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PubMedDate not supplied

[Infectious endocarditis in mitral valve prolapse].

The paper reports on 13 cases of infectious endocarditis in the patients with prolapse of the mitral valve admitted for a period of 10 years (1979-1989) into the Clinic of Cardiology of the Fundeni Hospital. These cases stand for 3.6% of the cases with prolapse of the mitral valve admitted during that period, and 5% of the patients with infectious endocarditis. Our study dealt only with the cases of the prolapse of the mitral valve, clinically and echographically documented before the appearance of the septic graft. The hemocultures were positive in all the patients (viridans streptococci in 84.61% cases). The symptomatology, the clinical objective data and the paraclinical results (phonocardiographic, echocardiographic, electrocardiographic, radiologic, investigations with isotopes), the response to the treatment (medical, surgical) and the evolution in time were analyzed. An increase was found during endocarditis in the number of patients with holosystolic murmurs (30.7% cases) versus those with click-telesystolic murmur, the appearance in 41.15% of the cases of valvular vegetations at the Echo examination, and in 15.38% cases of ruptures of cordages. Mitral insufficiency secondary to endocarditis became worse, in 30.76% cases. The treatment with antibiotics resulted in the healing of the infection in all the cases. The surgery was not necessary in any patient during the evolution of endocarditis. The surgery (valvular prosthesis) was made in 23.07% cases, which presented, after curing the septic graft, important mitral regurgitation with cardiac insufficiency refractory to the medical treatment. Prophylaxis of the infectious endocarditis in the prolapse of mitral valve with mitral regurgitation is necessary.

Adult↗
PubMed1991

An audit of anticoagulation and endocarditis prophylaxis after heart valve surgery.

OBJECTIVE: to audit anticoagulant control and endocarditis prophylaxis following heart valve surgery. DESIGN: retrospective review of all 190 patients living in Canterbury who had heart valve surgery between January 1981 and December 1986 to determine the incidence of endocarditis and complications of anticoagulation. RESULTS: there were 35 late deaths, of which nine were attributed to thromboembolism (3), major bleeding (2), or endocarditis (4). The rate of thromboembolic events, and major bleeding was 4.6 and 3.3/100 patient years of warfarin therapy respectively, while the incidence of late endocarditis was 0.96/100 patient years. Two episodes of endocarditis occurred after minor dental procedures performed without antibiotic prophylaxis. Many dentists indicated that they would not have recommended prophylactic therapy for these procedures. Some patients had inadequate recall of important details of anticoagulant control or endocarditis prophylaxis. Only 24% knew their latest prothrombin ratio, yet a survey of general practitioners revealed that, in their view, the majority of patients may be capable of monitoring their own anticoagulant therapy. CONCLUSION: the incidence of potentially preventable long term complications of heart valve surgery is comparable to other series. Nevertheless, these complications could be reduced by better patient education possibly enhanced by greater involvement of the patient in their anticoagulant control. The indications for antibiotic prophylaxis for dental procedures should be broadened for this group of patients.

Adolescent↗
PubMed1991

Evaluation of the immune response in protection against experimental Streptococcus defectivus endocarditis.

Immune protection from endocarditis caused by Streptococcus defectivus was examined by using a rabbit model. Previously we had demonstrated that immunization with nutritionally variant streptococci (NVS, now referred to as Streptococcus, species defectivus and adjacens) protected rabbits against endocarditis when they were challenged with the homologous strain. However, when high-titer immune globulin was transferred to nonimmunized rabbits, no protection was achieved. In the present study, immunosuppressive treatments were given to previously immunized rabbits, and alterations in the level of protection were determined by using the rabbit endocarditis model. Control-immunized rabbits as well as immunized rabbits receiving cyclosporin A or methylprednisolone treatments were protected from S. defectivus endocarditis at levels between 50% and 67%. Rabbits in each of these groups cleared S. defectivus organisms from the circulation by 3 hours after infection. Nitrogen mustard-treated rabbits (immunized or nonimmunized), however, were unable to clear S. defectivus organisms as efficiently (almost 100 times as many organisms in the blood when compared with other groups) by 3 hours, and all were susceptible to endocarditis. These data suggest that circulating phagocytes such as monocytes and granulocytes function to a certain extent in protection against S. defectivus endocarditis. Moreover, when neutrophils were transfused into granulocytopenic and monocytopenic rabbits, efficient clearance was prolonged, indicating that polymorphonuclear leukocytes were involved in the later (greater than 1 hour after infection) phase of protection.

Animals↗
PubMed1990

Pneumococcal endocarditis in adult patients. A report of five cases and review of the literature.

A retrospective survey of patients with pneumococcal infective endocarditis at the University Hospital, Leiden, over a 10-year period (1976-1986) yielded five cases. Applying strict case definitions, four patients had definite and one patient possible pneumococcal endocarditis. The commonest presenting signs and symptoms were malaise, fever, and congestive heart failure. Predisposing conditions were previous splenectomy in one case and a valve prosthesis in another. The aortic valve was the most common site of infection. In four of the five patients the diagnosis of endocarditis was made during life. These patients were treated appropriately, i.e. with antibiotics to which S. pneumoniae is sensitive. In three patients, surgical intervention was performed in the acute phase because of progressive heart failure. Paravalvular abscesses were observed at surgery in all these cases. The four patients treated in our series recovered fully; the single fatal case constituted an unrecognized case of pneumococcal endocarditis. If recognized and treated appropriately (particularly with early selective surgery) endocarditis can be cured. In a statistical analysis of 36 patients with pneumococcal endocarditis reported during the past five years, we found a significantly higher occurrence and mortality in men than in women; no other clinical features were associated with a poor outcome of illness.

Adolescent↗
PubMedDate not supplied

[Endocarditis caused by Staphylococcus aureus in drug addicts and non-addicts: the same microbe in 2 diseases].

46 Staphylococcus aureus endocarditis episodes diagnosed with strict criteria in non drug addict patients, and 25 episodes in drug addict patients have been comparatively analyzed. Infection was found in the left side of the heart in 87% of the non addict patients and in 16% of the addicts. On the contrary, 84% of the addicts had endocarditis of the tricuspid and pulmonary valves while only 13% of the non addicts had right heart involvement. The right side endocarditis in the non addicts was always due to intracardiac catheters. 54% of the endocarditis episodes in the non addicts were fatal. Only two addicts, both when had left side endocarditis, died. Mortality was conditioned by infection of the left side of the heart as well as by the existence of heart failure. No significant differences were found between the evolution of patients treated with only one agent or of those treated with a beta-lactam antibiotic plus gentamicin. The emergency valve replacement significantly improved the prognosis of patients with prosthetic valve endocarditis.

Adolescent↗
PubMed1989

[Surgical aspect of active infective endocarditis].

Twenty patients with active infective endocarditis, 11 with native valve endocarditis (NVE) and 9 with prosthetic valve endocarditis (PVE), were treated surgically from 1975 through April 1987 at Kyushu University Hospital. The operative indications were congestive heart failure mainly due to massive aortic regurgitation in 18, periannular abscess in 6, major embolism in 5 and severe hemolysis in 3 patients. In the group of NVE, single aortic valve replacement was performed in 4 patients and multiple valve replacement in the remainder. One patient died early postoperatively from LOS. Two patients with recurrent infective endocarditis, which occurred within 60 days after previous prosthetic valve replacement, were operated subsequently as early PVE. All other patients became NYHA class I postoperatively except for one patient who died from thrombosed valve. In the group PVE, re-AVR was done in 3, re-MVR in five, double valve replacement in two and re-fixation of the prosthesis to the aortic annulus in one patient. Two patients with early PVE died from recurrent endocarditis late postoperatively. One of 7 patients with late PVE, who had suffered from myocardial and cerebral infarction before reoperation, died from multiple organ failure. There were 3 patients with perivalvular leakage due to late active PVE, whose preoperative signs of inflammation were negative or minimum. As recurrent perivalvular leakage due to persistent infective endocarditis might frequently occur in such cases, complete resection and debridement of infected foci should be emphasized.

Adolescent↗
PubMed1988

[Endocarditis or bacteremia caused by Streptococcus bovis and colorectal neoplasms].

Streptococcus bovis is a relatively frequent causative agent of endocarditis or bacteriaemia, particularly in the elderly. In the past S. bovis has often been incompletely or even falsely classified. For therapeutic and prognostic reasons it is important to classify this agent exactly with biochemical methods even in the routine laboratory. Endocarditis or bacteriaemia due to S. bovis are often seen in conjunction with malignant, potentially malignant or benign colorectal neoplasias. After endocarditis or bacteriaemia due to S. bovis thorough investigation of colon and rectum is indicated. On the other hand, in presence of fever in patients with colorectal tumors, S. bovis bacteriaemia or endocarditis must be considered. The available literature is inconclusive on the question whether, after S. bovis endocarditis or bacteriaemia with initially normal colorectal findings, examination of the upper gastrointestinal tract and periodic inspection of the colon is needed. Up to now there has been no satisfactory explanation for the concomitant occurrence of endocarditis or bacteriaemia due to S. bovis and colorectal neoplasia.

Aged↗
PubMed1988

[Cardiac echo-Doppler in the diagnosis and surveillance of the course of acute endocarditis].

Infectious endocarditis is still currently a problem. Its frequency is not decreasing and new etiologies have developed, which are often responsible for acute endocarditis, resistant to hospital bacteria. The cardiac Doppler has a role in the positive diagnosis of endocarditis, especially on native valves. This examination permits an accurate evaluation of valvular and perivalvular lesions (abscess, mycotic aneurysms) and their repercussions on the ventricle. Studies in this last decade, have emphasized that the presence of vegetations is a factor of gravity. The Doppler permits an "active" monitoring in high risk forms: endocarditis of the aortic orifice, endocarditis with perivalvular abscess, endocarditis occurring on a prosthetic valve.

Acute Disease↗
PubMed1986

[Infectious endocarditis surgically-treated in the active phase. Apropos of 46 cases].

The clinical and microbiological characteristics, the surgical indications and procedures, the evolution and the principal prognostic factors were reviewed in 46 cases of infectious endocarditis operated in the active phase. Using this date, the authors try to determine the optimal time for surgery during the acute active phase of infectious endocarditis. The study population comprised 28 men and 18 women aged 7 to 64 years (average age: 30). The patients were selected on strict criteria: positive blood cultures during the 48 hours prior to surgery (29 cases), positive valve or valve prosthesis culture (15 cases), the presence of an active cardiac abscess at surgery (7 cases), the presence of a large number of bacteria on histological examination of the valve (17 cases). The patients were divided into two groups: those with endocarditis of native valves (27 cases) and those with endocarditis on prosthetic valves (19 cases). The preoperative clinical features included all the classical signs of IE but congestive cardiac failure was particularly prevalent (62% of cases). Microbiologically, most cases of native valve endocarditis (67%) were due to sensitive organisms (streptococci) whilst the more virulent organisms (staphylococci, gram-negative bacteria and fungi) were observed in prosthetic valve endocarditis (64% of cases). The commonest surgical indication was haemodynamic deterioration (30 cases). The indications were mixed in 15 cases but only one case was operated for uncontrolled infection alone in this series. The surgical procedure was technically complex in 6 cases. Operative mortality was high (18 cases, 39%). The main cause of death was low cardiac output (13 cases).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1988

Enterococcal bacteremia: clinical features, the risk of endocarditis, and management.

The enterococci, members of the group D streptococci and the predominant aerobic streptococci of the gastrointestinal and female genital tracts, have long been recognized as significant pathogens in infective endocarditis. Over the past 2 decades, enterococci have become increasingly important nosocomial pathogens, related to their intrinsic resistance to many antibiotics, especially the cephalosporins, and the greatly increased use of antimicrobial therapy in hospitals. Recent reports have documented an alarming increase in the frequency of high-level resistance to aminoglyclosides, and strains resistant to ampicillin by production of a beta-lactamase and to vancomycin have now been encountered. We have reviewed the clinical features and course of 153 cases of enterococcal bacteremia occurring in a university hospital over the 14-year period, 1970 to 1983, 1) to understand better the importance of enterococci as human pathogens, 2) to identify the clinical features of enterococcal bacteremia, 3) to isolate those findings that help to identify associated endocarditis, and 4) to develop guidelines for more effective antimicrobial therapy of bacteremic enterococcal infections. The annual incidence of enterococcal bacteremia in our center rose three-fold over the period reviewed. In 65 cases (42%), bacteremia was polymicrobial, caused by Enterococcus and at least 1 other microorganism, usually an aerobic gram-negative bacillus. Most bacteremias were nosocomial and derived from infections of the urinary tract (29 cases), intravenous catheters (24 cases), intra-abdominal infections or surgical wounds (46 cases), burn wounds (25 cases), or cholangitis (21 cases); only 1 case originated from a pneumonia. Endocarditis was identified in association with 12 of 35 community-acquired bacteremias, but only 1 of 118 bacteremias acquired in the hospital (P less than .001). Endocarditis was also significantly associated with pre-existent valvular heart disease and cryptogenic bacteremia, and was negatively associated with polymicrobial enterococcal bacteremia (no endocarditis in 65 cases, P less than .001). Isolated enterococcal bacteremia produced an indolent infection rarely associated with shock (3 of 64 cases evaluated, all cases due to valve destruction by endocarditis); conversely, with polymicrobial enterococcal bacteremia, primarily with gram-negative bacilli, shock or disseminated intravascular coagulation developed in 50% of cases (P less than .001).(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1988

Incidence and risk factors of prosthetic valve endocarditis.

UNLABELLED: To study the incidence and risk factors of prosthetic valve endocarditis (PVE) we followed 99.5% of 912 patients who had valve replacements from 1 January 1981 to 31 December 1985 for 1-6 (mean 3) years. PVE occurred in 27 patients (2.96% or 0.98% per patient-year). The incidence of PVE in the aortic position (3.9%) was significantly higher than in the mitral position (1.5%): chi-square = 6.1, P less than 0.025. PVE developed in 19 of 329 patients with bioprostheses (5.8%), and in 8 of 583 patients with mechanical valves (1.4%): chi-square = 14.48, P less than 0.005). Actuarially at 5-year follow-up, 90.7% +/- 2.16% of the bioprosthetic group and 98.4% +/- 0.56% of the mechanical valve group was free of PVE (P less than 0.001). Antecedent endocarditis increased both the incidence and relative risk of PVE 7-fold compared to patients without antecedent endocarditis (chi-square = 32.0, P less than 0.0001). Bioprosthetic valve replacement in infective endocarditis increased the risk of PVE 12-fold compared to valve replacement by mechanical prostheses. IN CONCLUSION: in the order of importance, antecedent endocarditis, bioprostheses and aortic position are risk factors in the development of PVE. Bioprostheses implanted in patients with antecedent endocarditis further enhance the risk of PVE.

Adolescent↗
PubMed1988

Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study.

In a prospective study, the clinical value of transoesophageal two-dimensional echocardiography (TOE) as compared with transthoracic two-dimensional echocardiography (TTE) was determined in patients with suspected infective endocarditis. Ninety-six patients were studied consecutively with an electronic sector scanner using 2.25 and 3.5 MHz probes for TTE and a 3.5 MHz probe embedded in tip of a flexible 12 mm gastroscope for TOE. Results of surgery and autopsy were available for 20 of the 96 patients with infective endocarditis and echocardiographically demonstrated vegetations and 70 control patients with valvular heart disease without infective endocarditis and no signs of vegetations, who were studied preoperatively with TTE and TOE. For TTE and TOE, the measured sensitivity was 63% and 100%, specificity 98% and 98%, positive predictive accuracy 92% and 95%, and negative predictive accuracy 91% and 100%, respectively. In 39 patients who had positive blood cultures, vegetations were found by TOE in 32 patients (82%), but in only 27 patients (69%) by TTE. Image quality was the main factor contributing to the superiority of TOE over TTE: it was reduced in 11/20 patients (55%) in whom vegetations were not detected by TTE. Another important factor was the size of vegetations. Only 6/24 vegetations (25%) of less than 5 mm but 9/13 vegetations of 6-10 mm, and 14/14 vegetations of greater than 11 mm detected by TOE were also observed with TTE. The clinical importance of detecting vegetations was demonstrated by the rate of embolism. In patients with vegetations embolism was 25% when blood cultures were positive and 21% when they were negative. In patients without echocardiographically detectable vegetations signs of embolism were seen in no patient with positive and 7% of the patients with negative blood cultures. Evidence of vegetations was found on the aortic valve in 14 patients and on the mitral valve in seven patients in whom valvular incompetence was not present, indicating that the valve had not yet been damaged significantly. TOE is superior to TTE in detecting vegetations in suspected infective endocarditis because of better image quality, particularly when vegetations are small. TOE seems to be indicated in patients with suspected endocarditis and reduced image quality or negative TTE results. Early detection of vegetations on valves may help confirm the diagnosis of infective endocarditis at an early stage and hopefully lead to an improved prognosis by reducing delay in instituting appropriate therapy.

Echocardiography↗
PubMed1988

Quiescent Q fever endocarditis exacerbated by cardiac surgery and corticosteroid therapy.

Q fever endocarditis occurs in up to 11% of patients infected by Coxiella burnetti. Major clues for the diagnosis are culture-negative endocarditis, hepatic involvement, rash, and thrombocytopenia. Characteristically, the diagnosis is delayed. In our patient, Q fever endocarditis occurred without previously recorded signs of infection. Fever, rash, and hepatic involvement all occurred following aortic valve replacement. The histologic picture of the excised valve was consistent with endocarditis, and serologic tests disclosed elevated IgA and IgG antiphase 1 antibody titers against C burnetti, compatible with Q fever endocarditis. It is assumed that the exacerbation of quiescent Q fever endocarditis was caused by cardiac surgery and steroid therapy.

Adult↗
PubMed1984

Favorable ten-year experience with valve procedures for active infective endocarditis.

We have reviewed our 1972 to 1982 experience with valve procedures for infective endocarditis in 52 consecutive patients to evaluate the results of an interdisciplinary policy of early operation for uncontrolled complications. There were 47 patients with native valve endocarditis and five with prosthetic valve endocarditis. Twenty-seven were drug addicts and 25 were not. Thirty-seven (71%) required operation during the active phase of the disease and 15 during the inactive phase. Ninety-three percent of the addicts, 41% of the nonaddicts, and all patients with prosthetic valve endocarditis were in the active group. The distribution of infected valves was as follows: aortic, 21 active and 10 inactive; mitral, six active and three inactive; aortic and mitral, five active and two inactive; aortic and tricuspid, one active and none inactive; and tricuspid, four active and none inactive. Streptococcus was the most common infecting organism in both groups--predominantly group D in addicts and non-D in nonaddicts. Staphylococcus, gram-negative rods, and fungi occurred only in the active group. Indications for operation were congestive heart failure alone (19 active and 15 inactive), congestive heart failure and refractory infection or major emboli (nine active and none inactive), and resistant or refractory infection alone or with emboli (nine active and none inactive). Periannular abscess or aneurysm formation was most frequent at the aortic valve site in patients with native valve endocarditis; it occurred in 13 of 25 patients (52%) in the active group and in one of 12 patients (8%) in the inactive group. Six patients with preoperative stroke syndromes underwent operation without neurological deterioration; two patients had rupture of cerebral mycotic aneurysms postoperatively. Hospital mortality was 8% (3/7) in the active group and 0% in the inactive group. The late actuarial survival rate was 64% at 5 years and 54% at 10 years. Seven of nine deaths in the addict group were related to continued drug use, with five deaths occurring in the first 18 months. These results support a policy of early operation for uncontrolled complications with attention to the particular problems of active endocarditis.

Actuarial Analysis↗
PubMed1980

Experimental endocarditis in rabbits. 4. Experiments with Serratia marcescens: on the significance of serum susceptibility and proteolytic capacity of the strains and the influence of an indwelling catheter.

In order to investigate the course of Serratia marcescens endocarditis in groups of rabbits with and without an indwelling catheter, 130 rabbits were pretreated to produce left-sided endocarditis. Three clinical isolates of S. marcescens were used to infect the rabbits, i.e. CDC O13 (serum sensitive, proteolytic), SM 104 (serum resistant, proteolytic) and SM 55 (highly serum resistant, non-proteolytic). Ten rabbits with an indwelling catheter were challenged with CDC O13 and none of them died or showed evidence of endocarditis 28 days later. In groups of rabbits with indwelling catheters which were challenged with SM 104 or SM 55 there was a high incidence of endocarditis (19/20, 18/20, respectively), while groups without catheters inoculated with the same strains had a lower incidence (5/20, 15/20, respectively). In contrast to earlier observations with Streptococcus faecalis, the clinical and pathological data were not significantly influenced by the presence or absence of proteolytic capacity of the infecting strains. The results indicate that the ability of S. marcescens to establish endocarditis depends significantly on the degree of serum resistance of the strains. This difference was only demonstrable in experiments without an indwelling catheter during the infection period. The distrurbing influence of an indwelling catheter is discussed, and it is concluded that experimental models using indwelling catheters are inappropriate for studies on the pathophysiology of endocarditis.

Animals↗
PubMed1980

Infective endocarditis, 1970-1979. A study of culture-positive cases in St. Thomas' Hospital.

Ninety-three episodes of culture-positive endocarditis occurred in 88 patients in the years 1970 to 1979. Streptococci caused two-thirds of the cases, with Streptococcus mitior and Streptococcus sanguis most common. Among the Group D streptococci, Streptococcus bovis was much more common than Streptococcus faecalis. Staphylococci accounted for a quarter of the episodes. Streptococcal endocarditis was commonest in the elderly, whereas staphylococcal endocarditis occurred at all ages. Degenerative heart disease was the underlying cardiac factor in nearly half the streptococcal cases, but staphylococci most often affected normal heart valves. When prosthetic valves were infected endocarditis of early onset was staphylococcal but that of late onset was streptococcal. Narcotic abuse was a common cause of staphylococcal endocarditis, second only to surgical wound infection following valve replacement. Streptococci affected the mitral and aortic valves equally but the staphylococci more usually involved mitral or tricuspid valves. The overall mortality was 36 per cent but was much higher for staphylococcal than streptococcal endocarditis.

Adolescent↗
PubMed1995

[Mitral valve repair for infectious endocarditis].

Fourteen patients with mitral regurgitation resulting from infectious endocarditis underwent mitral valve repair between December 1988 and July 1994. There were nine males and five females aged from 14 to 70 years (mean 40.2 +/- 19.7 years). Three patients had active endocarditis. Time between the onset of endocarditis symptoms and surgery ranged from 1 to 24 months (mean 8.3 months). Bacterial findings were Streptococcus in eight patients, Staphylococcus in one, and unknown in five. All macroscopically infected tissue was excised in patients with active endocarditis. Carpentier's reconstructive techniques were mainly used. There were no hospital deaths. Mean follow-up was 29 months and complete. Thirteen patients were in New York Heart Association functional class I and one in class II. There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidity. We conclude that mitral valve repair is an attractive procedure in patients with mitral regurgitation resulting from infectious endocarditis.

Adolescent↗
PubMed1995

Fungal prosthetic valve endocarditis.

Fungal prosthetic valve endocarditis is an unusual cause of endocarditis, yet very important because of its historical poor prognosis. This article will review the incidence, presentation, diagnosis, and treatment results of fungal prosthetic valve endocarditis. In addition, 11 patients at The Cleveland Clinic over the last 16 years were treated with a strategy consisting of aggressive perioperative amphotericin B therapy, radical surgical debridement of all infected tissue and prosthetic valve replacement with biological tissue when possible, as well as the chronic use of oral azole antifungal agents for suppression. This combined approach has resulted in 82% of patients being discharged and a 55% 5-year survival rate. Unfortunately, 36% of patients developed recurrent fungal prosthetic valve endocarditis, at an average of 25.8 months after their first operation for fungal prosthetic valve endocarditis. The use of oral antiazole antifungal agents for suppression may prevent the high incidence of recurrent endocarditis in this patient population.

Amphotericin B↗