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PubMed2001

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices.

BACKGROUND: Operation for active infective endocarditis carries high mortality and morbidity rates, especially when the annulus is involved. Overall the literature favors the use of autograft and homograft valves because of better resistance to infection. In our clinic during the last 5 years we used an aggressive surgical approach to infective endocarditis in combination with implantation of mechanical or stented bioprosthetic devices. METHODS: From 1994 to 1999, 50 adults with aortic and/or mitral valve endocarditis underwent valve replacement. The median age of the 36 men and 14 women was 58 years (range, 17 to 78 years). All patients had active endocarditis at the time of operation. Native valve endocarditis was present in 48 patients and prosthetic valve endocarditis was present in 2 patients. The aortic valve was affected in 24 patients, the mitral valve in 21 patients, and both the aortic and mitral valves in 5 patients. Two of the patients with mitral endocarditis also had infection of the tricuspid valve. Annular destruction was present in 24 patients (48%). The patients were treated with radical excision of all infected tissue. The annular defects were closed, if possible, with direct sutures. Otherwise, a reconstruction was performed. Follow-up was 100% complete with a median follow-up period of 45 months (range, 6 to 66 months). RESULTS: The procedures were performed without lethal bleeding complications. Early mortality was 12% and the actuarial survival at follow-up was 80%. In none of the patients who died was death related to the prosthetic valve or recurrence of the endocarditis. Only 1 patient (2%) developed recurrence of the infective endocarditis and was reoperated with a Ross procedure. Three and a half years later the patient developed severe valve insufficiency of the autograft and was operated again with implantation of a mechanical device. CONCLUSIONS: Native and prosthetic valve endocarditis can be treated successfully with aggressive surgical debridement and implantation of mechanical or stented bioprosthetic devices with a low risk of recurrent endocarditis.

Adolescent↗
PubMed2001

[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.

Endocarditis, Bacterial↗
PubMed2003

[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.

Adolescent↗
PubMed2001

Relapses, recurrences, valve replacements, and mortality during the long-term follow-up after infective endocarditis.

BACKGROUND: Late prognosis after infective endocarditis has not been systematically studied in large series of patients with different underlying heart conditions in recent years. METHODS: We studied an inception cohort study of 420 patients discharged after treatment of endocarditis from a university tertiary care hospital. The patients were aged 34.2+/-17.2 years (mean +/- SD), ranging from 2 months to 83 years; 270 (64.3%) were men and 150 (35.7%) were women. Mean follow-up was 6.1+/-4.3 years for survivors and 3.7+/-3.7 years for the patients who died during the follow-up. We studied the frequency and risk factors for relapses and recurrences of endocarditis, cardiac valve replacements, and deaths during the follow-up. Statistical analysis was performed through comparison of groups, of event-free survival, and risk ratios. RESULTS: Relapses were observed in 14 (3.3%) patients. There was one recurrence of endocarditis in 48 (11.4%) patients, two (0.5%) in 2 patients, three in 1 patient (0.2%), and five (0.2%) in 1 patient. Valve replacement was performed in 83 (19.7%) patients. Ninety-eight (12.3%) patients died. Risk factors for recurrent endocarditis were increasing age (risk ratio 1.02) and male sex (risk ratio 1.61). Risk factors for valve replacement were recurrent endocarditis (risk ratio 1.62) and prosthetic valve endocarditis (risk ratio 1.61). Risk factors for death were increasing age (risk ratio 1.03) and recurrent endocarditis (risk ratio 2.06). CONCLUSIONS: The long-term event-free survival for patients who survived their first episode of endocarditis was low. Recurrent endocarditis, prosthetic valve endocarditis, and increasing age contributed to the high rate of events during the follow-up.

Adolescent↗
PubMed2005

Blood culture-negative endocarditis in a reference center: etiologic diagnosis of 348 cases.

To identify the current etiologies of blood culture-negative infective endocarditis and to describe the epidemiologic, clinical, laboratory, and echocardiographic characteristics associated with each etiology, as well as with unexplained cases, we tested samples from 348 patients suspected of having blood culture-negative infective endocarditis in our diagnostic center, the French National Reference Center for Rickettsial Diseases, between 1983 and 2001. Serology tests for Coxiella burnettii, Bartonella species, Chlamydia species, Legionella species, and Aspergillus species; blood culture on shell vial; and, when available, analysis of valve specimens through culture, microscopic examination, and direct PCR amplification were performed. Physicians were asked to complete a questionnaire, which was computerized. Only cases of definite infective endocarditis, as defined by the modified Duke criteria, were included. A total of 348 cases were recorded-to our knowledge, the largest series reported to date. Of those, 167 cases (48%) were associated with C. burnetii, 99 (28%) with Bartonella species, and 5 (1%) with rare, fastidious bacterial agents of endocarditis (Tropheryma whipplei, Abiotrophia elegans, Mycoplasma hominis, Legionella pneumophila). Among 73 cases without etiology, 58 received antibiotic drugs before the blood cultures. Six cases were right-sided endocarditis and 4 occurred in patients who had a permanent pacemaker. Finally, no explanatory factor was found for 5 remaining cases (1%), despite all investigations.Q fever endocarditis affected males in 75% of cases, between 40 and 70 years of age. Ninety-one percent of patients had a previous valvulopathy, 32% were immunocompromised, and 70% had been exposed to animals. Our study confirms the improved clinical presentation and prognosis of the disease observed during the last decades. Such an evolution could be related to earlier diagnosis due to better physician awareness and more sensitive diagnostic techniques. As for Bartonella species, B. quintana was recorded more frequently than B. henselae (53 vs 17 cases). For 18 patients with Bartonella endocarditis, the responsible species was not identified. Species determination was achieved through culture and/or PCR in 49 cases and through Western immunoblotting in 22. Comparison of B. quintana and B. henselae endocarditis revealed distinct epidemiologic patterns. The 2 cases due to T. whipplei reflect the emerging role of this agent as a cause of infective endocarditis. Because identification of the bacterium was possible only through analysis of excised valves by histologic examination, PCR, and culture on shell vial, the prevalence of the disease might be underestimated. Among patients who received antibiotic drugs before blood cultures, 4 cases (7%) were found to be associated with Streptococcus species (2 S. bovis and 2 S. mutans) through 16S rDNA gene amplification directly from the valve, which shows the usefulness of this technique in overcoming the limitations of previous antibiotic treatment. Right-sided endocarditis occurred classically in young patients (mean age, 36 yr), intravenous drug users in 50% of cases, and suffering more often from embolic complications. Finally, 5 cases without etiology or explaining factors were all immunocompetent male patients with previous aortic valvular lesions, and 3 of the 5 presented with an aortic abscess. Further investigations should be focused on this group to identify new agents of infective endocarditis.

Adolescent↗
PubMed2001

Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review.

The pulmonic valve is the least commonly involved valve in infective endocarditis. Pulmonic valve endocarditis is usually associated with tricuspid valve endocarditis, and isolated pulmonic valve endocarditis is exceedingly rare. The predisposing factors for developing pulmonic valve endocarditis include a congenitally anomalous pulmonic valve, intravenous drug abuse, and the presence of indwelling intravenous or flow-directed pulmonary artery catheters. More cases of group B streptococcus endocarditis are being reported. The risk factors for group B streptococcus endocarditis include diabetes mellitus, cancer, alcoholism, malnutrition, immunocompromised status, intravenous drug abuse, postpartum and postabortion states, and underlying valvular disease. The vegetations of this type of endocarditis are usually large and have a higher tendency to result in embolism. The presentation of group B streptococcus endocarditis is usually acute and may result in rapid valve destruction if not treated promptly. A case of isolated pulmonic valve endocarditis caused by group B streptococcus, Streptococcus agalactiae, is presented that was diagnosed with multiplane transesophageal echocardiography in a 40-year old, alcoholic, malnourished man, who was successfully treated with intravenous penicillin G. The literature on the isolated pulmonic valve endocarditis caused by group B streptococcus is reviewed.

Adult↗
PubMed1994

[Sampling study on practitioners' attitude to the prevention of infectious endocarditis].

UNLABELLED: BACKGROUNDS AND METHODS: The opinions and the experience of Veneto practitioners about prevention of infective endocarditis were detected through a sample survey among the 386 practitioners of Health and Social Unit Nr 16, 17, and 36 of Veneto Region. The interview was carried out through a questionnaire, sent by mail, asking for: 1) general information on the practitioner's profession; 2) information about the previous experience in diagnosis and care of heart diseases, particularly of infective endocarditis, of atrial septal defect ostium secundum type without pulmonary hypertension, of unstable angina, and moderate mitral stenosis; 4) attitudes in the prevention of infective endocarditis. Of 386 practitioners surveyed, 186 (48.2%) responded. More than 60% of the responders held a diploma of specialization and 7% were cardiologists, half of the responders had worked in public hospitals. The 63.8% of the practitioners had patients over sixty in a percentage of 15-44%. In 1990 only 5.9% of the practitioners observed new cases of infective endocarditis, while half of them stated that some of their patients had suffered from this disease in the past. RESULTS: The assessment of the level of severity for every heart disease is ranged between 0 (the minimum) and 10 (the maximum). The statistical analysis showed that the minimum arithmetic mean (+/- SD) is given for atrial septal defect without pulmonary hypertension with 4.6 +/- 2. Then for moderate mitral stenosis with 7.1 +/- 1.6, unstable angina pectoris with 7.4 +/- 2 and the maximum mean is given for infectious endocarditis with 8 +/- 1.7. ANOVA statistical analysis applied on the four paired series of assessment of severity carried out a high significant difference (F of Snedecor = 328.2; P < 0.001) among assessments, and among practitioners (F = 1.71; P < 0.01). High significant linear correlation (at least P < 0.01) is observed among the severity of the four heart diseases. Vice versa not significant association is showed between severity for every heart diseases and the experience of the interviewed. CONCLUSIONS: Most practitioners would prescribed prophylaxis for infective endocarditis to patients with rheumatic valve disease (91% of the responders), with previous episodes of infective endocarditis (90.4%), with prosthetic valve (67.6%) or with degenerative valve disease (57.3%). On the contrary most practitioners would not prescribe the prevention for infective endocarditis to patients with coronary heart disease (84.9%), with coronary bypass (71.4%), with mitral valve prolapse without insufficiency (60.6%), with dilatative cardiomyopathy (67%) or with obstructive cardiomyopathy (57.8%). A prevailing trend in case of congenital heart disease and mitral valve prolapse with insufficiency was not observed. The 86.6% of practitioners would prescribe the prophylaxis for infective endocarditis in case of dental extraction, but only the 64.4% would prescribe it in case of any potentially haemorrhagic oral or dental procedure. The 61.7% of the responders would not prescribe the prevention for infective endocarditis to patients receiving the prophylaxis for rheumatic fever. The practitioners would use in the following order: amoxicillin (77.3%), erythromycin (76.9%), penicillin V (76.3%) and ampicillin-gentamycin (61.3%). On the contrary, most responders would prescribe neither tetracycline (73%) nor spiramycin (69.8%). There is no prevailing trend to the employ of oral cephalosporins. The 90.3% of the practitioners think that infective endocarditis can be a quite interesting and useful subject for an up-to-date course.

Analysis of Variance↗
PubMed1994

Aortic valve endocarditis. Determinants of early survival and late morbidity.

BACKGROUND: Aortic valve surgery for endocarditis remains a high-risk procedure. The objective of this study was to analyze the interaction between the various subsets of endocarditis (native, prosthetic, healed, and active), timing of surgery, and their influence on early and late outcomes. METHODS AND RESULTS: During a 20-year period starting January 1972, 200 patients underwent aortic valve replacement for infective endocarditis (age range, 13 to 88 years; median, 53 years). There were 51 (26%) females, and 109 (55%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 132 (66%) and 68 (34%) patients, respectively. Surgery was required in 120 (60%) during the active phase (AE) and 80 (40%) during the healed phase (HE) of endocarditis. The main indication for surgery in the healed group was progressive congestive heart failure. The indications for the active group were congestive heart failure (68%), continuing active sepsis (70%), echocardiographic vegetation (28%), peripheral emboli (30%), and arrhythmias (13%). Streptococcal infections predominated in NVE, staphylococcal in PVE and AE; culture-negative endocarditis predominated in the healed group. Isolated aortic valve surgery was performed in 68% of the patients, and concomitant procedures (32%) included mitral valve and coronary bypass procedures. The overall operative mortality (OM) was 12.5%. The OM was 7.5% and 22% for NVE and PVE, respectively (P = .004), and 7% for HE versus 15% for AE (P = .06). The OM for early PVE was 33% versus 18% for late PVE (P < .05). Multivariate logistic regression analysis identified PVE and New York Heart Association functional class IV to be independent predictors for early death. Recurrent endocarditis occurred 26 times in 24 patients (11 early, 13 late), with three operative deaths in the early group, all due to residual staphylococcal infections. Freedom from recurrent endocarditis was significantly different between HE (96 +/- 3% and 86 +/- 6% at 5 and 10 years, respectively) and AE (89 +/- 3% and 83 +/- 4%, respectively (P = .02). Long-term survival for discharged patients was 81 +/- 3% and 63 +/- 5% at 5 and 10 years, respectively, with no significant difference between NVE, PVE, AE, and HE. CONCLUSIONS: These data suggest that for active endocarditis, surgery should be delayed to achieve a healed status provided there is no pressing need for immediate surgery. Patients with staphylococcal endocarditis, particularly on a prosthesis, should be operated on sooner and should be covered with antibiotics for an extended period to prevent recurrent PVE. This study stresses the need for aggressive antibiotic prophylaxis, particularly in the presence of a prosthesis.

Aortic Valve↗
PubMed1996

Analysis of 109 cases of infective endocarditis in a tertiary care hospital.

BACKGROUND: Early diagnosis and treatment can benefit the outcome of patients with infective endocarditis. The older diagnostic criteria (von Reyn criteria) relied upon tissue pathology and blood culture results, but the sensitivity was low. A newly proposed criteria, Duke criteria which apply echocardiographic findings as a major factor in diagnosis, have shown a better sensitivity in the diagnosis of infective endocarditis. METHODS: From 1984 to 1994, 120 episodes of endocarditis in 119 patients were reviewed retrospectively. One hundred and nine episodes fulfilling the Duke criteria were enrolled. The demographic data, antecedent disease, predisposing factors for infective endocarditis including systemic disease, prosthetic valve, intravenous drug abuse, dental or surgical manipulation, culture results, echocardiographic findings, complications and outcome were recorded and analyzed. RESULTS: Sixty-six percent (72/109) was definite endocarditis, and 34% (37/109) was possible endocarditis, as categorized by Duke criteria. Eleven percent (12/109) of the patients were rejected by von Reyn criteria. The common possible predisposing factors were rheumatic heart disease, congenital heart disease, mitral valve prolapse, dental manipulation and intravenous drug abuse. Both patients with positive blood culture and negative blood culture results had one-fourth mortality rate. A notably higher mortality rate was found in patients with S. aureus endocarditis as compared with those of endocarditis caused by viridans streptococci(44% vs. 8%, p < 0.05). Patients with echocardiographic vegetations had a higher mortality rate (32% vs. 11%, p < 0.05) and more peripheral or organ embolic events (26% vs. 6%, p < 0.05) than those without vegetation. CONCLUSIONS: The Duke criteria are more sensitive than the von Reyn criteria for diagnosis of infective endocarditis. S. aureus endocarditis carried a higher mortality rate than viridans streptococci endocarditis. The present study also indicated that patients with discernible valvular vegetation on echocardiogram had a high mortality rate and occurrence of peripheral or organ embolic events. However, there was no statistical significance in the development of congestive heart failure and CNS complications between the patients with and without vegetation.

Adolescent↗
PubMed1996

[Characteristics and treatment of Staphylococcus aureus endocarditis].

In order to evaluate whether there were changes of the clinical features of Staphylococcus (Staph.) aureus endocarditis in recent years, the data of 21 cases of Staph. aureus endocarditis diagnosed from 1977 to 1994 were analyzed and compared with those of 11 cases of Staph. aureus endocarditis from 1957 to 1977. The results showed the following changes in recent years. The incidence of Staph. aureus endocarditis cases has been increasing. Cases of right-sided endocarditis increased in the recent two decades and this increase was related to intravenous drug abuse and increased use of vascular intervention. Right-sided endocarditis was different from left-sided endocarditis in their risk factors, underlying heart diseases, clinical manifestations and prognosis. The clinical manifestations of ventricular-wall endocarditis were atypical and it could be definitely diagnosed only with echocardiogram. Complications of Staph. aureus endocarditis became more common and serious, in recent decades but hospital mortality decreased markedly due to effective antibiotic management. The authors believe that sound knowledge of Staph. aureus endocarditis is essential for the proper diagnosis and treatment of Staph. aureus endocarditis.

Adolescent↗
PubMed2003

Risk factors for metastatic infection in patients with Staphylococcus aureus bacteremia with and without endocarditis.

Background: Staphylococcus aureus bacteremia (SAB) may be complicated by endocarditis or metastatic infection without evidence of endocarditis (MIWE). The aim of this study was to identify risk factors for MIWE and endocarditis in patients with SAB. METHODS: We performed a retrospective chart review to compare characteristics of patients with uncomplicated SAB and patients whose SAB course was complicated by MIWE or endocarditis. We reviewed the charts of patients with SAB diagnosed in our department from 1992 to 1999 for S. aureus portal of entry, secondary foci of infection, underlying conditions, previous valvular defects, and foreign material. Endocarditis was defined according to the Duke criteria. Patients were classified as having MIWE when the diagnosis of endocarditis was not definite according to the Duke criteria and when there was evidence of at least one secondary metastatic infection other than endocarditis. RESULTS: Some 109 patients had 111 episodes of SAB. Sixty-three patients had no evidence of metastatic infection and constituted the control group. Twenty-seven patients developed at least one episode of MIWE. A community-acquired SAB (CI 95% OR: 1.4-12.3, P<0.02), two or fewer underlying conditions (CI 95% OR: 1.2-83, P<0.04), and a non-severe portal of entry (CI 95% OR: 1.2-20, P<0.03) were independently predictive for MIWE. The characteristics of 21 patients with endocarditis were compared with those of the control group. Only a previous valvular defect was significantly associated with endocarditis. CONCLUSION: A previous valvular defect seems to be an important factor for developing endocarditis during SAB. Risk factors for having MIWE may differ from those found for patients with endocarditis.

Journal Article↗
PubMed1989

New approaches to the diagnosis and treatment of infective endocarditis: review of 100 consecutive cases.

To assess the effect of our new, more aggressive approach to treating infective endocarditis, we retrospectively reviewed our recent experience with this disease. Between 1983 and 1989, we treated 100 patients with endocarditis, in 94 of whom the diagnosis was confirmed. Fifty-four (57%) of the 94 patients had native valve endocarditis, and the other 40 patients (43%) had prosthetic valve endocarditis. The patients' mean ages were 50 years for native valve disease and 58 years for prosthetic valve disease (p < 0.05). The male-to-female ratio was 4:1. Among the patients with confirmed endocarditis, 87 (93%) had significant underlying risk factors for endocarditis. Upon physical examination of the 94 patients, 16 (17%) were afebrile, 15 (16%) had negative blood cultures, and 26 (28%) had no cardiovascular symptoms or immunologic findings. Echocardiography was of limited value: its sensitivity was 56% for native valve endocarditis and 33% for prosthetic valve endocarditis. The ratio of affected valves was 5 aortic:4 mitral: 1 tricuspid in both forms of the disease. Viridans streptococcus was isolated in 23 (25%) of the confirmed cases, Enterococcus faecalis in 17 (18%), Staphylococcus aureus in 13 (14%), and coagulase-negative staphylococcus in 14 (15%). Gram-negative, anaerobic, and fungal organisms accounted for only 13 (14%) of the confirmed cases. The mean duration of intravenous therapy was 29 days. Twenty (37%) of the native valve patients and 16 (40%) of the prosthetic valve patients received antibiotics on an outpatient basis. Vancomycin was used in 44 (47%) of the cases, nafcillin or ampicillin in 40 (44%), and other beta-lactam agents in 9 (10%). The mean hospital stay was significantly longer for prosthetic valve endocarditis patients than for those with native valve disease (29 versus 23 days; p < 0.01). Cardiac catheterization was performed in 9 native valve patients (17%) and 6 prosthetic valve patients (15%). Valve surgery was performed in 33 native valve patients (61%) and 22 prosthetic valve patients (55%). Failure, defined as in-hospital death or recurrent endocarditis, accounted for 14 (28%) of the native valve cases (17% death and 11% relapse) and 8 (20%) of the prosthetic valve cases (10% death and 10% relapse), for an overall failure rate of 24%. The rate of failure was independent of the infecting pathogen or the type of antimicrobial therapy applied. Our experience verified that, in many patients with significant underlying risk factors, the diagnosis of endocarditis may be made on an empiric basis.

Journal Article↗
PubMed2004

Infective endocarditis following orthotopic heart transplantation: 10 cases and a review of the literature.

BACKGROUND: Infective endocarditis is a known complication of cardiac transplantation. However, published information has been limited to case reports and small case series. METHODS: Cardiac transplantation has been performed at Temple University Hospital since 1983. We identified transplant patients with ICD-9 codes for endocarditis or bacteremia. A diagnosis of endocarditis required fulfillment of the Duke criteria and presence of a vegetation. Clinical and microbiologic data were collected. Demographic and survival information were compared with heart transplant recipients without endocarditis. We reviewed all previously published cases using a MEDLINE search. RESULTS: Ten of 659 heart transplant recipients had endocarditis (1.5%, 187 cases per 100,000 person years). Mitral and tricuspid valves were involved predominantly. No patient had aortic valve infection. Patients with tricuspid valve infection had a greater median number of endomyocardial biopsies (n=23) than those with mitral valve infection (n=9, P=0.10). The major pathogens were Staphylococcus aureus (4 cases) and Aspergillus fumigatus (3 cases). Factors associated with S. aureus infection were new hemodialysis catheters, cellulitis, and a contaminated donor organ. All patients with A. fumigatus had antecedent cytomegalovirus viremia and disseminated fungal infection, including endophthalmitis. Endocarditis-related mortality was 80%. Median survival after transplant was 1.4 years in patients with endocarditis, compared with 9.3 years in other heart transplant recipients (P<0.001). CONCLUSIONS: Endocarditis is substantially more common in heart transplant recipients than in general populations. Frequent central venous catheter access and multiple endomyocardial biopsies appear to predispose to infection. Aspergillus is a common pathogen and endocarditis follows infection elsewhere. The prognosis of post-cardiac transplant endocarditis is poor.

Adult↗
PubMed1992

Epidemiology of bacterial endocarditis in The Netherlands. I. Patient characteristics.

BACKGROUND: Studies of the epidemiology of bacterial endocarditis are usually based on a retrospective review of medical records from referral centers serving diverse patient populations. These studies are therefore likely to suffer from selection bias. We conducted a nationwide prospective epidemiologic study of endocarditis in the Netherlands. METHODS: During a 2-year period, all cases of consecutively hospitalized patients with suspected endocarditis in the Netherlands were reported to us. While hospitalized, patients were visited for an in-person interview and a review of the medical record. RESULTS: Of 559 episodes, 438 met the criteria for endocarditis; these included 89 episodes of prosthetic valve endocarditis and 349 episodes of native valve endocarditis. Adjusted for age- and sex-specific population figures, the incidence was 19 per million person-years. The incidence increased significantly with age, and men were more often affected than women (266 and 172 cases, respectively). Rheumatic and congenital cardiac lesions formed most of the underlying heart diseases. Mitral valve prolapse was present in only 29 patients with native valve endocarditis (8.3%). A history of intravenous drug abuse was present in 32 patients (7.3%). Viridans streptococci, staphylococci, and enterococci together constituted 86% of the isolated bacterial strains. Only 1.1% of the patients had culture-negative endocarditis. Overall case fatality was 19.7% and varied widely according to causative microorganism. CONCLUSION: The distribution of causal microorganisms, the case fatality rate, and the incidence rate of endocarditis are age related. Therefore, a meaningful comparison of data is only possible between population-based cohorts of patients with endocarditis.

Age Factors↗
PubMed2005

Diagnosis of infectious endocarditis in patients undergoing valve surgery.

PURPOSE: Histologic examination of valve samples is considered as the gold standard for the diagnosis of infectious endocarditis. Molecular tools are also very promising for patients with negative-culture endocarditis. Thus, we studied the contribution of valvular histology, culture, and 16S rRNA PCR amplification plus sequencing to the diagnosis of infectious endocarditis in patients undergoing valve surgery. SUBJECTS AND METHODS: We performed culture, histological examination, and broad-range PCR amplification plus sequencing on valve samples taken from 127 patients with infectious endocarditis and from 118 patients without endocarditis. The sensitivity and specificity of these tests for the diagnosis of endocarditis in patients undergoing valve surgery were studied. RESULTS: The sensitivity of PCR was of 61% (64/105) whereas that of histological examination was of 63% (62/98) and that of valve culture was of only 13% (14/105). All 68 positive PCR results considered reliable according to an interpretation scheme were from patients with infectious endocarditis, resulting in a 100% (118/118) specificity of the interpreted molecular approach. The specificity of histology was also of 100% (118/118) when using stringent criteria (ie, presence of vegetation, microorganisms, and/or valvular inflammation with mainly polymorphonuclear cells). PCR identified an etiological agent in 38% (5/13) of definite blood culture-negative infectious endocarditis. CONCLUSION: We show that valvular histology with stringent criteria is the gold standard for the diagnosis of infectious endocarditis. Broad-range amplification of 16S rRNA gene is indicated for infectious endocarditis of unknown etiology, whereas valve culture is of limited sensitivity.

Adult↗
PubMed2005

Cryopreserved aortic viable homograft for active aortic endocarditis.

BACKGROUND: To evaluate the short and long-term results of cryopreserved aortic viable homograft (CAVH) in the treatment of active aortic endocarditis. METHODS: From January 1992 to December 2002, 104 patients (23 females, 81 males) with a mean age 51 +/- 13 years (from 14 to 77) underwent CAVH replacement for active aortic valve endocarditis. Seventy-six patients (73%) had endocarditis of the native aortic valve, 28 (27%) had endocarditis of prosthetic aortic valve; among them, eight had a recurrent infection. Eighty-three patients (80%) had isolated aortic endocarditis. Plurivalvular endocarditis was observed in 21 (20%) patients, (aortic and mitral in 16 patients, aortic and tricuspid in 5). Intraoperative transesophageal echocardiography was systematically used. Anatomical lesions included perforations in 89 (86%) patients, vegetations in 79 (77%) patients and periannular extensions in 60 (58%) patients. Precise bacteriologic diagnosis was available in 82 (80%) patients. RESULTS: Cryopreserved aortic viable homografts were inserted using the aortic root replacement technique in 93 (89%) patients and the subcoronary technique in 11 (11%) patients. Associated procedures were performed in 38 (37%) patients: mitral (n = 23) and tricuspid (n = 3) valve repair, partial homograft mitral valve replacement (n = 3), partial homograft tricuspid valve replacement (n = 3), coronary bypass graft (n = 3), and ascending aorta replacement (n = 3). Hospital mortality was 5 (5%) patients. Causes of death included: myocardial infarction (n = 2), myocardial failure (n = 2), and multiorgan failure (n = 1). During follow-up (61 +/- 36 months, from 6 months to 136 months), 9 secondary deaths occurred (2 were cardiac related), 14 aortic valvular redo surgeries were performed (2 for nonstructural failure, 6 for structural failure, and 6 for endocarditis). Actuarial survival at ten years was 83%, with 93% of the patients free from cardiac death. At ten years, actuarial rate for freedom from reoperation was 76% and freedom from recurrent endocarditis was 93%. No thromboembolic complications were observed. CONCLUSIONS: The CAVH has proven its effectiveness in treating the destructive lesions of active aortic endocarditis. It has provided satisfactory immediate and long-term results. Allowing the possibility to avoid a prosthetic material, CAVH could represent an option for surgically treating active aortic endocarditis more rapidly.

Adolescent↗
PubMed2006

Risk factors of prosthetic valve endocarditis: a case-control study.

BACKGROUND: Prosthetic valve endocarditis is an important cause of the morbidity and mortality associated with heart valve replacement surgery. The objective of this study was to assess risk factors of prosthetic valve endocarditis related to patients, perioperative events, and postoperative complications. METHODS: This was a retrospective case-control study conducted in a tertiary care hospital in Santander, Spain, from January 1986 to January 1998. Cases were patients with "definite" and "possible" infective endocarditis defined according to the Durack criteria. Controls were patients undergoing prosthetic valve replacement who at the time of the study had not developed infective endocarditis. Information was abstracted from medical records. Cases and controls (1:2) were matched by sex, age at operation (+/- 5 years), surgery of one or more valves in the same anatomic position, and date of operation (+/- 6 months). RESULTS: There were 81 cases and 162 controls. In the multivariate analysis, risk factors significantly associated with prosthetic valve endocarditis were functional class III or IV (New York Heart Association), alcohol consumption, prior history of endocarditis, fever in the intensive care unit, and gastrointestinal bleeding. Functional class III or IV and complications of the surgical wound were independent predictors of early infective endocarditis, whereas fever in the intensive care unit and gastrointestinal bleeding were predictors of prosthetic valve endocarditis late after operation. CONCLUSIONS: Patients with prosthetic valve endocarditis differ from people without infective endocarditis with regard to intrinsic and postoperative risk factors but not regarding perioperative-related variables.

Case-Control Studies↗
PubMed2006

Outcome after mitral valve repair for acute and healed infective endocarditis.

OBJECTIVE: To evaluate the long-term clinical and echocardiographic outcomes after mitral valve surgery for acute and healed infective endocarditis. METHODS: Of 37 consecutive patients presenting with native mitral valve endocarditis, mitral valve repair (MVRep) was feasible in 34 (92%) patients. In 17 (50%) patients, surgery was indicated during antibiotic therapy (acute endocarditis), whereas 17 (50%) underwent surgery after antibiotic therapy was completed (healed endocarditis). Patients were evaluated for early and long-term clinical and echocardiographic outcome. RESULTS: In-hospital death occurred in two (6%) patients and two (6%) died during follow-up, with a 2-year survival of 100% in healed endocarditis as compared to 76% (p=0.03) in patients undergoing surgery in acute endocarditis. No patient with acute endocarditis needed repeat mitral valve surgery. Three (9%) patients underwent re-operation because of early mitral regurgitation (n=1) or late recurrent endocarditis (n=2). The average grade of mitral regurgitation was 3.8+/-0.4 (all grades 3 to 4+) before surgery and 0.6+/-0.8 during follow-up (p<0.001). Significant reductions in left atrial (from 52+/-8mm to 46+/-8mm, p=0.004), left ventricular end-diastolic (from 61+/-8mm to 54+/-8mm, p=0.001), and end-systolic dimensions (from 41+/-8mm to 36+/-9 mm, p=0.02) were observed during follow-up, compared to preoperative dimensions. Of note, significant reverse remodeling was only observed in patients undergoing surgery in healed endocarditis. CONCLUSION: MVRep for mitral valve endocarditis is feasible with good clinical results, maintained valve competency with significant reductions in left atrial and left ventricular dimensions after surgery.

Acute Disease↗