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PubMed1996

Tricuspid valve reconstruction, a treatment option in acute endocarditis.

Tricuspid valve endocardititis is treated surgically by total valve excision or valve replacement. Both procedures are controversial with regard to the hemodynamic consequences and to the long-term prognosis. In the following, results of tricuspid valve repair in acute infective endocarditis are reported and discussed as an additional treatment option. Between January 1988 and December 1993, 118 patients were operated on for acute valve endocarditis at our institution. Eleven of these patients had tricuspid valve endocarditis, isolated (n = 7) or combined with endocarditis of a left-sided valve (n = 4). In the cases with isolated tricuspid valve endocarditis, the indication for surgery was intractable infection in six and hemodynamically relevant tricuspid insufficiency in one out of seven patients. In all patients with associated left-sided endocarditis, the indication was hemodynamic deterioration. In eight patients the tricuspid valve endocarditis was treated as follows: debridement, vegectomy, patch reconstruction of the cusps, reducing the cusps to two. In three patients reconstruction was not possible because of extensive involvement of all parts of the valve, including the valve ring and the papillary muscles. In these patients primary valve replacement (n = 1) or valve excision with secondary replacement (n = 2) was performed. In four patients tricuspid reconstruction was combined with mitral (n = 1), aortic (n = 1) or double valve replacement (n = 2). Postoperatively, signs of infection vanished in all surviving patients (n = 10) and tricuspid valve endocarditis healed without recurrences. Implanted prosthetic material did not lead to recurrent infection. One patient died early postoperatively after valve excision, in septic shock and multi-organ failure. In seven patients late echocardiographic follow-up showed tricuspid regurgitation grade 0 in three patients, I in two, II in one and III in one. Our results suggest that valve repair is a reasonable treatment option for tricuspid valve endocarditis in all cases with localized infection of the valve. Only if extensive valve destruction excludes valve repair, would we now favor primary valve replacement over simple valvulectomy. In all other cases primary valve reconstruction is the treatment of choice for tricuspid valve endocarditis, if surgery is indicated.

Acute Disease↗
PubMed2002

Nosocomial enterococcal endocarditis: a serious hazard for hospitalized patients with enterococcal bacteraemia.

OBJECTIVES: Enterococci are a major leading cause of infectious endocarditis and also a common cause of hospital-acquired bacteraemia, which is not believed to represent a serious hazard for the endocarditis. The incidence and risk factors for infectious endocarditis in patients with hospital-acquired enterococcal bacteraemia is determined. METHODS: Prospective analysis of 116 patients with enterococcal bacteraemia admitted to medical or surgical wards of a tertiary-care, university affiliated hospital during a period of 5 years. Echocardiography was performed when indicated by clinical criteria. RESULTS: Seventy-five (61.4%) episodes were hospital-acquired and 47 (38.5%) were community-acquired. Most patients had one or more underlying chronic diseases and major abdominal (58.6%) or genitourinary (38.6%) surgery. Seventeen patients (14.6%) developed enterococcal endocarditis. By univariate analysis the risk factors associated with endocarditis were community-acquired infection (P 0.012); monomicrobial bacteraemia (P 0.006); three or more positive blood cultures (P < 0.001); underlying valvulopathy (P < 0.001); presence of a prosthetic valve (P < 0.001) and age (P 0.012). Six patients (8%) developed nosocomial endocarditis. In this group of patients, three or more positive blood cultures (P < 0.01), bacteraemia as a result of Enterococcus faecalis (P 0.007); underlying valvulopathy (P < 0.001) and presence of a prosthetic valve (P < 0.001) were associated with endocarditis. By logistic regression, the presence of underlying valvulopathy and three or more positive blood cultures were associated with endocarditis (OR 21.0; CI 95% 1.65-26.9; P 0.019). CONCLUSIONS: The risk of developing infectious endocarditis in patients with hospital-acquired enterococcal bacteraemia is significant. Patients with underlying valvulopathy and three or more positive blood cultures with E. faecalis are prone to nosocomial enterococcal endocarditis.

Adult↗
PubMed1995

The risk of infective endocarditis after cardiac surgical and interventional procedures.

The risk of infective endocarditis after cardiac surgery relates mainly to the risk of infective endocarditis on prosthetic valves. The frequency of prosthetic infective endocarditis varies according to the criteria used in the literature, ranging from 0.4 to 1.3% for early infective endocarditis, with an annual linear risk of late infective endocarditis of 0.5%. This figure seems to be independent of either the type or the location of prostheses, but it does nevertheless increase if more than one valve has been replaced. The most commonly isolated microorganisms in early infective endocarditis are staphylococci. The bacteriological findings in late prosthetic infective endocarditis are similar to those seen in the native disease. The portal of entry is more easily identified in early than in late infective endocarditis (50%). The risk of infective endocarditis in surgically treated congenital heart disease is very low when the patient has a left-to-right shunt or valvar stenosis; it increases amongst patients with tetralogy of Fallot and patients with complex cyanotic congenital heart disease, mainly when there is a residual ventricular septal defect or prior palliative surgery. The risk of infective endocarditis in patients with intracavitary electrodes such as pacemakers and defibrillators, after the interventional procedure itself and after heart transplant, is very low. This leads us to conclude that antibiotic prophylaxis is only warranted in those patients with a prosthetic valve and after surgical treatment of tetralogy of Fallot and other complex cyanotic congenital heart diseases.

Cardiac Surgical Procedures↗
PubMed1983

Imipenem therapy of experimental Staphylococcus aureus and Streptococcus faecalis endocarditis.

Imipenem was very active in vitro against 36 Staphylococcus aureus isolates from cases of infective endocarditis; the MBC90 was 0.06 mg/l (four- to eight-fold more active than nafcillin). The in-vitro activity of imipenem against 22 Streptococcus faecalis isolates from proven endocarditis cases was similar to that of penicillin G (MBC90 = 8 mg/l). Imipenem was compared with nafcillin and with penicillin plus gentamicin in the therapy of experimental endocarditis induced in rabbits by Staph. aureus and Str. faecalis, respectively. The dosages were chosen to simulate closely serum antibiotic concentrations found in humans receiving standard parenteral regimens. Imipenem was more rapidly bactericidal than nafcillin in experimental staphylococcal endocarditis. The mean +/- S.D. Staph. aureus concentrations within aortic valve vegetations (log10 cfu/g) after 5 days of therapy were as follows: imipenem = 1.39 +/- 0.61 versus nafcillin 2.39 +/- 0.36 (P less than 0.02). Both the imipenem and nafcillin regimens resulted in 'sterile' vegetations in congruent to 50% of rabbits with experimental staphylococcal endocarditis after 5 days of therapy (P greater than 0.05). Imipenem was also equivalent to penicillin plus gentamicin in the therapy of experimental enterococcal endocarditis for 5 days, as assessed by the mean cfu/g vegetation and the percentage of vegetations rendered sterile. However, 7 days of therapy cured experimental enterococcal endocarditis in 72% of rabbits receiving penicillin plus gentamicin versus 20% for imipenem alone (P less than 0.05). Imipenem deserves further evaluation in the therapy of infective endocarditis, both in experimental animal models of infection and in humans. This agent may prove useful in the therapy of staphylococcal endocarditis in a variety of difficult clinical situations. Therapy of enterococcal endocarditis with imipenem alone is not advisable, pending further data.

Animals↗
PubMed1990

Nonenterococcal group D streptococcal septicemia: association with unrecognized endocarditis.

68 patients presented to the Veterans General Hospital, Taipei with nonenterococcal group D streptococcal septicemia in the years 1985-1987. 36 patients (53%) had nonenterococci as part of a polymicrobial bacteremia. The large intestine was not examined in most patients. Five patients (7%) had associated colonic carcinoma, and 17 patients (25%) had colorectal diseases. Only 7/68 patients (10%) were clinically diagnosed as having infective endocarditis by the doctors in charge. The others were regarded as having septicemia. The charts of these patients were reviewed retrospectively to diagnose infective endocarditis based on strict definitions. One (1%) had definite endocarditis proved at autopsy. 16 patients (24%) had probable endocarditis due to the presence of either a new regurgitant murmur or both a predisposing heart disease and embolic phenomena; 39 (57%) had possible endocarditis based on evidence of having either a predisposing heart disease or embolic phenomena; and only 12 (18%) had no evidence of endocarditis. 27 patients (40%) had at least one predisposing heart disease associated with endocarditis. 51 patients (75%) had at least one lesion suggesting embolic phenomena. 30 patients (44%) had electrocardiographic abnormalities. This high incidence of arrhythmia in nonenterococcal septicemia is of particular interest and could be related to cardiac involvement in some patients. The overall mortality, 62% (42/68), was extremely high in our series, but in those who were clinically diagnosed and treated as infective endocarditis, the mortality was low, 14% (1/7). We suggest all patients with nonenterococcal septicemia associated with either heart disease or lesions of CNS, lung, heart, kidney or limbs suggesting embolic phenomena should be regarded as having possible or probable endocarditis. Treating such patients as having infective endocarditis may reduce the mortality in nonenterococcal septicemia.

Adult↗
PubMed2003

Can structured clinical assessment using modified Duke's criteria improve appropriate use of echocardiography in patients with suspected infective endocarditis?

BACKGROUND: Although echocardiography has been incorporated into the diagnostic algorithm of patients with suspected infective endocarditis, systematic usage in clinical practice remains ill defined. OBJECTIVE: To test whether the rigid application of a predefined standardized clinical assessment using the Duke criteria by the research team would provide improved diagnostic accuracy of endocarditis when compared with usual clinical care provided by the attending team. METHODS: Between April 1, 2000 and March 31, 2001, 101 consecutive inpatients with suspected endocarditis were examined prospectively and independently by both teams. The clinical likelihood of endocarditis was graded as low, moderate or high. All patients underwent transthoracic echocardiography and appropriate transesophageal echocardiography if deemed necessary. All diagnostic and therapeutic outcomes were evaluated prospectively. RESULTS: Of 101 consecutive inpatients (age 50+/-16 years; 62 males) enrolled, 22% subsequently were found to have endocarditis. The pre-echocardiographic likelihood categories as graded by the clinical and research teams were low in nine and 37 patients, respectively, moderate in 83 and 40 patients, respectively, and high in nine and 24 patients, respectively, with only a marginal agreement in classification (kappa=0.33). Of the 37 patients in the low likelihood group and 40 in the intermediate group, no endocarditis was diagnosed. In 22 of 24 patients classified in the high likelihood group, there was echocardiographic evidence of vegetations suggestive of endocarditis. Discriminating factors that increased the likelihood of endocarditis were a prior history of valvular disease, the presence of an indwelling catheter, positive blood cultures, and the presence of a new murmur and a vascular event. General internists, rheumatologists and intensive care physicians were more likely to order echocardiography in patients with low clinical probability of endocarditis, of which pneumonia was the most common alternative diagnosis. CONCLUSION: Although prediction of clinical likelihood varies between observers, endocarditis is generally found only in those individuals with a moderate to high pre-echocardiographic clinical likelihood. Strict adherence to indications for transthoracic echocardiography and transesophageal echocardiography may help to facilitate more accurate diagnosis within the moderate likelihood category. Patients with low likelihood do not derive additional diagnostic benefit with echocardiography although other factors such as physician reassurance may continue to drive diagnostic demand.

Adult↗
PubMed1989

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

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

Adolescent↗
PubMed1989

[Surgical management of infective endocarditis].

We reviewed fourty-six patients who had undergone surgery for infective endocarditis in the past fifteen years and identified risk factors affecting the outcome. Twenty-nine patients had infection of the native valve only, 11 had infective endocarditis associated with congenital heart disease, and 6 had prosthetic valve endocarditis. Overall hospital mortality was 6.5%. Prosthetic valve endocarditis carried a higher mortality (33%) than native valve endocarditis (3.4% or congenital heart disease with infective endocarditis (0%). For the patients with active endocarditis, the early mortality rate was higher (13%) than with inactive endocarditis (3.2%). Staphylococcal infections were more likely to cause severe valve destruction and residual infection than streptococcal infection. Our results indicated that surgical management of infective endocarditis should be done after the completion of adequate antibiotic therapy. Early diagnosis should reduce the mortality, prevent fatal complications, and lead to qualitative improvement of infective endocarditis.

Adolescent↗
PubMed1984

The use of beta-lactam antibiotics in the treatment of septicaemia and endocarditis.

Despite the availability of numerous beta-lactam antibiotics, benzylpenicillin remains the most important beta-lactam antibiotic in the treatment of bacterial endocarditis. Penicillin alone and in combination with an aminoglycoside is effective in the treatment of endocarditis due to all streptococci, Streptococcus pneumoniae, penicillin-susceptible Staphylococcus aureus, Haemophilus aprophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Listeria monocytogenes. Oral phenoxymethylpenicillin in combination with streptomycin is effective in treating endocarditis due to viridans streptococci. Ampicillin is effective in endocarditis due to Haemophilus influenzae, H. parainfluenzae, H. paraphrophilus, Listeria monocytogenes and Escherichia coli. Oral amoxicillin with gentamicin has been used to treat enterococcal endocarditis. The penicillinase-resistant penicillins are effective in treating S. aureus endocarditis. Carbenicillin or ticarcillin in combination with tobramycin or gentamicin are used to treat endocarditis due to Serratia marcescens and Pseudomonas aeruginosa. The use of piperacillin in combination with tobramycin against P. aeruginosa endocarditis has been associated with failure and increased resistance. The cephalosporins have been used to treat endocarditis caused by susceptible organisms. There have been few data on the efficacy of the newer cephalosporins in treating endocarditis. They have been used to treat septicaemia due to susceptible organisms with good results.

Amoxicillin↗
PubMed1994

[Infective endocarditis today; heart surgery in its treatment: how and when].

The authors report the experience of 161 surgical cases operated between 1980 and 1992 because of valve endocarditis. Two hundred and two surgical procedures were performed. Patients were divided into two groups: Group I (EN) considered 117 patients with endocarditis on the native valve; Group II (EP) included 64 patients with prosthetic endocarditis. In 23 patients the prosthesis was implanted for previous endocarditis on the native valve (EP1); in 41 patients the prosthesis was implanted for other valve diseases (EP2). Each group was described according to sex, age, site of endocarditis, previous cardiac diseases, socio-economical level, hemodynamic and infective conditions at surgery, etiology of endocarditis, surgical indication, pathology report, surgical procedure and results. The results were evaluated considering surgical mortality, late mortality and recurrence of endocarditis. The main risk factors were correlated to overall survival and recurrency. Hospital mortality was 7.6% in EN, 13% in EP1, 36.5% in EP2; endocarditis recurrency was 20.3% in EN, 65% in EP1, 19.2% in EP2. Sixteen patients with prosthetic endocarditis were submitted to a second reoperation with 50% mortality; 4 patients to a third reoperation with 50% mortality; 1 patient to a fourth reoperation with no mortality. Actuarial overall survival was 40.3% at 12 years in Group EN, 33.3% at 12 years in Group EP1, 73.4% at 12 years in Group EP2. Finally the Authors report the experience of 12 stentless grafts (autologous, homologous and eterologous) implanted between March 1991 and July 1994 in patients with valve or prosthetic endocarditis with no recurrency at 42 months of follow-up.

Actuarial Analysis↗
PubMed1994

[Neurologic complications of infective endocarditis].

BACKGROUND: Neurologic involvement is a frequent cause of morbidity and mortality in patients with endocarditis. The aim of this study was to evaluate the most relevant clinical, epidemiologic and evolutive characteristics of patients presenting neurologic complications during the evolution of endocarditis. METHODS: Fifty adult non intravenous drug addict patients who had neurologic complications during endocarditis were prospectively evaluated. The presence of cerebral ischemia, hemorrhage, or infectious complications were studied by established criteria. RESULTS: Neurologic complications were detected in 50 of the 282 patients (18%) with endocarditis diagnosed over 17 years in one institution. The most common complications were seen in patients with mitral endocarditis of either native valves (28%) or prosthetic valves (30%). The prevalence was identical in the endocarditis of either type of valve (18%). The most frequent complication was cerebral ischemia (29 episodes) and central nervous system infection (8 episodes). Fifty-nine percent of the complications presented prior to the diagnosis of endocarditis with half of the remaining 41% occurring during the first 2 weeks of antibiotic treatment. Endocarditis by Staphylococcus aureus was associated with neurologic complications in 40% of the cases. Global mortality was 48%, being related with prosthetic endocarditis, the existence of cerebral hemorrhage or central nervous system infection, etiology by S. aureus and the presence of anticoagulant treatment. CONCLUSIONS: Neurologic complications are frequent during the evolution of infectious endocarditis, both or an initial feature and during its evolution. The presence of complications considerably impairs the prognosis of this disease.

Adolescent↗
PubMed1996

[Aminoglycosides in the treatment of infectious endocarditis].

The role of aminoglycosides in the treatment of infective endocarditis is well established. The combination of a beta-lactam with an aminoglycoside shortens the treatment of endocarditis due to penicillin-sensitive streptococci (MIC < or = 0.1 micrograms/mL) when compared to beta-lactams alone. Patients at higher risk (e.g. with prosthetic valves, clinical duration of symptoms > 3 months) should be treated with penicillin for 4 weeks in combination with an aminoglycoside for 2 weeks. Once-daily dosing (ODD) of aminoglycosides can be recommended in penicillin-sensitive streptococcal endocarditis. The treatment of endocarditis due to streptococci relatively and/or highly resistant to penicillin requires combined treatment with penicillin plus an aminoglycoside for a longer duration. At present ODD of aminoglycosides cannot be recommended. Enterococcal endocarditis requires combined treatment for 4 to 6 weeks. Based upon experimental data, ODD of aminoglycosides appears to be markedly inferior to q 8 h dosing. Enterococcal isolates should be screened for high-level resistance to streptomycin and gentamicin. Gentamicin is the preferred agent if susceptibility testing is not performed. Aminoglycosides are administered during the initial 3 to 5 days of treatment for staphylococcal endocarditis on native valves in order to shorten the duration of bacteremia. For staphylococcal prosthetic valve endocarditis, aminoglycosides are administered for the initial 2 weeks of treatment. However, there are no reliable clinical data for methicillin-susceptible isolates to support this recommendation. In prosthetic valve endocarditis due to coagulase-negative staphylococci combination with an aminoglycoside appears to suppress the emergence of rifampin-resistant variants during treatment. There are no data on ODD of aminoglycosides in staphylococcal endocarditis. Right-sided staphylococcal endocarditis due to methicillin-susceptible staphylococci is adequately treated with a two-week course of a beta-lactam plus an aminoglycoside. This short regimen can be recommended for low risk patients, e.g. those without significant heart failure and vegetations < 2 cm3 and with an aminoglycoside-susceptible isolate.

Aminoglycosides↗
PubMed1997

[Nosocomial infective endocarditis in patients without hear prosthesis].

BACKGROUND: Infective endocarditis is a complication of nosocomial bacteremia and is associated with a high mortality rate. The objective of the present study was to know the clinical and microbiological characteristics of nosocomial endocarditis (NE) diagnosed in a general hospital in a five-year period. PATIENTS AND METHODS: Twenty-one patients diagnosed of NE following Durack's criteria at Juan Canalejo Hospital from January 1990 to January 1995 were studied. Endocarditis in patients with cardiac valve prosthesis were excluded. RESULTS: NE represented 12% of the total endocarditis cases diagnosed during the study period. The mean age of patients was 52.6 years (range: 17-79 years) and male accounted for 81% of cases. NE was related to an intravascular catheter in 85.7% of cases, whereas a urinary source was found in 14.3%. Staphylococcus aureus was the microorganism recovered most frequently (62%), followed by Staphylococcus epidermidis (20%), which was always associated with intravascular catheters. Left valve involvement predominated (76.2%) and the involvement of right cavities was detected exclusively in patients with an intravascular catheter as known source of NE. Transoesophageal echocardiography detected vegetations in 19% of cases in which transthoracic echography failed to identify them. Surgery was required by 28.5% of patients and its indication was always congestive heart failure refractory to medical treatment. The overall mortality rate was 28.5%, compared with 26.8% in community acquired endocarditis. Two patients with Candida spp. endocarditis were not treated surgically and the outcome was satisfactory. CONCLUSIONS: Nosocomial endocarditis represent a significant percentage of endocarditis once endocarditis on prosthetic cardiac valves has been excluded. To remark Staphylococcus spp. in the etiology of this entity, the intravascular catheter as risk factor, and left cavities as location. Transoesophageal echocardiography is of great diagnostic usefulness. In contrast with reports in literature, the mortality rate in our series was similar to that of community endocarditis.

Adolescent↗
PubMed1997

[A review of infectious endocarditis due to Candida].

OBJECTIVE: As fungal endocarditis is a serious disease, frequently requiring cardiac surgery, a review was made of the experience of our Departments in this pathology. DESIGN: A retrospective analysis of clinical, echocardiographic and surgical data. SETTING: Patients studied in a tertiary care Hospital with cardiac surgery available. PATIENTS: Between 1984 and 1994 there were ten cases of candida endocarditis in nine patients, four male and five female, mean age--45 +/- 12 years (31-65). INTERVENTIONS: The following parameters were analysed: clinical (predisposing factors, clinical evolution, complications, therapy and mortality), echocardiographic (presence of vegetations, abscesses, valvular regurgitations). Patients studied in other Centres and referred to our Department only for examination (echocardiograms) were excluded from this analysis. RESULTS: Eight cases in seven patients were prosthetic valve endocarditis and two native valve endocarditis. No patient was drug addicted. Seven cases of prosthetic valve endocarditis developed less than one year after surgery and another had a gynecological fungal infection as the cause of the endocarditis. Four patients had had previous endocarditis. There were four embolic events and three developed heart failure. There were three perivalvular infections, six valvular regurgitations and only one case with huge vegetations on echocardiography. Nine patients were treated with amphotericin B, in five fluocytosin was added and in four ketoconazol, which was replaced by flukonazol in one patient. Therapy was continued for at least eight weeks. Six patients were operated during the acute stage and one died. One patient was operated on late after the infection. Three patients died during the active stage. In a follow up of 5.2 +/- 4.8 years (8 months to 8 years) there was one fatal candida endocarditis relapse, one fatal candida sepsis, one non cardiac death, one patient developed a periprosthetic leak and one had recurrent systemic embolization. Abscesses/pseudoaneurysms were found in five out of seven patients submitted to surgery. CONCLUSION: Candida infective endocarditis has a bad prognosis, specially in those patients not operated early; it develops in patients with predisposing factors, which in our series were a previous infective endocarditis (four patients) and/or a prosthetic valve implantation less than one year before; it has important morbidity with multiple embolic events, perivalvular involvement, valvular regurgitation and heart failure.

Adult↗
PubMed1999

Echocardiography in patients with suspected endocarditis: a cost-effectiveness analysis.

PURPOSE: We sought to determine the appropriate use of echocardiography for patients with suspected endocarditis. PATIENTS AND METHODS: We constructed a decision tree and Markov model using published data to simulate the outcomes and costs of care for patients with suspected endocarditis. RESULTS: Transesophageal imaging was optimal for patients who had a prior probability of endocarditis that is observed commonly in clinical practice (4% to 60%). In our base-case analysis (a 45-year-old man with a prior probability of endocarditis of 20%), use of transesophageal imaging improved quality-adjusted life expectancy (QALYs) by 9 days and reduced costs by $18 per person compared with the use of transthoracic echocardiography. Sequential test strategies that reserved the use of transesophageal echocardiography for patients who had an inadequate transthoracic study provided similar QALYs compared with the use of transesophageal echocardiography alone, but cost $230 to $250 more. For patients with prior probabilities of endocarditis greater than 60%, the optimal strategy is to treat for endocarditis without reliance on echocardiography for diagnosis. Patients with a prior probability of less than 2% should receive treatment for bacteremia without imaging. Transthoracic imaging was optimal for only a narrow range of prior probabilities (2% or 3%) of endocarditis. CONCLUSION: The appropriate use of echocardiography depends on the prior probability of endocarditis. For patients whose prior probability of endocarditis is 4% to 60%, initial use of transesophageal echocardiography provides the greatest quality-adjusted survival at a cost that is within the range for commonly accepted health interventions.

Adult↗
PubMed1995

Surgical management of infective endocarditis associated with cerebral complications. Multi-center retrospective study in Japan.

To establish guidelines for the surgical treatment of patients with infective endocarditis who have cerebrovascular complications, we conducted a detailed retrospective study of 181 of 244 patients with cerebral complications among 2523 surgical cases of infective endocarditis of the Japanese Association of Thoracic Surgery. The results showed that 9.7% of all patients with infective endocarditis had associated cerebral complications: 108 (44.3%) had active native valve endocarditis, 96 (39.3%) had healed native valve endocarditis, and 40 (16.4%) had prosthetic valve endocarditis. The hospital mortality of the patients with cerebral complications was 11.0% in the group as a whole: 13.9% in active native valve endocarditis, 3.1% in healed native valve endocarditis, and 37.5% in prosthetic valve endocarditis. Diseased valves included the following aortic valve in 55.5%, mitral valve 49.8%, tricuspid valve in 1.3%, and pulmonary valve in 1.3%. In 181 patients with cerebral complications, organisms were detected as follows: gram-positive cocci in 133 (73.5% [Streptococcus in 85, Staphylococcus in 32]), gram-negative in 18 (9.9%), fungus in 11 (6.1%), and unknown in 64.6%, cerebral bleeding in 31.5%, cerebral abscess in 2.8%, and meningitis in 1.1%. Hospital mortality rate and an exacerbation rate of cerebral complications, including related death, according to the interval from onset of cerebral infarction to cardiac surgery, were as follows: 66.3% and 45.5% within 24 hours, 31.3% and 43.8% between 2 and 7 days, 16.7% and 16.7% between 8 and 14 days, 10.0% and 10.0% between 15 and 21 days, 26.3% and 10.5% between 22 and 28 days, and 7.0% and 2.3% over 4 weeks later, respectively. A significant correlation existed between the interval and the exacerbation of cerebral complications (tied p = 0.008). Preoperative risk factors affecting exacerbation of cerebral complications were as follows: (1) severity of cerebral complications (p = 0.006), (2) intervals (p = 0.012), and (3) uncontrolled congestive heart failure as indications for cardiac surgery (p = 0.014). One patient underwent a cardiac operation within 24 hours of the onset of cerebral hemorrhage and died of cerebral damage. No exacerbations occurred in 10 patients who underwent their operation between 2 and 28 days. Nevertheless, exacerbations occurred in 19.0% of patients whose operation was done more than 4 weeks later. These data suggest that cardiac operations can be done safely 4 weeks after cerebral infarction, and if the delay is more than 2 weeks, the exacerbation rate will be around 10%. The risk of progression of cerebral damage is still significant 15 days and even 4 weeks after cerebral hemorrhage.

Adult↗
PubMed1983

Prosthetic valve endocarditis: an overview.

Infection of an intracardiac prosthesis, the incidence of which is about 2.5% among patients having undergone valve replacement, is a serious complication with considerable morbidity and mortality. Early prosthetic valve endocarditis (PVE), with an onset within 60 days of valve replacement, accounts for approximately one-third of all cases, while the remaining two-thirds, occur more than two months postoperatively (late prosthetic valve endocarditis). Prosthetic valve endocarditis is most commonly caused by Staphylococcus epidermidis, less frequently by viridans streptococci, Staphylococcus aureus, and gram-negative bacilli. The most likely pathogenetic mechanisms in prosthetic valve endocarditis are intraoperative contamination and postoperative infections at extracardiac sites. Prominent clinical features include fever, new or changing heart murmurs, leukocytosis, anemia and hematuria. The etiologic microorganism can be isolated in more than 90% of all cases. Patients with proven prosthetic valve endocarditis should be examined daily to detect signs of congestive heart failure and changes in murmurs; electrocardiographic monitoring is essential for documentation of arrhythmias. With limitations, echocardiography, especially two-dimensional, may help to demonstrate vegetations or valvular dehiscence. Cinefluoroscopy may reveal loosening or dehiscence of the sewing ring or impaired motion of a radio-opaque poppet due to thrombus or vegetation. Cardiac catheterization, not always necessary even when surgical intervention is anticipated, may provide valuable information on the degree of dysfunction, multiple valve involvement, left ventricular function and extent of concomitant coronary artery disease. In patients with mechanical valves, prosthetic valve endocarditis may be associated with a high incidence of valve ring and myocardial abscesses; the reported frequency of valve ring abscesses is lower with porcine heterografts. Infections on mechanical valves characteristically localize to the sewing ring with subsequent detachment of the prosthesis and valvular incompetence; infections on porcine heterografts tend to localize to the cusps, leading to valvular incompetence because of leaflet destruction. Large vegetations may result in functional stenosis. Over the last ten years the overall mortality of prosthetic valve endocarditis was 53.8%; 73.6% in early and 43% in late prosthetic valve endocarditis. More recently, however, the survival rate appears to be improving. In general, the mortality associated with prosthetic valve endocarditis caused by fungi and Staphylococcus aureus is highest and that of streptococci lowest.(ABSTRACT TRUNCATED AT 400 WORDS)

Anti-Bacterial Agents↗
PubMed1992

Epidemiology of bacterial endocarditis in The Netherlands. II. Antecedent procedures and use of prophylaxis.

BACKGROUND: The reported frequency with which endocarditis is ascribed to an antecedent dental or medical procedure varies from 3% to 62%. METHODS: We performed a nationwide prospective study of the epidemiology of bacterial endocarditis in the Netherlands. During a 2-year period, all consecutively hospitalized patients suspected of having endocarditis were visited while still hospitalized for a review of the medical record and an in-person interview that focused on antecedent procedures and administered prophylaxis. All information was checked with pharmacists and dental and medical practitioners. RESULTS: Of 427 patients with late prosthetic or native valve endocarditis, 275 were eligible for antibiotic prophylaxis because of a previously known cardiac lesion (n = 197) or a prosthetic valve (n = 78). Of these 275 patients, 64 (23.3%) had undergone a procedure with an indication for prophylaxis within 180 days of onset; in 31 (11.3%) the procedures had been within 30 days of onset. Antibiotic prophylaxis had been administered to 17 (26.6%) of the 64 patients and to eight (25.8%) of the 31 patients. CONCLUSION: The results indicate that medical and dental procedures cause only a small fraction of endocarditis. The majority of patients develop the disease along other routes. For an incubation period of 180 days, full compliance with prophylaxis might have prevented endocarditis in 47 (17.1%) of 275 patients with late prosthetic or native valve endocarditis involving a previously known cardiac lesion who underwent a procedure with an indication for prophylaxis. For an incubation period of 30 days, prophylaxis might have prevented endocarditis in 23 (8.4%) of these 275 patients, or 5.3% of all patients with endocarditis (n = 427).

Anti-Bacterial Agents↗