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PubMedDate not supplied

The surgical treatment of infective endocarditis.

We have reviewed 108 cases of bacterial endocarditis treated surgically since 1968. The mean age of the patients was 47.7 +/- 15.6 years (+/- SD) (range, 14-79 yr). Seventy-seven percent were male. The most common causative organisms were staphylococci (46%), streptococci viridans group (5%), and other streptococci (20%). Forty-five percent, 25%, and 13% of patients had native aortic valve, native mitral valve, or native double valve (AV/MV) involvement, respectively. Eighteen patients had prosthetic valve endocarditis. No patient underwent surgery for tricuspid valve endocarditis. Seventy-three patients were considered to have active endocarditis (AE) (positive blood or tissue cultures and/or annular abscess). The 35 remaining patients had healed endocarditis (HE). Preoperative complications in patients with either AE or HE were stroke (11%, 11%), renal failure (33%, 3%; p less than 0.001), pulmonary edema (83%, 34%; p less than 0.001), anemia (36%, 8%; p less than 0.01), and inotrope dependence (22%, 6%; p less than 0.05). Hospital mortality for native valve AE was 19.5% (11/56), and for healed endocarditis, 5.7% (2/35). Independent predictors of hospital mortality were inotrope dependence (p less than 0.001), annular abscess (p less than 0.01), pulmonary edema (p less than 0.01), and staphylococcal infection (p less than 0.05). The 5-year actuarial survival for operative survivors was 68.4 +/- 7.5% (AE) and 78.3 +/- 9.2% (HE). We conclude that the operative mortality for patients with continuing sepsis is high and that surgery should be undertaken early in staphylococcal endocarditis. If surgery is successful, then the long-term prognosis is good.

Adolescent↗
PubMedDate not supplied

Legionella micdadei prosthetic valve endocarditis.

Legionella usually causes pneumonia, but occasionally is in the differential diagnosis of "culture negative endocarditis" which sometimes involves prosthetic heart valves. Legionella prosthetic valve endocarditis is nearly always due to Legionella pneumophila and its clinical presentation is indistinguishable from other causes of prosthetic valve endocarditis. Diagnosis of Legionella prosthetic valve endocarditis is by recovery of the organism from the blood, demonstration or isolation of the organism from the prosthetic heart valve, or by persistently high Legionella titers which are extremely elevated in prosthetic valve endocarditis compared to Legionella pneumonia. We believe this is the first case reported of prosthetic valve endocarditis caused by Legionella micdadei, and the first case of Legionella prosthetic valve endocarditis with microscopic hematuria.

Aged↗
PubMed1997

[Tricuspid valve endocarditis. Demonstration of a rare disease exemplified with 3 case reports].

BACKGROUND: Endocarditis of the tricuspid valve is a rare form of valvular endocarditis and occurs mainly in patients with special risk factors. CASE REPORTS: The three case reports demonstrate 3 young patients (age 30 to 37 years, 2 female and 1 male) with a typical history of those risk factors. The two women were intravenous drug addicts and one of them had suffered already an episode of tricuspid valve endocarditis several years ago. The man developed his infection after implantation of a pacemaker. In all of the three patients the endocarditis was due to infection with staphylococci twice staphylococcus epidermidis and once staphylococcus aureus. In two of the three patients the endocarditis could not be cured by intravenous antibiotics alone and these patients had to undergo cardiac valvular surgery. All patients left the hospital after several weeks without signs of infection. CONCLUSION: In clinical praxis the introduction of a special endocarditis service, a small team which has to be consulted in every suspected case of endocarditis, seems to be beneficial as well as the use of the Duke criteria for diagnosis in those cases.

AIDS-Related Opportunistic Infections↗
PubMed2006

Bartonella henselae endocarditis in a child.

14-year-old white male with a past medical history of congenital bicuspid aortic valve, Streptococcus viridans endocarditis, and pulmonary valve homograft presented with culture-negative endocarditis. Molecular studies identified the causative organism as Bartonella henselae and subsequent serologic studies supported this diagnosis. This rare cause of endocarditis may be under recognized in children. Bartonella henselae endocarditis should be considered in all children with culture-negative endocarditis, and molecular studies using a polymerase chain reaction-based assay should be routinely utilized in the evaluation of all endocarditis cases that are culture negative to rapidly diagnosis this treatable cause of endocarditis.

Adolescent↗
PubMed1998

[Surgery of acute aortic valve endocarditis: prognosis in paravalvular abscess].

The occurrence of paravalvular abscesses in the course of an acute endocarditis of the aortic valve indicates an advanced stadium of the disease. The infection has spread beyond the limits of the valve leaflets, and ongoing destruction of the paravalvular tissue is to be expected, if the endocarditis is continually treated by antibiotics alone. Surgery of acute endocarditis with paravalvular abscess, however, supposedly carries an increased risk of early mortality and late morbidity. The following prospective study was carried out to determine whether a radical surgical approach together with aggressive postoperative antibiotic therapy could help to improve results. Between 1988 and 1995, 138 patients were operated during the acute phase of infective endocarditis; in 102 the aortic valve was involved. Among these, 44 had paravalvular abscesses at the time of surgery. The mean age of both groups was the same, but there was a higher rate of concomitant coronary artery disease, multiple valve involvement, advanced NYHA-class, and staphylococcal disease among the patients with abscesses. All interventions were carried out with cardiopulmonary bypass and cardioplegic arrest. The aortic valve was resected, abscesses were removed, and each part of potentially infected or necrotic tissue was resected as complete as possible, irrespective of the possibility to jeopardize the conduction system or to create large tissue defects. The aortic valve was replaced with a mechanical prosthesis in each case. The postoperative antibiotic regimen was specifically directed against the microorganisms isolated preoperatively; therapy was only modified, if signs of systemic infection did not disappear three days after surgery. The operative mortality was 10% among patients without an abscess and 11% in patients with a paravalvular abscess. Early recurrent endocarditis was recorded in two patients without and in only one patient with an abscess. Late recurrent endocarditis was noted in three patients; none of them had abscesses at the time of surgery. We conclude that the operative risk of acute endocarditis of the aortic valve with a paravalvular abscess does not have to be inevitably higher compared to cases without paravalvular involvement. To achieve these results, it is necessary to use a radical surgical approach and to adjust postoperative antibiotic therapy, if infectious signs do not disappear shortly after surgery.

Abscess↗
PubMed2006

Cardiobacterium hominis endocarditis: Two cases and a review of the literature.

Cardiobacterium hominis, a member of the HACEK group (Haemophilus parainfluenzae, Haemophilus aphrophilus, and Haemophilus paraphrophilus, Actinobacillus actinomycetemcomitans, C. hominis, Eikenella corrodens, and Kingella species), is a rare cause of endocarditis. There are 61 reported cases of C. hominis infective endocarditis in the English-language literature, 15 of which involved prosthetic valve endocarditis. There is one reported case of C. hominis after upper endoscopy and none reported after colonoscopy. Presented here are two cases of C. hominis prosthetic valve endocarditis following colonoscopy and a review of the microbiological and clinical features of C. hominis endocarditis. Patients with C. hominis infection have a long duration of symptoms preceding diagnosis (138+/-128 days). The most common symptoms were fever (74%), fatigue/malaise (53%), weight loss/anorexia (40%), night sweats (24%), and arthralgia/myalgia (21%). The most common risk factors were pre-existing cardiac disease (61%), the presence of a prosthetic valve (28%), and history of rheumatic fever (20%). Of the 61 cases reviewed here, the aortic valve was infected in 24 (39%) and the mitral valve in 19 (31%) patients. The average duration of blood culture incubation before growth was detected was 6.3 days (range, 2-21 days). Complications were congestive heart failure (40%), central nervous system (CNS) emboli (21%), arrhythmia (16%), and mycotic aneurysm (9%). C. hominis is almost always susceptible to beta-lactam antibiotics. Ceftriaxone is recommended by the recently published American Heart Association guidelines. The prognosis of C. hominis native valve and prosthetic valve endocarditis is favorable. The cure rate among 60 patients reviewed was 93% (56/60). For prosthetic valve endocarditis, the cure rate was 16/17 (94%). Valve replacement was required in 27 (45%) cases.

Aged↗
PubMed1976

Intramuscular clindamycin for therapy of infective endocarditis. Report of 23 cases and review of the literature.

Twenty-three patients with infective endocarditis received intramuscular clindamycin (Cleocin) for treatment. Thirteen had acute Staphylococcus (S.) aureus endocarditis but none had involvement of the aortic valve. Eleven of these 13 infections were heroin-related and involved the tricuspid valve.Twenty-one patients were successfully treated. Two patients with heroin-related S. aureus infection failed to respond to intramuscularly administered clindamycin, but responded to retreatment with methicillin. There have been 34 reported cases of endocarditis treated with clindamycin. Although 80 percent of all cases due to staphylococci responded favorably, almost all were heroin-related tricuspid valve infections. In addition 91 percent of cases due to aerobic streptococci responded but, surpisingly, treatment failed in three of four cases of anaerobic endocarditis. Although clindamycin can be useful in streptococcal endocarditis and in some cases of heroin-related S. aureus tricuspid endocarditis, caution should be exercised in its use. It is "less" bactericidal than the penicillins or cephalosporins, and organisms have become resistant during treatment. Furthermore, patients with anaerobic endocarditis have not responded well, and data are not available to recommend administration of clindamycin for acute S. aureus infections engrafted on the aortic or mitral valve.

Adolescent↗
PubMed1985

Changing pattern of infective endocarditis.

There has been a significant trend toward an increase in the age of patients with endocarditis, and it seems likely that the age of these patients will continue to increase as the population ages. The proportion of patients with endocarditis who have rheumatic heart disease as an underlying lesion has decreased from about 40 percent in patients studied from 1950 to 1970 to about 25 percent in more recent series, and this trend will probably continue. Prosthetic valves and degenerative heart disease will undoubtedly become increasingly important underlying heart lesions in patients with endocarditis. Another large group of patients with infective endocarditis have no diagnosable underlying heart disease and comprise an increasing proportion of patients with endocarditis. Because of the aging of the population, more Streptococcus bovis and enterococcal endocarditis should be expected. With more prosthetic valves and with the aging of the population, more staphylococcal endocarditis should be anticipated. Economic forces will probably result in earlier discharge from the hospital, with either shorter courses of therapy or completion of therapy at home and perhaps more valve replacements.

Adult↗
PubMed1992

Increased risk of bacterial endocarditis in inflammatory bowel disease.

PURPOSE: The purpose of this retrospective as well as prospective case-control study was to analyze a possible overrepresentation of inflammatory bowel diseases among patients with native valve endocarditis as well as the factors that predispose patients with inflammatory bowel disease to infective endocarditis. PATIENTS AND METHODS: Among 213 consecutive patients treated for proven native valve endocarditis, six (2.8%) had inflammatory bowel diseases (three with ulcerative colitis and three with Crohn's disease). Three patients with inflammatory bowel disease were from the retrospective group, and three were from the prospective group. The prevalence of inflammatory bowel diseases has been determined to be 0.0641% in the Düsseldorf area. RESULTS: On the basis of these data, a 44-fold overrepresentation of inflammatory bowel diseases among the 213 patients with endocarditis was calculated with a statistical significance of p much less than 0.001. CONCLUSIONS: Inflammatory bowel disease may be considered an independent risk factor for bacterial endocarditis. Reasons may be more frequent bacteremias as a result of the higher incidence of diagnostic and therapeutic interventions, as well as increased permeability of the damaged mucosa for bacteria and the therapeutic immunosuppression in patients with active inflammatory bowel disease. Prophylaxis for bacterial endocarditis should be carefully considered before expected bacteremias in patients with highly active inflammatory bowel disease even in the absence of cardiac factors predisposing to bacterial endocarditis.

Adolescent↗
PubMedDate not supplied

Reactivity of the glycocalyx of endocarditis-producing viridans group streptococci.

We correlated quantity of streptococcal polysaccharides and endocarditis production by those bacterial strains. To investigate this finding further, we studied the composition of the glycocalyx using a spectrophotometric assay and lectin analysis of exopolysaccharides from endocarditis- and non-endocarditis-producing strains of viridans streptococci. Identical weights of glycocalyx from the clinical endocarditis isolates produced significantly different absorbances as compared with the nonendocarditis isolates (P < 0.0012, Wilcoxon rank test). Lectin-binding experiments showed that endocarditis-producing streptococci contained increased amounts of glucose, galactose, sialic acid, and mannose. These data suggest that the glycocalyx of endocarditis-producing viridans streptococci is both qualitatively and quantitatively different from non-endocarditis-producing isolates. These differences can be measured in vitro.

Endocarditis, Bacterial↗
PubMed1993

Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis.

OBJECTIVES: This study was conducted to determine the implications of negative findings on a transesophageal echocardiographic study in which neither a vegetation nor an abscess is identified in patients with clinically suspected infective endocarditis. BACKGROUND: Echocardiography is the procedure of choice for evaluating suspected infective endocarditis in patients. Transesophageal echocardiography has been shown to be superior to transthoracic imaging. Although the importance of positive results or a diagnostic study is known, the significance of negative findings on a transesophageal study is not clear. METHODS: All transesophageal echocardiographic studies performed over a 2-year period for suspected infective endocarditis were reviewed and the clinical course of patients with an initially negative study result was assessed to determine their final diagnosis. RESULTS: Of the 105 patients identified, 65 had a negative transesophageal study result. In the majority of this group (56 of 65), an alternate diagnosis was made or there was no infective endocarditis on follow-up examination, or both. Of the remaining nine patients, four were treated for endocarditis without a definite diagnosis and five had infective endocarditis proved by either repeat transesophageal study (n = 3), pathologic findings (n = 1) or a diagnostic clinical course (n = 1). Gram-positive bacteremia and the presence of a prosthetic valve in the aortic position tended to be more common in the latter group. CONCLUSIONS: A negative transesophageal study result reduces the likelihood that endocarditis is present. Repeat examination, however, should be considered in high risk patients, such as those with prosthetic valves or unexplained bacteremia, to avoid a missed diagnosis.

Adult↗
PubMedDate not supplied

Inability to validate a predictive score for infective endocarditis in intravenous drug users.

We sought to identify presenting features that should increase the accuracy of diagnosis of endocarditis in symptomatic intravenous drug use (IVDU) patients. We used two data sets of IVDU patients to develop and validate a score for endocarditis. A retrospective analysis of admitted IVDU patients was conducted with subsequent validation of endocarditis score on consecutive admitted IVDU patients at the same urban teaching hospital emergency department. Statistical comparison was made of presenting clinical features in patients with and without positive blood cultures or vegetation on their echocardiogram. Multivariable analysis of significant features was carried out. A clinical score was developed using a likelihood ratio to determine weighting. Validation of the score was tested by application to a second set of admitted symptomatic IVDU patients. The performance of the score was assessed by comparison of receiver operating characteristic curves for the two data sets. Factors associated with endocarditis on multivariable analysis were past history of endocarditis (negative correlation), total white blood cell (WBC) count, percentage neutrophils and bands on differential WBC count, infiltrate on chest x-ray, and arterial oxygenation (negative correlation). Prospective validation showed poor predictive performance of the endocarditis score. Presenting clinical, radiographic, and laboratory features do not appear helpful in estimating the clinical likelihood of endocarditis in symptomatic IVDU patients.

Adult↗
PubMed1994

Homograft aortic valve and root replacement for severe destructive native or prosthetic endocarditis.

Ten male patients with a mean age of 57.5 years (range 27-75 years) underwent homograft aortic valve or root replacement for destructive aortic valve endocarditis. Six patients had native valve endocarditis (one with associated native mitral valve endocarditis) and four had prosthetic valve endocarditis (one with associated prosthetic mitral endocarditis). Causative organisms were Streptococci in six patients, Staphylococci in one, Q fever in one and no organisms were isolated in the remaining two patients. All the patients were operated while on antibiotics (mean lengths of treatment 13 days; range 2-42). The main indication for surgery was cardiogenic shock in five patients, progressive cardiac failure in four patients and uncontrolled sepsis in one patient. Operative procedures involved homograft aortic root replacement with coronary reimplantation (seven patients; associated prosthetic mitral valve replacement in one patient), infracoronary homograft aortic valve replacement (three patients) and a number of other procedures were performed to reconstruct the disrupted cardiac anatomy. Patients were followed up for a mean of 13.2 months (range 2-21). One patient died 4 months postoperatively of an unrelated cause; all the others are asymptomatic with no evidence of recurrent endocarditis. We conclude that homograft aortic valve or root replacement is an effective method of managing destructive aortic valve endocarditis.

Aortic Valve↗
PubMed2006

Update on infective endocarditis.

With infective endocarditis afflicting 15,000 patients each year and with a mortality rate that still hovers at almost 40%, the disease remains a very serious health problem. Surprisingly, the incidence has not declined over the last 30 years, and now with more health care interventions, such as pacer/defibrillators, and an increasingly elderly population with degenerative valvular heart disease, the number susceptible to endocarditis is actually increasing. Given the weak evidence for endocarditis prophylaxis, there remains a large population at risk. Much has been learned recently about the pathogenesis of endocarditis, including the role of endothelial damage, platelet adhesion, and microbial adherence to the vegetation or intact valvular tissue. Three-fourths of patients have preexisting structural heart disease. Once infection is manifest, major cardiac complications include congestive heart failure, embolization, mycotic aneurysms, renal dysfunction, and abscess formation. The diagnosis of endocarditis has been enhanced recently by modifications in the Duke criteria to include the use of transesophageal echocardiography and microbial antibody titers. Surgery continues to play an important role, with criteria for emergency, urgent, and early surgery now defined. The major organisms involved in infective endocarditis include streptococci and staphylococcus (representing 75% or so of all cases). Enterococcal infections account for many of the remaining cases, although small series and case reports suggest almost all organisms that infect humans can be implicated at times. A sizeable number of "culture-negative" cases still occur despite all the improvements in diagnostic methodology. Recent guidelines for the diagnosis, treatment, and management of infective endocarditis from the American Heart Association are reviewed and the issues surrounding prophylaxis are summarized. International cooperative databases are now being developed that hold promise for a continual reexamination of the epidemiology of this highly aggressive disease and may help provide sorely needed prospective trial data that will enhance our understanding and treatment.

Anti-Infective Agents↗
PubMed2005

Time-related distribution, risk factors and prognostic influence of embolism in patients with left-sided infective endocarditis.

BACKGROUND: Few studies evaluated systemic arterial embolism after beginning of symptoms of infective endocarditis in a large series of patients. METHODS: We studied 629 patients with left-sided infective endocarditis, aged 37.9+/-17.3 years, 396(63%) men and 233(37%) women. Endocarditis occurred on native valves in 405(64.4%) patients and on prosthetic heart valves in 224(35.6%). Infecting microorganisms were streptococci in 297(47.3%) patients, Staphylococcus aureus in 77(12.3%), Staphylococcus epidermidis in 56(8.9%), enterococci in 51(8.1%), Gram-negative bacteria in 33(5.2%), fungi in 9(1.4%) and other microorganisms in 27(4.2%). In 79(12.6%) patients blood cultures were negative. RESULTS: 146 embolic events occurred in 133(21.1%) out of 629 patients; in 63(47.4%) of them emboli affected the central nervous system, in 57(42.9%) affected peripheral organs and in 13(9.7%) affected both the central nervous system and peripheral organs. Embolism occurred between beginning of symptoms of endocarditis and antimicrobial therapy in 56(42.1%) patients and on the day therapy started in 18(13.5%); 109(81.9%) embolic events occurred up to the 15th day of antimicrobial therapy. Embolic risk was higher in S. aureus endocarditis (relative risk 2.97); in patients with a mitral (relative risk 2.4) or aortic (relative risk 3.3) prosthetic valve and vegetations on echocardiography. Embolic risk was lower in patients with a longer duration of symptoms. The death risk doubled in patients with embolism (relative risk 2.01). CONCLUSIONS: Embolic events were more frequently early events after beginning of symptoms of infective endocarditis. Embolic risk was higher in S. aureus endocarditis and in patients with prosthetic heart valves and vegetations on echocardiography.

Adolescent↗
PubMed2004

Histoplasma endocarditis: clinical and mycologic features and outcomes.

OBJECTIVES: To define the salient clinical and microbiologic characteristics and outcome of infective endocarditis caused by Histoplasma capsulatum. METHODS: Case report and review of 43 literature cases. RESULTS: Infection involved both native (36 cases) and prosthetic (7) heart valves, had a high rate of systemic embolization (58%), and a more delayed diagnosis than bacterial endocarditis. Cardiac involvement generally occurred on mitral and/or aortic valves, and almost always in the setting of disseminated disease. Antemortem diagnosis was best made by serology (serum antibody titers or urinary antigen) or culture of blood (positive in <20% of cases), bone marrow, excised valves, and other non-blood specimens. Other diagnostic methods included histopathology and immunofluorescent staining of tissue samples. Untreated infection was uniformly fatal. Prolonged antifungal therapy with amphotericin B, without surgical intervention, appeared more effective than for Candida endocarditis. CONCLUSIONS: Histoplasma endocarditis is an infrequent but important cause of left-sided, blood culture-negative endocarditis. Its true prevalence may be underestimated because of the relative difficulty in making a precise microbiologic diagnosis. Amphotericin B therapy appears more effective than for Candida endocarditis, while the role for azole treatment and secondary prophylaxis remains uncertain. Indications for surgical valve replacement are similar to those for bacterial endocarditis.

Antifungal Agents↗
PubMed2001

Recurrent infective endocarditis: a multivariate analysis of 21 years of experience. arenzul@tin.it.

BACKGROUND: To evaluate which variables predict recurrence of endocarditis after surgical treatment, we reviewed our 21-year experience. METHODS: Between January 1979 and May 2000, 308 consecutive valve replacement procedures for infective endocarditis were performed in 271 patients. Univariate and multivariate time-related analyses were performed to retrospectively evaluate the role of the following variables in the development of recurrent postoperative endocarditis: gender, site of endocarditis, previous valve disease, drug abuse, diabetes, positive valve/blood cultures, sepsis, perivalvular involvement, previous embolic events, type of replacement device, and persistent postoperative fever. RESULTS: Clinical and echocardiographic follow-up was 97.36% complete, mean follow-up time was 53.2+/-3.4 months. Recurrent endocarditis developed in 58 cases (22.5%). Variables predicting recurrence were prosthetic endocarditis (p = 0.00001), positive valve culture (p = 0.0039), and persistence of fever at the seventh postoperative day (p = 0.000001). CONCLUSIONS: Correct protocols of antibiotic therapy guided by microbiology may reduce the incidence of recurrent endocarditis to allow for surgery on sterile tissues and to prevent prosthetic infection. Recurrence rate is not affected by the choice of valve substitute, but can be prevented by complete surgical debridement.

Adolescent↗
PubMed1998

Conservative operation for infective endocarditis of the mitral valve.

BACKGROUND: Subvalvular preservation is necessary to maintain left ventricular function, but accidental retention of infected tissue could cause postoperative endocarditis. METHODS: We examined 71 consecutive patients who underwent operation for mitral endocarditis. Endocarditis was uncontrolled and active in 24 patients, partially treated (unfinished antibiotic course) in 17, and healed in 30. RESULTS: Valves were repaired in 17% versus 59% versus 63% and replaced with subvalvular preservation in 25% versus 6% versus 3% of the uncontrolled active, partially treated, and healed groups, respectively. Thirty-day mortality was 29% versus 0% versus 3.3% (p=0.003), total mortality was 46% versus 18% versus 17% (p=0.035), and complications-related mortality was 38% versus 11% versus 13% (p=0.054), respectively. There was a trend toward lower complications-related mortality with subvalvular preservation than without. Postoperative endocarditis occurred in 3 of 30 patients without and 1 of 41 patients with subvalvular preservation. CONCLUSIONS: Postoperative mortality in uncontrolled active mitral endocarditis remains high, but results are good with partially treated or healed endocarditis. Subvalvular preservation improves outcome, does not increase postoperative endocarditis rates, and should be performed whenever feasible.

Anti-Bacterial Agents↗