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PubMed2006

Q fever endocarditis masquerading as Mixed cryoglobulinemia type II. A case report and review of the literature.

BACKGROUND: The clinical manifestations of Q fever endocarditis are protean in nature. Mixed cryoglobulinemia type II is rarely a facet of the presenting clinical manifestations of Q fever endocarditis. CASE PRESENTATION: We report a case of a 65-year-old pensioner with such an association and review the literature. As transesophageal echocardiograms are usually normal and blood cultures are usually negative in Q fever endocarditis, many of the manifestations (fever, rash, glomerulonephritis/evidence of renal disease, low serum C4 complement component, presence of mixed type II cryoglobulin, constitutional symptoms as arthralgias and fatigue) can be attributed to Mixed cryoglobulinemia type II per se. The use of Classic Duke Endocarditis Service criteria does not always suffice for the diagnosis of Q fever. CONCLUSION: The application of the modified criteria proposed by Fournier et al for the improvement of the diagnosis of Q fever endocarditis will help to reach the diagnosis earlier and thus reduce the high mortality of the disease. We would like to stress the importance of ruling out the diagnosis of Q fever endocarditis in cases of mixed type II cryoglobulinemia.

Aged↗
PubMed1982

Spectrum of the infective endocarditis in the past five years.

One hundred and thirty patients at our Heart Institute with infectious endocarditis during the past 5 years were reviewed to provide an overview of the spectrum of infective endocarditis and to assess the accuracy of echocardiography in detecting the infective valvular and endocardial lesions. Of the 130 patients, 36 (28%) had the previous cardiovascular surgery. The mean age of the patients was 34 years, and only 11% of the patients were over 50 years of age. Of the 94 patients who had no cardiovascular surgery before developing infective endocarditis, 6 underwent urgent surgery, 49 had elective surgery and the remaining 39 were followed up with medical treatment. The mortality rate of the 55 patients who were operated on was 5.5% as against 18.0% in 39 without surgery. Half of the 36 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of the 5 patients with bioprosthetic valve endocarditis, only one survived as a result of prompt medical and surgical treatment. Streptococci were still commonly found, about 75% in the group without surgery and 50% in the group with surgery. Gram-negative bacilli and fungi were found in patients with prosthetic valve endocarditis. In 61 patients, morphologic abnormalities confirmed at surgery or necropsy were compared with the preoperative echocardiograms. Vegetations were identified preoperatively in 50 (95%) of the 53 valves involved, and valve destruction was correctly predicted in all 23 cases. Mycotic aneurysm was detected preoperatively in only 3 of the 12 patients in whom it occurred. Thirteen patients, in whom vegetation was recorded, were treated successfully with antibiotics alone and they needed no surgical intervention during the 2-year follow up period. The presence of a vegetation in an echocardiography does not necessarily require surgical intervention in itself or predict the ultimate course.

Adolescent↗
PubMed1997

Arthritis and meningitis--the first manifestations of bacterial endocarditis in 2 patients.

We have encountered 2 patients in whom the first manifestations of bacterial endocarditis were arthritis (in 1 case septic arthritis and in the other nonseptic arthritis) and bacterial meningitis. These presentations were followed by acute heart failure due to aortic valve destruction, although the patients showed no significant cardiovascular manifestations on admission. Aortic valve replacement was performed in each case and the patients' postoperative course was comfortable. We would like to emphasize the following points. (1) Arthritis and meningitis are uncommon in patients with bacterial endocarditis. However, it is necessary to consider the possibility of bacterial endocarditis when these clinical manifestations present together. Such a combination can cause rapid valve destruction. When more than 2 rare complications of bacterial endocarditis coexist, surgery should be considered as soon as the definite diagnosis of bacterial endocarditis is established, even if congestive heart failure has not yet developed. (2) Arthritis associated with bacterial endocarditis might be truly septic rather than mediated by circulating immune complexes as is commonly believed.

Aged↗
PubMed2001

Recurrent aortic valve endocarditis caused by Gemella morbillorum--report of a case and review of the literature.

Gemella morbillorum (G. morbillorum) is part of the commensal flora of the oropharynx and intestinal tract, and on rare occasions causes infective endocarditis. A 55-year-old man with massive aortic regurgitation caused by recurrent infective endocarditis with G. morbillorum had a history of prior endocarditis caused by alpha-hemolytic streptococcus and multiple antibiotic allergies 5 years prior, and was successfully treated by aortic valve replacement. Almost all the reported cases of endocarditis caused by G. morbillorum have been bacteriologically cured with antibiotics and this is the first reported case of recurrent endocarditis caused by G. morbillorum in which the initial infection was bacteriologically cured by antibiotics and the secondary infection treated with valve replacement. This organism can be one of the causes of infective endocarditis and prompt surgical repair is mandatory if the infection is refractory or there is progression of congestive heart failure under antibiotic cover.

Anti-Bacterial Agents↗
PubMed2005

Successful treatment of Corynebacterium striatum endocarditis with daptomycin plus rifampin.

OBJECTIVE: To report a case of Corynebacterium striatum endocarditis that was treated successfully with daptomycin plus rifampin following an unsuccessful attempt at vancomycin desensitization and failure of linezolid therapy. CASE SUMMARY: A 46-year-old woman with hemodialysis-dependent chronic renal failure was admitted for a graft-related infection. She presented with C. striatum endocarditis that was treated with daptomycin plus rifampin due to a history of allergies to vancomycin and beta-lactam antibiotics and failure of linezolid therapy. The patient received daptomycin and rifampin for a total of 6 weeks. Three months after completion of treatment, no recurrence of endocarditis was evident. DISCUSSION: Daptomycin is a lipopeptide antibiotic, with rapid bactericidal activity. It has demonstrated efficacy in animal models of staphylococcal, streptococcal, and enterococcal endocarditis. Case reports of its activity in methicillin-resistant Staphylococcus aureus endocarditis have also been documented. CONCLUSIONS: Daptomycin, which has shown in vitro activity against C. striatum, may be a viable treatment option for patients with C. striatum endocarditis who are either allergic or refractory to traditional antibiotics.

Anti-Bacterial Agents↗
PubMed2005

Pathology of bartonella endocarditis in six dogs.

In a 5-year retrospective study of dogs presenting to the Veterinary Medical Teaching Hospital at the University of California, Davis, there were 31 histologic diagnoses of valvular endocarditis. By polymerase chain reaction (PCR) amplification of embedded valvular tissue, Bartonella organisms were exclusively associated with 6 out of 31 cases (19%). Confirmed Bartonella cases involved the aortic valve alone (five out of six) or in combination with the mitral valve (one of six). Microscopic features of Bartonella endocarditis were compared with valves from non-Bartonella endocarditis and with valvular change unrelated to infectious agents (endocardiosis). Features of Bartonella endocarditis included a combination of fibrosis, mineralization, endothelial proliferation, and neovascularization with variable inflammation. None of these features is specific; however, the combination is distinct both from endocarditis caused by culturable bacteria and from endocardiosis. Ultrastructural analyses revealed both extracellular and intraendothelial bacteria. Clinical history, serology, and PCR are currently necessary to establish an etiologic diagnosis of Bartonella endocarditis.

Animals↗
PubMed2005

Nosocomial endocarditis in a tertiary hospital: an increasing trend in native valve cases.

INTRODUCTION: Changes in the etiology, epidemiology, and outcome of infective endocarditis (IE) have been observed in recent years. Newer invasive therapeutic interventions have increased the risk of bacteremia and nosocomial endocarditis in the population at risk. A retrospective analysis of hospital-acquired IE cases was performed in a tertiary hospital during 1985 to 1999. MATERIAL AND METHODS: Cases included were those classified as "probable" or "definite" by the IE diagnostic criteria of Durack. Nosocomial acquisition was considered if diagnosis was made > 72 h after hospital admission and there was no evidence that IE was present at the time of admission. Patients receiving a diagnosis within 60 days of a previous hospital admission were also classified as nosocomial, when a risk procedure for bacteremia was performed, or when any predisposing factor for IE was present during hospitalization. Early prosthetic valve endocarditis (PVE) cases (< 1 year) were excluded from the analysis. Clinical characteristics, etiology, predisposing cardiac condition, source of infection, and outcome were analyzed. Results were compared with those obtained in community-acquired cases. RESULTS: Of 493 cases of IE diagnosed over 15 years, 38 were considered to be hospital acquired. Twenty-eight cases were native valve endocarditis (NVE) in non-IV drug user patients, and 10 cases were late PVE. Overall, the most frequent microorganisms involved were staphylococci (58%). The main sources of infection were intravascular procedures or catheter-related infections (55%). When nosocomial NVE cases were compared with community-acquired cases, mortality was greater (29% vs 9.7%) in hospital-acquired endocarditis. Analysis of time trends showed an increased rate of nosocomial cases in NVE throughout the years of the study. CONCLUSIONS: In NVE, the number of cases that are hospital acquired has been increasing during the last 15 years. These cases are frequently associated with invasive intravascular procedures or IV catheter-related infections. Most patients have a previous valvulopathy that predisposes to IE. The spectrum of microorganisms involved is different from the community-acquired cases. Also, the outcome of endocarditis is worse in nosocomial NVE patients.

Adolescent↗
PubMed2000

Endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child.

Varicella is generally a benign, self-limited childhood illness; however, severe, life-threatening complications do occur. A live, attenuated vaccine exists to prevent this illness, but controversy remains concerning the need to vaccinate children for what is generally a benign, self-limited disease, although more states are currently recommending this vaccine. We report a previously healthy 3-year-old who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed group A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocarditis of a normal heart valve. We are unaware of previous reports of endocarditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, aortic valve endocarditis was diagnosed. A 6-week course of intravenous penicillin G was administered. Two weeks after the initiation of therapy, the diastolic murmur was harsher, and echocardiography revealed a large vegetation on the posterior leaflet of the aortic valve, with severe aortic insufficiency and a dilated left ventricle. The patient subsequently developed congestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worsening aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by aortic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GABHS after varicella, illustrates the need for the health care practitioner to consider both common and life-threatening complications in patients with varicella. While cellulitis, encephalitis, and septic arthritis may be readily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superinfection should also be entertained. The case we report is unique in that the patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally normal heart with a previously unreported pathogen. Although a child may have been vaccinated against varicella, the chance of contracting the virus still exists and parents should be informed of this risk. group A beta-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella.

Aortic Valve Insufficiency↗
PubMed2004

Surgical treatment of infective endocarditis.

OBJECTIVE: The objective of this study is to determine the surgical indication in the treatment of infective endocarditis. SETTING: Retrospective study in a tertiary care--Wessex Cardiothoracic--Centre. SUBJECTS AND DESIGN: Case records of patients admitted with infective endocarditis for surgical treatment between 1984 to 1994 at Wessex Cardiothoracic Centre were analysed. This analysis includes the age, sex, microbiology results, risk factors, surgical indication and early results. RESULTS: A total of 123 patients was admitted with bacterial endocarditis treated surgically since 1984. The mean age was 51.9 years with male:female ratio of 3:1. The most common causative organism was streptococcus (63%) and staphylococcus (30%). Native valve endocarditis occurred in 111 patients, affecting the aortic, mitral, combined aortic and mitral valve in 69%, 33%, and 8% of cases, respectively. Late prosthetic valve endocarditis occurred in 12 patients. The most common indication for surgery was heart failure (84%), uncontrolled sepsis (8%), and recurrent endocarditis (2.5%). Hospital mortality was 1.6%. Complete heart block and cerebrovascular accident developed in 4% and 2.4%, respectively. CONCLUSIONS: Heart failure is the main indication for surgery. Valve replacement with mechanical prosthesis is a safe procedure with a low rate of mortality and complication.

Adolescent↗
PubMed1997

A study of 47 bacteremic Staphylococcus aureus endocarditis cases: 23 with native valves treated surgically and 24 with prosthetic valves.

A retrospective review of medical records from the Staphylococcus Laboratory, Copenhagen, 1982-1991, was carried out at the Department of Clinical Microbiology, Statens Serum Institut, 1994-1995, to investigate the clinical features and outcome of two subgroups of bacteremic Staphylococcus aureus endocarditis cases in non-drug addicts: patients with prosthetic valve endocarditis (PVE) and patients with native valve endocarditis treated surgically. Twenty-four cases of PVE were included. Six cases were early (within 60 days of valve implantation) and 18 were late. The overall in-hospital mortality was 42%. Surgical treatment resulted in a non-significantly lower mortality as compared with medical treatment alone (0% vs 50%, p = 0.19). Medical treatment of aortic and mitral valve endocarditis resulted in similar mortality rates (44% and 50%, respectively). Twenty-three cases of native valve infective endocarditis had the valve replaced surgically. The in-hospital mortality was 22%, which was significantly lower as compared with medical therapy (69%, p < 0.0001). The treatment changed significantly during the study period: 6 of 112 patients (5%) were treated surgically in the first half of the period (1982-1986) compared to 17 of 124 patients (14%) in the second half (1987-1991, p = 0.049). Severe congestive heart failure was the main indication for cardiac surgery in 21 patients. In conclusion, a shift towards a more aggressive surgical approach has taken place in the 10-year period. This development should be strengthened in the future as surgical intervention may improve survival in patients with infective endocarditis caused by S. aureus whether the infected valve is prosthetic or native.

Aged↗
PubMed1994

A clinical consideration of systemic embolism complicated to infective endocarditis in Korea.

OBJECTIVES: Infective endocarditis is still one of the important fatal diseases in Korea, especially when systemic embolisms are supervene. So, identification of patients who are in the high risk of embolism and who can be helped by early surgical intervention is very important. Considering these, we tried to elaborate the risk factors for the systemic embolism in patients with an infective endocarditis and the influence of systemic embolism on the mortality and morbidity in patients with an infective endocarditis. METHODS: We retrospectively reviewed the clinical records of 97 patients who were admitted with the infective endocarditis between January 1983 and October 1993. RESULTS: Among 97 patients, 80 patients met our diagnostic criteria. The mean age of patients was 38 years old. There were 43 males and 37 females. The mean duration of fever since the fever developed by history was 38 days. Valvular heart disease was the most frequent underlying heart disease. Mitral regurgitation and aortic regurgitation were the most common among valvular heart diseases. Pneumonia and acute pharyngotonsillitis were the most frequent predisposing factors of infective endocarditis. Blood cultures were positive in 51 patients (63.8%). Streptococcus viridans was the organism isolated most frequently, and Staphylococcus aureus was the second most frequently isolated one. Vegetations were detected in 58 patients (76.3%) by an echocardiography. Mitral valve and aortic valve were the most frequently involved incidence rate of embolism was 50% and the most frequent embolism site was the central nervous system and extremities were the next. Embolism occurred at the mean of 37 days after onset of fever. Overall in-hospital mortality rate was 26.3% and a cardiac-origin was the major cause of death. The only statistically significant risk factor for mortality was systemic embolism. The analysis of the relation between an incidence of embolism and the multivariables (age, presence of vegetation, location of vegetation, size of vegetation, causative organisms) showed that only the growth of Staphylococcus aureus had a significant trend toward a risk of subsequent systemic embolism. CONCLUSION: This study suggests that systemic emboli increases the mortality rate in patients with infective endocarditis. Age of patients, presence of vegetation, size and location of vegetation are not the risk factors for embolism, while certain organism, especially Staphylococcus aureus, could be a risk factor for the systemic embolism.

Adolescent↗
PubMed1995

Early and late survival after surgical treatment of culture-positive active endocarditis.

OBJECTIVE: To describe a 30-year experience with surgically treated culture-positive active endocarditis. DESIGN: We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991. RESULTS: The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62% of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71% and 60%, respectively. Univariate determinants of an adverse long-term survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively. CONCLUSION: Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.

Adolescent↗
PubMed1997

Efficacy of deoxycholate amphotericin B and unilamellar liposomal amphotericin B in prophylaxis of experimental Aspergillus fumigatus endocarditis.

OBJECTIVE: To evaluate and compare in vivo the protective efficacy of unilamellar liposomal amphotericin B (L-AmB) with that of deoxycholate amphotericin B (D-AmB) in experimental endocarditis. MATERIAL AND METHODS: In the rabbit model of experimental Aspergillus fumigatus endocarditis, two doses of each antifungal agent (1.5 mg/kg each) were administered intravenously at 4 hours and at 30 minutes before challenge with an inoculum of A. fumigatus. Three days later, the animals were sacrificed, and the aortic vegetations were analyzed. RESULTS: All 19 animals that did not receive chemoprophylaxis acquired endocarditis. In contrast, endocarditis developed in 2 of 10 animals pretreated with D-AmB (P < 0.01) and 3 of 8 animals pretreated with L-AmB (P < 0.01). Both D-AmB and L-AmB prevented the development of endocarditis due to A. fumigatus and decreased the concentration of fungi in the aortic vegetations by more than 1 log10. CONCLUSION: In the rabbit experimental model of Aspergillus endocarditis, D-AmB and L-AmB were equally effective in reducing the incidence of the infection and the tissue burden of fungi.

Amphotericin B↗
PubMed1998

Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study.

BACKGROUND: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear. OBJECTIVE: To quantitate the risk for endocarditis from dental treatment and cardiac abnormalities. DESIGN: Population-based, case-control study. SETTING: 54 hospitals in the Philadelphia area. PATIENTS: Persons with community-acquired infective endocarditis not associated with intravenous drug use were compared with community residents, matched by age, sex, and neighborhood of residence. MEASUREMENTS: Information on demographic characteristics, host risk factors, and dental treatment was obtained from structured telephone interviews, dental records, and medical records. RESULTS: During the preceding 3 months, dental treatment was no more frequent among case-patients than controls (adjusted odds ratio, 0.8 [95% CI, 0.4 to 1.5]). Of 273 case-patients, 104 (38%) knew of previous cardiac lesions compared with 17 controls (6%) (adjusted odds ratio, 16.7 [CI, 7.4 to 37.4]). Case-patients more often had a history of mitral valve prolapse (adjusted odds ratio, 19.4 [CI, 6.4 to 58.4]), congenital heart disease (adjusted odds ratio, 6.7 [CI, 2.3 to 19.4]), cardiac valvular surgery (adjusted odds ratio, 74.6 [CI, 12.5 to 447]), rheumatic fever (adjusted odds ratio, 13.4 [CI, 4.5 to 39.5]), and heart murmur without other known cardiac abnormalities (adjusted odds ratio, 4.2 [CI, 2.0 to 8.9]). Among case-patients with known cardiac lesions--the target of prophylaxis--dental therapy was significantly (P = 0.03) less common than among controls (adjusted odds ratio, 0.2 [CI, 0.04 to 0.7] over 3 months). Few participants received prophylactic antibiotics. CONCLUSIONS: Dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors. Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed. Current policies for prophylaxis should be reconsidered.

Adolescent↗
PubMed1999

[The Ross procedure in the acute phase of infectious endocarditis in childhood].

The Ross procedure of aortic valve replacement with a pulmonary autograft has several advantages in childhood over mechanical prostheses or homografts, especially in infectious endocarditis requiring early surgery. Between January 1997 and July 1998, 3 children with no known previous cardiac disease, aged 14 months, 10 and 11 years, had aortic valve infectious endocarditis. The causal organism was not identified in 1 case and the other two were due to staphylococcus aureus and corynebacterium diphteriae. All children had severe, rapidly progressive aortic regurgitation complicated by pulmonary oedema in the baby and systemic emboli in the two older children. Surgery was performed within 9 days, 1.5 month and 2 months after the onset of the disease. The postoperative course was uncomplicated in the 3 cases. Postoperative Doppler echocardiography showed absence of autograft dysfunction or stenosis, with the presence of pulmonary regurgitation in 1 case. Pulmonary autograft has the advantages of not requiring anticoagulation, of allowing growth of the aortic ring, of not being limited by the age of the patient and of having a low risk of degeneration and infectious endocarditis. Therefore, it seems particularly indicated for cases of complicated infectious endocarditis requiring early aortic valve replacement. The early (4.8%) and late (4.3%) mortality rates were comparable to those of other techniques and are lower than those associated with valve replacement with mechanical prostheses in cases of endocarditis (8.5% versus 40%). The secondary morbidity is 18.8% with dysfunction of the autograft and/or stenosis of the pulmonary homograft. Despite a limited follow-up, aortic valve replacement by a pulmonary homograft seems better than aortic valve replacement with a homograft or mechanical prosthesis, especially in cases of complicated infectious endocarditis requiring surgery in the acute phase. Further studies are required to confirm these encouraging results.

Aortic Valve↗
PubMed2000

Surgical treatment of infective mitral valve endocarditis: predictors of early and late outcome.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to review our experience in surgical treatment of infective mitral valve endocarditis, and to identify predictors of early and late outcome. METHODS: Ninety-one consecutive patients (52 males, 39 females, mean age 55.6 years) underwent surgery between 1973 and 1997 for endocarditis of isolated mitral (n = 65, 71%), mitral and aortic (n = 25, 28%) and mitral, aortic and tricuspid valves (n = 1, 1%). Native valve endocarditis (NVE) was present in 60 patients (66%) and prosthetic valve endocarditis (PVE) in 31 (34%). The main indications for surgery were heart failure in 32 patients, valve dysfunction in 23, vegetations in 21, and persistent sepsis in 11. Eighty-six patients (95%) were in NYHA classes III-IV, and 58 (64%) had active culture-positive endocarditis at surgery. Mechanical valves were implanted in 73 patients and bioprosthetic valves in 13; valves were repaired in five patients. The impact of 46 parameters on early and late outcome was defined by means of univariate and multivariate statistical analysis. Follow up was complete (mean 5.5 years; range: 0-23.1 years; total 507.3 patient-years). RESULTS: Operative mortality rate was 11% (n = 10). Recurrent infection was recorded in five patients (6%), and reoperation was required in eight (9%). Freedom from recurrent infection and reoperation at 10 years was 89.1% and 87.8% respectively. There were 22 late deaths, 15 from cardiac causes. Actuarial survival rates for all patients at 5, 10 and 15 years were 73.0%, 62.7% and 58.7% (for hospital survivors, the corresponding rates were 81.9%, 69.7% and 66.0%). On multiple logistic regression and Cox proportional hazards models, the following were independent predictors: preoperative pulmonary edema (p = 0.01) for operative mortality; PVE (p = 0.02) for recurrence; younger age (p = 0.02) and PVE (p = 0.02) for reoperation; male gender (p = 0.004) and longer ITU stay for survival (if all patients were included); male gender (p = 0.01) and myocardial invasion by infection (p = 0.02) for survival (if only the hospital survivors were analyzed). CONCLUSION: Surgery for infective mitral valve endocarditis carries a relatively high, though acceptable, risk but provides satisfactory freedom from recurrent infection, reoperation and improved long-term survival. Analysis of these data demonstrated that the preoperative hemodynamic status was the major predictor of in-hospital outcome, PVE increased the risk for recurrent infection and reoperation, whereas male gender and myocardial invasion by the infective process critically reduced the probability of long-term survival. The type of offending pathogen, the activity of infection and the involvement of more than one valve did not appear to influence early and/or late outcome.

Actuarial Analysis↗
PubMed2000

Aortic valve replacement for endocarditis: determinants of early and late outcome.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine risk factors for operative mortality, recurrent infection, reoperation and long-term survival following aortic valve replacement (AVR) for infective endocarditis. METHODS: Between 1973 and 1997, 109 patients (91 male, 18 female, mean age 52.6 years) underwent isolated AVR for infective endocarditis in our unit. Native valve endocarditis was present in 89 (81.6%) and prosthetic valve endocarditis in 20 (18.4%). Active culture-positive endocarditis was present in 53 (48.6%). Preoperatively, 99 patients (90.8%) were in NYHA classes III and IV. Indications for surgery included cardiac failure in 41 patients, valvular dysfunction in 38, vegetations in 18, sepsis in seven, abscess in six and embolism in four. Mechanical valves were implanted in 69 patients (63.3%) and bioprostheses in 40 (36.7%), including a homograft in 19 (17.4%). Follow up was complete (mean 5.8 years; range: 0-23.8 years; total 633.5 patient-years). RESULTS: The operative mortality was 10.1% (11 deaths). At ten years, freedom from recurrent infection was 94.2%, and freedom from reoperation 83.6%. Biological valve and younger age were significant adverse parameters for freedom from reoperation (p = 0.01 and p = 0.01). There have been 21 late deaths, 15 due to cardiac causes. Kaplan-Meier survival, including operative mortality, at five and ten years was 77.4% and 68.0%, respectively. On Cox proportional hazards regression, Staphylococcus aureus infection (p = 0.008) and older age (p = 0.04) were independent adverse predictors of survival. CONCLUSION: AVR for endocarditis carries a relatively high operative mortality, but can result in a satisfactory freedom from recurrent infection, reoperation and long-term survival. Analysis of our series demonstrates that implantation of a biological valve limits the freedom from reoperation and that infection by Staph. aureus reduces the probability of long-term survival.

Adolescent↗
PubMed2000

Prophylaxis for infective endocarditis. Who needs it? How effective is it?

OBJECTIVE: To review guidelines for using antibiotic prophylaxis to prevent infective endocarditis, and to present recent changes and controversies regarding these guidelines. QUALITY OF EVIDENCE: Data are from physiologic and in vitro studies, as well as studies of animal models, and from retrospective analyses of human endocarditis cases. Systematic reviews and guidelines are also examined. As no randomized clinical trials have examined prophylaxis for bacterial endocarditis, many recommendations presented are based on consensus guidelines. MAIN MESSAGE: Antibiotic prophylaxis to prevent bacterial endocarditis should be used in high- and moderate-risk patients with cardiac disease. It should be given before procedures in which bacteremias are likely with organisms that cause endocarditis, such as viridans streptococci. For most procedures, a single dose of amoxicillin (2 g by mouth 1 hour before the procedure) is sufficient to ensure adequate serum levels before and after the procedure. CONCLUSION: Infective endocarditis continues to have high rates of morbidity and mortality. Antibiotic prophylaxis, therefore, is important to combat this preventable disease. For high- and moderate-risk patients with cardiac disease, the cost-benefit ratio favours prophylaxis.

Animals↗