isolated in three of the ten patients with preoperative culture-negative IE. Despite positive histopathological findings in seven patients, no microorganisms were cultured either pre- or intraoperatively. Among the remaining 42 patients (51%) with active IE, 25 valve cultures were sterile and 17 valve swabs were presumed to be contaminated. CONCLUSION: In patients with active IE in whom the causative agent could be isolated and identified before surgery, intraoperative valve swabs did not contribute further to patient management. In isolating contaminants, the risk of inappropriate modification of the antibiotic regimen is imminent. The diagnostic validity in culture-negative IE appears negligible.     

Comparison of allografts and prosthetic valves when used for emergency aortic valve replacement for active infective endocarditis

Aortic valve replacement (AVR) using allografts is an established method of treating aortic valve disease. It is uncertain, however, whether the increased technical demands of allograft AVR can be justified in emergency operations. This study reports 15 patients treated between 1987 and 1990 for acute bacterial or fungal endocarditis involving the aortic valve. Patients underwent emergency AVR because of severe congestive failure, overwhelming sepsis or cerebral emboli. Eight patients received prosthetic valves (group I: 4 mechanical, 4 porcine) and 7 received human allografts (group II: 5 aortic and 2 pulmonary). The groups were comparable in age (group I, 55 years; group II, 51 years), intravenous drug abuse (group I, 1; group II, 3), and previous AVR (group I, 3; group II, 2). One group I and 4 group II patients had septal abscesses. Additional procedures in group I included mitral valve replacement (2), tricuspid valve replacement (1) and aortic root replacement (1). Additional procedures in group II were mitral valve repair (1), root replacement (1), atrial septal defect closure (1) and aortocoronary bypass (1). Mean bypass times (group I, 189 minutes; group II, 204 minutes) and cross-clamp times (group I; 108 minutes; group II, 121 minutes) were similar. Operative deaths occurred in 4 of 8 group I and 1 of 7 group II patients. All surviving patients have been successfully followed (group I, 28 months; group II, 18 months). No group I patient has required reoperation. One group II patients required reoperation for recurrent infection affecting the allograft, and another group II patient died 10 months postoperatively from noncardiac causes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic diagnosis of infective endocarditis of all four cardiac valves

Cross-sectional echocardiography in a 78-year-old woman with infective endocarditis demonstrated echogenic masses on all four cardiac valves. The echocardiographic diagnosis was confirmed at autopsy.