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PubMed2001

[Attempt of estimation of Q fever endocarditis frequency in Poland].

Up to now no Q fever endocarditis (caused by rickettsia Coxiella burnetii) has been diagnosed in Poland. Potential endocarditis caused by Coxiella burnetii strains can be related to a group of strains present in Poland or sensitivity of Polish Population. The aim of the study was to estimate frequency of Q fever endocarditis is patients of National Institute of Cardiology and to characterize Coxiella burnetii strains and correlation between frequency of Q fever endocarditis and the group of strains. In all patients infective endocarditis and valvular heart disease were diagnosed. In all cases vegetations on TTE or TEE and negative blood cultures were confirmed. No fungal antigens or elevated anti-Candida and anti-Aspergillus antibodies were found. Serological investigations as far as it concerns C. burnetii antibodies were negative in all cases. No Coxiella burnetii infection were found in patients with infective endocarditis and negative blood cultures in the National Institute of Cardiology. However due to high probability of occurrence of such an infection in Poland further investigations in other centers would be useful.

Antibodies, Bacterial↗
PubMed2002

Abiotrophia endocarditis: a case report and review of literature.

Nutritionally Variant Streptococci (NVS) were first grouped under viridans streptococci, although they differed from the latter by variant growth characteristics. NVS cause approximately 5% of cases of bacterial endocarditis. Infective endocarditis caused by NVS has a higher rate of complications than endocarditis caused by other viridans streptococci. Recently NVS were separated from other viridans streptococci to form a new genus Abiotrophia. Since then, only four case reports have described the clinical course of Abiotrophia endocarditis. Therefore, current knowledge on this disease derives from previous data on NVS endocarditis. We present the case of Abiotrophia endocarditis, followed by discussion of relevant literature.

Adult↗
PubMed2002

Early clinical course and long-term outcome of patients with infective endocarditis complicated by perivalvular abscess.

BACKGROUND: Perivalvular abscess is an ominous development in patients with infective endocarditis. There is little information concerning the long-term outcome of these patients. METHODS: Patients admitted to a tertiary care centre in Ottawa between November 1987 and December 1995 because of infective endocarditis complicated by perivalvular abscess were identified by chart audit and by review of the transesophageal echocardiography database. The patients were followed for at least 4 years to determine cardiac complications, late cardiac surgery, long-term outcome and functional status. RESULTS: Forty-three consecutive patients with infective endocarditis and perivalvular abscess (32 men and 11 women; mean age 56 [standard deviation 16] years) were identified; 17 had native valve endocarditis and 26 had prosthetic valve endocarditis. Of the 43 patients, 31 had cardiac surgery during the hospital stay; 6 died in hospital, and 10 died during follow-up. Twelve patients received medical treatment alone; none died in hospital, and 8 died during follow-up. The medically treated patients had less severe heart failure than the surgically treated patients (p = 0.12), but the 2 groups were similar in age and infective organisms. After a mean of 4.5 years of follow-up, the cumulative death rate was 57%; survival was similar among the medically and surgically treated patients. The survivors were younger than the nonsurvivors (p = 0.04). Complications of perivalvular abscess, including pseudoaneurysms and fistulae, were common, occurring in all medically treated patients and in 10 of the 24 surgically treated patients who had follow-up transesophageal echocardiography. INTERPRETATION: Patients with infective endocarditis and perivalvular abscess had a high rate of death after hospital discharge and a high incidence of complications of perivalvular abscess, despite early surgical intervention in most patients. Lower age was the only predictor of long-term survival.

Abscess↗
PubMed1975

[Epidemiology and clinical aspects of infectious endocarditis].

There has been a change in the epidemiological, etiological and clinical pattern of infective endocarditis. This changing pattern has been substantiated by comparison of 156 cases of infective endocarditis seen over the period 1947-1957 (period I) and 227 cases treated during the period 1961-1974 (period II). Epidemiologically the pathomorphosis consists in a slight decline in "medical" cases, contrasted with a marked increase of--predominantly acute--cases after cardiac surgery. Etiologically the change is characterized mainly by a reduction of streptococci (61%/33%) and a much higher incidence of virulent organisms, especially staphylococci (3%/21%), as the infective agent. With regard to the clinical picture of infective endocarditis, the changing pattern is apparent in an increase in atypical and misleading features and an often oligosymptomatic presentation. In period II the classical signs were more often absent. The difference in the course of infective endocarditis consists in a higher hospital mortality during period II. In this period the main cause of death was refractory heart failure, often provoked by acute rupture of the aortic valve. The factors which may be responsible for this change and the clinical implications are discussed. The difficulties in early diagnosis and the role of misleading symptoms of this still "malignant" disease are outlined. Special interest is focused on the diagnostic problems involved in recognizing acute endocarditis, right-heart endocarditis and acute rupture of the aortic valve.

Adult↗
PubMed2002

[Timing of surgery in infective endocarditis: impact on the outcome and recurrence].

Timing of surgery in infective endocarditis remains a challenge in the face of potential drug toxicity on one hand and recurrence of endocarditis on the other. The aim of the study was analysis of risk factors for hospital mortality and recurrent endocarditis. A total of 131 patients with infective endocarditis have been observed during 1999-2001. Eighty seven of them were male and 44 female with mean age of 50+/-16 years. Sixty three (48.1%) patients underwent surgery, remaining 68 (51.9%) were treated conservatively. Hospital mortality was 25.2%. Postoperative perivalvular leak was associated with culture negative endocarditis (p=0.09) as well as with positive valve culture (p=0.04). Recurrence was related to positive valve culture (p=0.08) and embolism (p=0.02). Increased risk of death was associated with neurologic, embolic, renal complications, myocardial abscess, NYHA IV f.cl. and extracardial surgery. According to the data obtained, optimal surgery time in the group appeared to be between 17 and 45 days after the diagnosis of infective endocarditis has been made (p=0.049).

Adult↗
PubMed2002

[Amplification reaction to bacterial DNA for diagnosing infective endocarditis].

The aim of this study was to evaluate the usefulness of broad-range bacterial PCR in infective endocarditis of bacterial etiology, and to determine its specificity and sensitivity. Twenty five blood samples were taken for analysis from patients with infective endocarditis and acquired valvular heart disease. Infective endocarditis was diagnosed according to Duke criteria. There were two control groups consisting of patients with acquired valvular heart disease: 10 patients with urinary tract infection and 15 patients without. Three different primer pairs for the region of the gene coding for 16S rRNA were tested, to find the most specific one. The highest specificity was found for F/R primers, as the relevant amplified PCR product was present in every blood sample with infective endocarditis, and also in 4 out of 10 patients with urinary tract infection. Broad-range PCR in bacterial endocarditis is a fast, sensitive and inexpensive tool for the detection of bacteria, but it is far more prone to contamination than species specific-PCR. However, in controlled conditions it may be valuable in the identification of non-specific infection allowing for a more rapid clinical diagnosis of endocarditis.

Bacteria↗
PubMed2002

Prophylaxis of endocarditis.

For a long time it has been known that bacteraemias caused by medical or dental procedures may cause endocarditis in patients with specific types of congenital or acquired heart disease. In the 1940s it was thought that the administration of antibiotics before such procedures would prevent endocarditis. However, the beneficial effect of this preventive measure on the incidence of endocarditis did not live up to its expectations. Quite soon it became obvious that prophylaxis was not 100% efficacious in man, although it did prevent endocarditis in animals. A controlled study into the protective effect of prophylaxis in humans has never been carried out. In the last decade it has become dear from case-control studies that endocarditis prophylaxis is not a very effective preventive measure but that it reduces an already small risk even further. In this article the theoretical background of endocarditis prophylaxis and possible explanations for its lack of effect are discussed.

Animals↗
PubMed1992

Pigs with von Willebrand disease may be resistant to experimental infective endocarditis.

Indirect evidence suggests that the blood platelet is important in the pathogenesis of experimental infective endocarditis. Mechanical injury to the endocardial surface causes deposition of fibrin and platelets; injected microorganisms quickly localize to this lesion. Endocarditis pathogens also bind to and activate platelets. We used our previously described animal model for inducing infective endocarditis in normal pigs and applied it to animals with severe von Willebrand disease. The model uses catheter-induced trauma to the aortic valve and endocardium, followed by intravenous injection of group C streptococci. Control animals all showed typical clinical and laboratory evidence of endocarditis. In contrast, in pigs with von Willebrand disease (n = 4) endocarditis failed to develop. Studies in vitro of platelet-bacteria interactions showed that platelets derived from both normal and diseased pigs were equal in their ability to bind to and be activated by group C streptococci. These data suggest that normal platelet function is important in the pathogenesis of experimental infective endocarditis.

Animals↗
PubMed1992

Acute bacterial endocarditis. Optimizing surgical results.

BACKGROUND: Acute bacterial endocarditis continues to be a condition with high morbidity. Although the majority of patients are treated by high-dose antibiotics, a high-risk patient group requires surgical intervention, which is the subject of this article. METHODS AND RESULTS: From 1972 to 1991, 3,820 patients underwent heart valve replacement at the Brigham and Women's Hospital, Boston. Of this group, 158 patients underwent surgery for acute bacterial endocarditis: 109 had native valve endocarditis (NVE), and 49 had prosthetic valve endocarditis (PVE). There were 108 men and 50 women with a mean age of 49 years (range, 16-79 years); 64% were New York Heart Association functional class IV before surgery, and 12% of the group had a history of intravenous drug abuse. In both NVE and PVE groups, Streptococcus was the predominant infecting agent. Uncontrolled sepsis, progressive congestive failure, peripheral emboli, and echocardiographically demonstrated vegetations were the most common indications for surgery. Eighty-five percent of patients had a single-valve procedure, 15% had a multivalve procedure, and 34 patients had other associated major cardiac procedures. The operative mortality was 6% in NVE and 22% in PVE. Long-term survival at 10 years was 66% for NVE and 29% for PVE. Freedom from recurrent endocarditis at 10 years was 85% for NVE and 82% for PVE. The main factors associated with decreased survival overall were PVE and nonstreptococcal infection. CONCLUSIONS: The morbidity and mortality after surgical treatment of acute endocarditis depend on the site, the severity, and the subject infected. Early aggressive surgical intervention is indicated to optimize surgical results, especially in patients with nonstreptococcal infection or PVE.

Aortic Valve↗
PubMed2004

The Ross procedure as the surgical treatment of active aortic valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of aortic valve replacement (AVR) using the pulmonary autograft in patients with active aortic valve endocarditis, including an urgent Ross procedure in infants with the acute condition. METHODS: Nine patients aged between 8 months and 38 years, with a diagnosis of aortic valve endocarditis, have undergone AVR using the Ross procedure at the authors' institution since October 1997. The diagnosis was established by clinical and echocardiographic findings. Indications for surgery were severe aortic insufficiency and congestive heart failure in all patients, with the addition of thromboembolic events (n = 3), persistent hyperpyrexia (n = 3) and vegetations (n = 5). Four infants with no history of congenital cardiac malformation underwent urgent surgery because of acute bacterial endocarditis and rapid hemodynamic deterioration. Blood cultures were positive for Streptococcus pneumoniae in three patients, and Kingella kingi and Staphylococcus aureus in one patient each. Four patients were culture-negative. All patients were treated with intravenous antibiotics for four to six weeks postoperatively. RESULTS: There were no perioperative or late deaths, and no recurrent endocarditis at the implanted valves. Echocardiographic evaluation at discharge showed trivial to mild aortic insufficiency, with no stenosis at the left ventricular outflow tract. Similar findings were found across the right ventricular outflow tract. At follow up (range: 4 months to 5.5 years), none of the patients showed progression of aortic valve insufficiency or developed stenosis; three had mild and moderate homograft stenosis (Doppler gradient 20-40 mmHg), and all children had moderate homograft insufficiency. CONCLUSION: The Ross procedure is an excellent therapeutic option for active aortic valve endocarditis in young patients, and demonstrates low morbidity and mortality. Early surgery may be indicated in patients with acute aortic valve endocarditis because of the rapidly progressive nature of this disease.

Adolescent↗
PubMed2004

Tailored surgical therapy for acute native mitral valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has been shown superior to valve replacement for the treatment of non-infectious valve disease. The criteria and results of valve repair for native valve endocarditis are still being defined. The study aim was to examine the short- and long-term results of mitral valve repair and replacement for acute infective endocarditis and to define criteria for the use of each technique. METHODS: A total of 53 consecutive patients who presented with acute native mitral valve infective endocarditis (diagnosed less than six weeks before surgery) between January 1992 and June 2002 was retrospectively analyzed. RESULTS: Twenty-one patients (40%) underwent mitral valve repair, and 32 (60%) underwent valve replacement. Operative mortality was 0% for the repair group and 13% (4/32) for the replacement group (p = 0.14). Median follow up was 4 years (range: 6-108 months). At five years follow up, a median ejection fraction (EF) of 60% and mitral regurgitation (MR) grade of 1/4 was observed, with an overall late survival of 85% (19/21), in the repair group, while the replacement group had a median EF of 55% and an overall late survival of 73% (p = 0.73). Recurrent endocarditis occurred in 2/21 (10%) in the repair group and 1/32 (3%) in the replacement group (p = 0.34). CONCLUSION: Mitral valve repair is a safe and effective technique to treat acute native mitral valve infective endocarditis with favorable short- and long-term morbidity and mortality. Patients with advanced endocarditis and annular destruction require valve replacement. Mitral valve repair should be performed when technically feasible.

Acute Disease↗
PubMed2004

[Surgical interventions for complex native valve endocarditis].

OBJECTIVE: To elucidate the early and long-term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement. METHODS: Fifty-seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses (n = 19), root abscesses (n = 4), mitral posterior annular abscesses (n = 11), myocardial abscesses (n = 6), massive leaflet destruction (n = 32) and valvular vegetations (n = 55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall's procedure (n = 4), aortic valve replacement (n = 21), mitral valve replacement (n = 16) and double valve replacements (n = 16). RESULTS: The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow-up was 100% complete at a mean of 5.93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve-related). The NYHA functional status recovered to Class I in 17 patients, Class II in 27 and Class III in 2 at 1 year follow-up. Kaplan-Meier analysis showed the 5-year actuarial freedom from reoperation was (84 +/- 3)%, and actuarial survivorship at 5 years was (61 +/- 9)%. CONCLUSIONS: Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long-term clinical outcomes.

Adolescent↗
PubMed2004

Surgical treatment of infective mitral valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: The approach to mitral valve endocarditis is a surgical challenge, and the optimal procedure remains a matter of debate. In this condition, mitral valve repair appears feasible, but its long-term effects--as opposed to more often practiced valve replacement--have not yet been determined. Herein, the authors' experience of surgical treatment of infective mitral valve endocarditis is presented, with reference to surgical replacement or reconstruction. METHODS: A retrospective analysis was performed of all patients with infective native mitral valve endocarditis treated surgically at the University Hospital Zurich and the City Hospital Triemli Zurich between 1980 and 1996. Of 154 patients, 97 (63%) underwent mitral valve replacement, and 57 (37%) mitral valve reconstruction. RESULTS: The 30-day mortality was 3.2% (5/154); 4% (4/97) after replacement and 1.7% (1/57) after reconstruction (p = 0.67). Survival (Kaplan-Meier) was 93%, 81% and 61% after one, five and 10 years, respectively. There was no significant difference between valve replacement and reconstruction in terms of long-term survival (p = 0.15), but there was a trend towards better survival after reconstruction than replacement if only cardiac deaths were considered (p = 0.1). At follow up, reconstruction patients were significantly less frequently symptomatic (NYHA class III/IV) than replacement patients (0% versus 29%; p = 0.002), had a lower incidence of atrial fibrillation and need for pacemaker implantation (29% versus 47%; p = 0.04), and tended to have less dyspnea in daily life (20% versus 38%; p = 0.07). Reoperation in patients surviving more than 30 days was more common in replacement than in reconstruction patients. CONCLUSION: The present data suggest a trend for better clinical outcome after mitral valve reconstruction than after replacement when treating mitral valve endocarditis. These results encourage mitral valve reconstruction in mitral valve endocarditis, but recommendations to clinicians undertaking surgery on mitral valve endocarditis must be made with caution.

Adolescent↗
PubMed2004

Update on infective endocarditis.

Infectious Endocarditis is a disease almost invariably fatal if it is not treated in the proper manner. A review is presented of the cardiac abnormalities and procedures associated with its development as well as the most recent classification of the different modalities of endocarditis. The clinical manifestation, the causative organisms and diagnostic procedures are summarized. The American Heart Assciation and the American College of Cardiology (AHA/ACC) recommendations for management of native valve endocarditis, infective endocarditis in drug users, prosthetic valve endocarditis and culture negative endocarditis are summarized. The conditions that justify surgical interventions are also presented.

Clinical Trials as Topic↗
PubMed2005

[New etiologies responsible for infective endocarditis with negative blood cultures].

The prevalence of infective endocarditis with negative blood cultures varies in the different series from 5 to 25%. There are certain explanations of negative blood culture endocarditis: previous incorrect antibiotic therapy before obtaining blood samples (antibiotic treatment inhibits the growth of germs, and therefore bacteremia, without sterilizing the vegetations); infective endocarditis due to fastidious microorganism, that is of difficult cultivation and identification; infective endocarditis due to cell-dependent organism (e.g. Coxiella burnetii); infective endocarditis due to fungi; non-infectious involvement of the endocardium (at times with vegetations) during the course of certain disease. We underline three etiologies (Coxiella burnetii, Bartonella species and Whipple's disease bacterium) because their study have constituted the stimulus for the introduction into clinical evaluation of patients with suspected infective endocarditis of different diagnostic approaches, based on a correct sequential application of blood cultures, serodiagnosis and molecular microbiology.

Bartonella Infections↗
PubMed2005

[Short- and long-term prognosis of infective endocarditis in non-injection drug users: improved results over 15 years (1987-2001)].

INTRODUCTION AND OBJECTIVES: The treatment of infective endocarditis has undergone significant change within the last few years. The aim of this study was to evaluate the clinical features and prognosis of infective endocarditis over both the short and long term in patients who are not intravenous drug users. PATIENTS AND METHOD: We carried out a prospective study of 222 consecutive patients who were diagnosed with infective endocarditis between 1987 and June 2001 at two centers. RESULTS: Their mean age was 48 (19) years, with 145 (65%) being male. Overall, 154 (69%) had native valve endocarditis and 68 (31%) had prosthetic valve endocarditis. In 61 patients (27%), no predisposing heart disease was found. Staphylococci were the causal microorganisms in 37% of cases (81 patients), and streptococci, in 35% (78 patients). Some 48% of patients underwent surgery during the active disease phase. Overall, inpatient mortality was 17% (39 cases); a significant decrease had occurred in recent years, from 25% in 1989-1995 to 12% in 1996-2001 (P<.01). In addition, the percentage undergoing early elective surgery had increased between the two periods, from 22% to 32% (P<.05). During a follow-up of 60 (48) months, 15 patients (8%) needed late cardiac surgery and 18 (10% of the whole series) died. The 6-year survival rate was 72% overall, and 80% in those who survived the active disease phase. CONCLUSIONS: Short- and long-term prognoses for patients with infective endocarditis appear to have improved over recent years at our hospitals.

Adolescent↗
PubMed1991

Staphylococcus aureus endocarditis in community hospitals.

We compared 13 cases of Staphylococcus aureus endocarditis from community hospitals to previous series all of which originated from university or tertiary care hospitals. In our experience Staph. aureus was the third leading cause of endocarditis and accounted for 20% of cases. The infection presented as one of three syndromes: native valve endocarditis, prosthetic valve endocarditis and endocarditis in drug addicts. Laboratory data revealed leukocytosis; infiltrates, nodules, congestive heart failure and cardiomegaly were seen on chest x-ray; and echocardiography infrequently detected vegetations. Criteria which favored the diagnosis of endocarditis in staphylococcemic patients were: absence of a primary site of infection, community acquisition of infection, metastatic infectious sequelae and vegetations documented by echocardiography. Treatment requires prolonged intravenous administration of high dose bactericidal antimicrobial agents; commonly nafcillin or oxacillin combined for a variable period with gentamicin. The mortality rate in our series was 23% and complications occurred in 70% of cases.

Alabama↗
PubMed1991

Porcine bioprosthetic aortic valve endocarditis with ring abscess and aortic stenosis.

Porcine bioprosthetic valve endocarditis is an infrequent but serious complication of valve replacement surgery. Ring (or annular) abscess is a frequent finding in mechanical valve endocarditis. In contrast, porcine valve endocarditis most often involves the cusps, and annular infection is uncommon. Porcine valvular dysfunction secondary to endocarditis usually takes the form of incompetence, whereas stenosis is less frequent. We report a case of a 76-year-old female who developed endocarditis with Staphylococcus epidermidis nine months after placement of a Carpenter-Edwards porcine aortic valve. Her initial presentation included complete heart block and moderate aortic stenosis. Transesophageal echocardiography aided the diagnosis by demonstrating large vegetations, while transthoracic echocardiography showed only slight thickening of the valve leaflets. At operation, there was a circumferential abscess around the sewing ring causing valve dehiscence and virtual discontinuity of the aorta from left ventricle. Valve degeneration and organisms within the cusps were observed on microscopy. This case illustrates two infrequent complications of porcine aortic valve endocarditis, namely massive annular abscess with invasion of the conducting system and aortic stenosis. It also demonstrates the utility and limitations of transesophageal echocardiography in the diagnosis of this disorder.

Abscess↗