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PubMed1984

Clinical and echocardiographic correlations in right heart endocarditis.

UNLABELLED: The echocardiographic findings were correlated with the clinical findings and outcome in 23 patients with tricuspid valve or pulmonary valve endocarditis. There were 15 males and 8 females with a mean age of 33.1 +/- 8.4 years. Eighteen patients had tricuspid valve endocarditis, 1 patient had pulmonary valve endocarditis, 3 patients had concomitant mitral valve and tricuspid valve endocarditis, and 1 patient had tricuspid valve and pulmonary valve endocarditis. Twenty of the 23 (87%) patients had a history of intravenous drug abuse. The most common organisms were Staphylococcus aureus (10 of 23 patients or 43%), Streptococcus viridans (5 patients) and Pseudomonas aeruginosa (4 patients). Pulmonary manifestations with septic pulmonary emboli were present in 18/23 (80%) patients, and a regurgitant murmur in 16/23 (73%) patients. Vegetations on the tricuspid valve or pulmonary valve were detected in all patients who had 2D echo, but they were missed by M-mode echo in 2 patients. Nine of the 23 patients (40%) improved on medical therapy, 5 (21%) expired, and 7 (30%) required surgery (tricuspid valve or pulmonary valve replacement in 3, and tricuspid valve excision without replacement in 4). CONCLUSIONS: (1) 11 of 13 patients with persistent infection, multivalvular involvement, fungal or Pseudomonas infection and increasing size of vegetations by echo died or underwent surgery compared to only 1 of 8 patients without these features (P less than 0.01). (2) Staphylococcus aureus infection (10 patients) and flail tricuspid valve or pulmonary valve by echo (6 patients) were not predictive of outcome.

Adult↗
PubMed1992

Spectrum of right-sided infective endocarditis: an Indian experience.

We studied retrospectively 23 consecutive patients seen at our centre with right heart endocarditis. None of the patients had a history of intravenous drug abuse. All patients were found to have underlying congenital heart disease as a predisposing factor, of which ventricular septal defect (26%) and Fallot's tetralogy (26%) were the commonest. Postoperative endocarditis (26%) also constituted an important clinical subset. Fever (100%) and predominant pulmonary symptoms (69.5%) were the important presenting features. Congestive heart failure was present in 15 patients (65.2%) and predicted an adverse in-hospital outcome. Both the pulmonary and the tricuspid valves were affected equally with presence of vegetations at multiple sites in 10 patients (43.4%). Seven patients (30%) also had concomitant left-sided endocarditis. Medical therapy alone was successful in 15 patients (68.1%) with an overall in-hospital mortality of 31.8%. Five of 6 patients with postoperative endocarditis died, signifying an ominous prognosis of this subgroup when treated medically. The clinical spectrum of right-sided endocarditis in our country differs from the West. The frequent presence of underlying congenital heart disease, the rarity of drug abuse as a predisposing factor, equal involvement of the tricuspid and pulmonary valves and a greater incidence of congestive heart failure are some of these differences.

Adolescent↗
PubMed1996

[Immunologic studies in the differential diagnosis of infectious endocarditis and septicemia without endocardiac lesion].

Differential diagnosis between infective endocarditis and septicemia without endocarditis remains a crucial clinical difficulty. Value of immunological data during those pathologies has been evaluated in a 2 year prospective study. Sixty-one patients, admitted in an internal medicine and infectious diseases unit for a documented infectious disease, were included. They were separated in three groups: group I (n = 21): demonstrated infective endocarditis; group II (n = 19): septicemia without endocarditis and group III (n = 21): non septicemic well-defined infectious disease. Following parameters were studied: immune circulating complexes, C reactive protein, erythrocyte sedimentation rate, fibrinogen, rheumatoid factor, antinuclear antibodies, Treponema pallidum serodiagnostic and cryoglobulinemia. There were no differences between the three studied groups. In particular, immune circulating complexes were present in respectively 67%, 58% and 62% of the patients of the three groups. So, presence or absence of immunologic abnormalities does not provide help for diagnosis of endocarditis in a febrile patient.

Adult↗
PubMed1992

Severe mitral or aortic valve regurgitation, or both, requiring valve replacement for infective endocarditis complicating hypertrophic cardiomyopathy.

Certain clinical and morphologic findings are described in 11 patients with hypertrophic cardiomyopathy complicated by infective endocarditis that produced severe mitral or aortic valve regurgitation, or both, necessitating valve replacement. All 11 patients had changes in the operatively excised valve or valves characteristic of healed infective endocarditis. The infection involved only the mitral valve in seven patients, only the aortic valve in three patients and both valves in one patient. Study of the operatively excised mitral valves indicated that the healed vegetations were located most commonly on the left ventricular aspects of the anterior mitral leaflet, indicating that vegetation had formed at contact points of this leaflet with mural endocardium of the left ventricular outflow tract. In all 11 patients, the infective endocarditis either worsened preexisting valve regurgitation or initiated valve regurgitation and led to worsened signs and symptoms of cardiac dysfunction, necessitating valve replacement. Functional class improved in the nine patients who survived 7 to 101 months after valve replacement. Hypertrophic cardiomyopathy appears to be a factor predisposing to infective endocarditis. Patients with hypertrophic cardiomyopathy should receive prophylactic antibiotic therapy during procedures that predispose to infective endocarditis.

Adult↗
PubMed1994

Prosthetic valve endocarditis: analysis of risk factors for mortality.

Between 1975 and 1990, 70 episodes of prosthetic valve endocarditis (PVE) were diagnosed in 65 patients at Leiden University Hospital. The overall mortality rate was 27%. Antecedent endocarditis attributable to the same micro-organism (mortality 63%, P = 0.02) and Staphylococcus aureus as the causative micro-organism (mortality 100%, P = 0.001) were significant predictors for mortality. Sex, type and position of the valve and therapy had no significant influence on the mortality. All patients infected with S. aureus died, irrespective of whether they received medical treatment alone or in combination with surgery. None of the patients with streption, endocarditis had abscesses at reoperation; the mortality rate for this group was 14%. Abscess formation, especially in aortic valves, was the most important finding at reoperation and corresponded with a mortality rate of 55%. Ring abscesses occurred equally in patients with mechanical and bioprosthetic valves. Seven of the 15 patients (47%) with significant prosthetic valve dehiscence died. In patients with mitral valve endocarditis, localized dehiscence of the valve was observed. In conclusion a previous endocarditis attributable to the same micro-organism and the causative micro-organism (S. aureus) were important risk factors for mortality due to PVE.

Adolescent↗
PubMed2006

Surgical management of infective endocarditis: early predictors of short-term morbidity and mortality.

BACKGROUND: Infective endocarditis is a diagnostic and therapeutic challenge that ultimately requires surgical intervention in 20% of all cases. Early determinants of morbidity and mortality in this high risk population are not well described. METHODS: The aim of this study was to determine preoperative clinical, microbiological, electrocardiographic, and echocardiographic variables that predicted the need for permanent pacemaker implantation and in-hospital death in a surgical cohort of patients with active infective endocarditis. RESULTS: We identified 91 patients (61 males and 30 females, mean age 58 +/- 16 years) who underwent surgical intervention for active culture-positive infective endocarditis as defined by the Duke criteria. Native valve infective endocarditis was present in 78 (85.7%) and prosthetic valve endocarditis in 13 (14.3%) of cases. The aortic valve was infected in 61 (67.0%), the mitral in 35 (38.5%), and multiple valves in 8 patients (8.8%). The most common indication for surgical intervention was intractable heart failure. Twenty-two patients (24.2%) required pacemakers, while there were 14 (15.4%) in-hospital deaths. In age-adjusted and gender-adjusted analyses, the presence of left bundle branch block on preoperative electrocardiogram (ECG) and presence of depressed left ventricular systolic function (ejection fraction [EF] < 50%) predicted the need for a permanent pacemaker implantation, while the presence of depressed left ventricular function predicted in-hospital mortality. CONCLUSIONS: Preoperative ECG findings of left bundle branch block and reduced left ventricular function may allow for early risk stratification of this high risk population.

Adult↗
PubMed2007

Subcoronary Ross procedure in patients with active endocarditis.

BACKGROUND: The Ross procedure has gained increasing interest as an attractive alternative to a prosthetic aortic valve substitute within the last decade. Because of a probably better resistance to infection as one of its advantages, the pulmonary autograft is theoretically preferable for active endocarditis. METHODS: Between June 1994 and July 2003, the Ross procedure was performed using the subcoronary and inclusion technique in 296 patients (231 male, 65 female). Twenty patients had an active endocarditis of the aortic valve at the time of operation. A bicuspid valve was present in 10 patients. One patient had previous aortic valve surgery. Clinical and echocardiographic follow-up was complete. RESULTS: Early mortality was 1, late mortality was 0. There were no recurrence of endocarditis and no neurologic events during the mean follow-up of 47.3 +/- 28.6 months. All patients were in New York Heart Association class I. Mean and maximum pressure gradient across the autograft was 3.5 +/- 2.0 and 6.5 +/- 3.4, respectively, with no autograft insufficiency in 15, 1+ in 4. Comparing postoperative with the last investigations, there were no significant changes of pressure gradients or grade of regurgitation. Mean and maximum homograft pressure gradients were 7.9 +/- 3.7 and 16.2 +/- 8.1 mm Hg, respectively, at last investigation; most patients had no or mild homograft regurgitation (0+, n = 13; 1+, n = 5; 2+, n = 1). CONCLUSIONS: Native valve endocarditis can be treated with excellent results using the Ross procedure with the subcoronary and inclusion technique, with low mortality and morbidity rates and a very low recurrence rate of endocarditis.

Adult↗
PubMed2004

Austrian syndrome in a child-aortic valve endocarditis following pneumococcal meningitis.

A 7-year-old girl with a previously healthy heart underwent a Ross procedure after pneumococcal sepsis, meningitis and aortic valve endocarditis with extensive para-valvular involvement. While pneumococcal infections including respiratory tract infections, bacteraemia and meningitis are common in childhood, endocarditis caused by Streptococcus pneumoniae occurs rarely. Pneumococcal meningitis and aortic valve endocarditis is a known combination, described as Austrian syndrome. We suggest that children with pneumococcal meningitis should be screened with echocardiography for an aortic valve endocarditis. In case of aortic valve endocarditis and persistent infection, surgery should be considered early.

Anti-Bacterial Agents↗
PubMed2004

Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews.

INTRODUCTION: Endocarditis due to Listeria monocytogenes is a rare but serious disease often leading to valve dysfunction and heart failure. Two cases of listerial prosthetic valve endocarditis are reviewed along with 66 cases previously reported. RESULTS: The mean age of patients with listerial endocarditis increased from 47.1 years in the decades from 1955-1984 to 65.5 years from 1985-2000. Chronic debilitating diseases, solid tumours and immunosuppression associated with organ transplantation, hematologic neoplasia or AIDS were found in 41.1% of cases. Listerial endocarditis was a vegetative and destructive process, with dehiscense of the prosthesis and occasionally, abscess formation, fistulization and pericarditis. Treatment with penicillin or ampicillin alone or combined with gentamicin was adequate therapy in most cases. Vancomycin together with gentamicin may be a reasonable alternative therapy. CONCLUSIONS: Despite problems associated with microbial persistence and relapses in other forms of human listeriosis, antimicrobial therapy alone may be a successful treatment for listerial endocarditis, including cases occurring on prosthetic valves. Valve replacement may be reserved for complicated cases with valve dehiscense, cardiac failure or myocardial abscess. Overall mortality was 35.3%, although most patients who died did so before 1985 and since then mortality has been significantly reduced to 12%.

Aged↗
PubMed2004

Infective endocarditis: a five-year experience at a tertiary care hospital in Pakistan.

OBJECTIVES: Infective endocarditis is common and data regarding its pattern and outcome from developing countries is sparse. We therefore examined the spectrum, demographics and clinical features of infective endocarditis and sought to determine the factors affecting its clinical outcome. PATIENTS AND METHODS: Over a five-year period at our university hospital in Karachi, Pakistan, we identified 66 patients with infective endocarditis and compared their clinicoepidemiologic features and outcomes to subjects in the West. RESULTS: The male:female ratio was 2:1; overall median age was 24 years (35.5 years for men and 13.5 years for women) (p < 0.001). Median duration of symptoms before presentation was 20.5 days. Major predisposing cardiac abnormalities included congenital (50%) and rheumatic (23%) lesions, and a history of heart surgery (17%). Causative organisms and valvular sites of infection were similar to those seen in developed countries. Blood culture-negative infective endocarditis was found in 48% of cases. Renal failure was more frequent among culture-positive patients (p = 0.055). Risk factors for mortality included neurologic (p = 0.003) and embolic (p = 0.02) complications, renal (p = 0.03) and left ventricular failure (p = 0.002), and a history of cardiac surgery (p = 0.026). Overall mortality was 27%. CONCLUSIONS: Patients with infective endocarditis in Pakistan exhibit significant differences compared to their counterparts in the West, including younger age at presentation, incidence of predisposing cardiac conditions, and gender differences reflecting sociocultural bias. Neurologic and embolic complications, renal failure and heart failure predict a worse outcome.

Adult↗
PubMed2004

Managing embolic myocardial infarction in infective endocarditis: current options.

Systemic embolization is common in infective endocarditis and is known to occur in 45-65% of cases. Coronary artery embolism has been seen in as many as 60% of cases at necropsy. However, it only rarely has been described as resulting in transmural myocardial infarction. In most cases, coronary embolism is inferred from circumstantial evidence. We present two patients with myocardial infarction in the setting of acute infective endocarditis. Current issues regarding the management of myocardial infarction in infective endocarditis are described in this article. We also describe the first documented case of Lactobacillus jensenii endocarditis leading to myocardial infarction. Possible factors, which may be instrumental in producing endocarditis with this organism, are also discussed.

Adolescent↗
PubMed2005

Mitral valve repair provides improved outcome over replacement in active infective endocarditis.

OBJECTIVES: Mitral repair in active infective endocarditis still remains controversial. Several studies demonstrate the feasibility of mitral repair in infective endocarditis; however, superiority of repair has never been shown. The aim of the investigation was to compare valve repair and valve replacement in respect to the extent of destruction and to analyze survival, recurrent endocarditis, and reoperation (event-free survival). METHODS: Sixty-eight consecutive patients underwent surgical intervention for mitral endocarditis. Thirty-four (50%) patients had valve repair, and 34 (50%) patients had valve replacement. Leaflet destruction involving at least one mitral leaflet was present in 15 (44.1%) patients of the repair group and 11 (32.4%) patients of the replacement group. Repair of the mitral annulus with pericardium was performed in 4 (11.8%) patients in the repair group and 3 (8.8%) patients in the replacement group. Patients in both groups were similar concerning the progression of valvular destructions and comorbidities. RESULTS: Hospital mortality was 11.8% (8 patients). No significant differences were found in all baseline parameters, with the exception of a higher incidence of previous septic embolism and sepsis in the repair group. Actuarial event-free survival at 1 year was 88.2% in the repair group compared with 67.7% in the replacement group, and 5-year event-free survival was 80.4% in the repair group and 54.6% in the replacement group (P = .015). Mitral valve repair remained the superior treatment regarding event-free survival in the multivariate analysis (hazard ratio, 0.33; 95% confidence interval, 0.12-0.93; P = .02). CONCLUSIONS: Mitral valve repair offers excellent early and late results and is the preferable treatment option in the surgical therapy of native infective endocarditis.

Disease-Free Survival↗
PubMed1997

Valvular perforation in left-sided infective endocarditis: a prospective echocardiographic evaluation and clinical outcome.

We undertook this study to determine the use of transthoracic and transesophageal echocardiography in detecting valvular perforation and the clinical impact of the latter on the outcome of left-sided infective endocarditis. Transthoracic echocardiography was performed in 58 consecutive patients with infective endocarditis. According to the study protocol, a subgroup of 42 patients also underwent transesophageal echocardiogrophy. At referral, 20 (34%) of 58 patients had echocardiographic evidence of valvular perforation (group A). No valvular perforations were found in the remaining 38 patients (group B). During a follow-up period of 27 +/- 16 months, a major complication occurred in 18 of 20 patients in group A and in 11 of 38 patients in group B (p < 0.0001). Univariate analysis indicated previous infective endocarditis, aortic involvement, and New York Heart Association functional class had a predictive value for valvular perforation (p < 0.001). Stepwise regression analysis confirmed aortic valve perforation as the only independent predictive variable for surgery and death. Valvular perforation is a common complication of infective endocarditis and is associated with an adverse outcome. Transthoracic echocardiography can detect or suggest valvular perforation in infective endocarditis, but transesophageal echocardiography better defines this complication and predicts severe heart failure or the need for early surgical management.

Adult↗
PubMed1998

Are high-velocity tricuspid and pulmonary regurgitation endocarditis risk substrates?

BACKGROUND: A major predisposing cause of infective endocarditis is a susceptible cardiac substrate characterized by high-velocity turbulent flow. However, the risk incurred by high-pressure, high-velocity regurgitation across inherently normal pulmonary and tricuspid valves has not hitherto been examined. METHODS AND RESULTS: This study focused on 186 adult patients with congenital heart disease who had pulmonary vascular disease and inherently normal right-sided pulmonary and tricuspid valves. The observation period was approximately 1646 patient-years. Exclusion criteria were coexisting lesions that might have served as independent risk substrates for infective endocarditis. High-velocity turbulent pulmonary and tricuspid regurgitation were identified and quantified by color flow imaging and continuous wave Doppler echocardiography. Diagnoses of infective endocarditis were based on established clinical and laboratory criteria. Tricuspid regurgitation was moderate to severe in 80 patients and mild or absent in 106 patients. Pulmonary regurgitation was moderate to severe in 84 patients and mild or absent in 102 patients. With the exception of a single habitual intravenous drug abuser, no patient, irrespective of the degree of high-velocity turbulent pulmonary or tricuspid regurgitation, had infective endocarditis. CONCLUSIONS: High-velocity turbulent flow across inherently normal pulmonary and tricuspid valves rendered incompetent by pulmonary hypertension may represent a relatively low-risk or no-risk substrate for infective endocarditis.

Adolescent↗
PubMed1996

Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy.

PURPOSE: To compare the efficacy and safety of inpatient oral antibiotic treatment (oral) versus standard parenteral antibiotic treatment (intravenous) for right-sided staphylococcal endocarditis in injection drug users. PATIENTS AND METHODS: In a prospective, randomized, non-blinded trial, febrile injection drug users were assigned to begin oral or intravenous (IV) treatment on admission, before blood culture results were available. Oral therapy consisted of ciprofloxacin and rifampin. Parenteral therapy was oxacillin or vancomycin, plus gentamicin for the first 5 days. Antibiotic dosing was adjusted for renal dysfunction. Administration of other antibacterial drugs was not permitted during the treatment or follow-up periods. Bacteremic subjects having right-sided staphylococcal endocarditis received 28 days of inpatient therapy with the assigned antibiotics. Test-of-cure blood cultures were obtained during inpatient observation 6 and 7 days after the completion of antibiotic therapy, and again at outpatient follow-up 1 month later. Criteria for treatment failure and for drug toxicity were prospectively defined. RESULTS: Of 573 injection drug users who were hospitalized because of a febrile illness and suspected right-sided staphylococcal endocarditis, 93 subjects (16.2%) had two or more sets of blood cultures positive for staphylococci; 85 of these bacteremic subjects (14.8%) satisfied diagnostic criteria for at least possible right-sided staphylococcal endocarditis (no other source of bacteremia was apparent) and entered the trial. Forty-four (oral, 19; IV, 25) of these 85 subjects completed inpatient treatment and evaluation including test-of-cure blood cultures. There were four treatment failures (oral, 1 [5.2%]; IV, 3 [12.0%]; not significant, Fisher's exact test). Drug toxicity was significantly more common in the parenterally treated group (oral, 3%; IV, 62%; P < 0.0001), consisting largely of oxacillin-associated increases in liver enzymes. CONCLUSIONS: For selected patients with right-sided staphylococcal endocarditis, oral ciprofloxacin plus rifampin is effective and is associated with less drug toxicity than is intravenous therapy.

Administration, Oral↗
PubMed2001

Fungal left ventricular assist device endocarditis.

BACKGROUND: Infection remains as the most serious complication and represents a significant threat to patients during long-term mechanical circulatory support. Fungal infection is a particularly worrisome complication and left ventricular assist device (LVAD) endocarditis does pose a serious threat. METHODS: One hundred and sixty-five patients underwent TCI Heartmate LVAD implantation between July 1991 and December 1999 at our institution. Detailed medical records were kept prospectively for all patients, and a variety of infection-related endpoints were analyzed on patients with fungal LVAD endocarditis. RESULTS: Thirty-seven patients (22%) developed fungal infections during LVAD support. Five (3%) of those met our criteria for the diagnosis of fungal LVAD endocarditis. Microbial portals of entry were identifiable in all cases. Infections were managed successfully in 4 patients (80%). CONCLUSIONS: The successful management of fungal LVAD endocarditis currently requires early recognition of potentially nonspecific signs and symptoms, and timely institution of antifungal therapy. In some cases with device-specific manifestations of LVAD endocarditis, device removal and replacement is necessary. In patients with clinical manifestations of sepsis and fungal driveline site or pocket infections without positive blood culture, urgent transplantation may be the appropriate management. In the setting of shortage in the donor supply, device removal and replacement is necessary.

Amphotericin B↗
PubMed2001

Treatment of endocarditis with valve replacement: the question of tissue versus mechanical prosthesis.

BACKGROUND: It remains unknown whether there is any important clinical advantage to the use of either a bioprosthetic or mechanical valve for patients with native or prosthetic valve endocarditis. METHODS: Between 1964 and 1995, 306 patients underwent valve replacement for left-sided native (209 patients) or prosthetic (97 patients) valve endocarditis. Mechanical valves were implanted in 65 patients, bioprostheses in 221 patients, and homografts in 20 patients. RESULTS: Operative mortality was 18+/-2% and was independent of replacement valve type (p > 0.74). Long-term survival was superior for patients with native valve endocarditis (44+/-5% at 20 years) compared with those with prosthetic valve endocarditis (16+/-7% at 20 years) (p < 0.003). Survival was independent of valve type (p > 0.27). The long-term freedom from reoperation for patients who received a biologic valve who were younger than 60 years of age was low (51+/-5% at 10 years, 19+/-6% at 15 years). For patients older than 60 years, however, freedom from reoperation with a biological valve (84+/-7% at 15 years) was similar to that for all patients with mechanical valves (74+/-9% at 15 years) (p > 0.64). CONCLUSIONS: Mechanical valves are most suitable for younger patients with native valve endocarditis; however, tissue valves are acceptable for patients greater than 60 years of age with native or prosthetic valve infections and for selected younger patients with prosthetic valve infections because of their limited life expectancy.

Adult↗
PubMed2001

The St. Jude "Silzone" valve: midterm results in treatment of active endocarditis.

BACKGROUND: The Silzone-coated St. Jude Medical valve (SJM "Silzone" valve), developed to reduce prosthetic valve endocarditis (PVE), was recalled by SJM due to a higher rate of paravalvular leaks. The aim of this study was to determine the efficacy of the SJM "Silzone" valve in avoiding PVE and to evaluate the frequency of paravalvular leaks, when the valve was used exclusively for active bacterial endocarditis. METHODS: From January 1998 to December 1999, the SJM "Silzone" valve was implanted in 40 consecutive patients with active endocarditis (20 aortic, 14 mitral, and 6 both valves). Late transesophageal echocardiography was performed in 87% of survivors, and transthoracic echocardiography in the remaining 13%. Follow-up was 100%. RESULTS: Hospital mortality was 17.5%. Early PVE occurred in 2 of 40 patients (5%). There were two late deaths without signs of recurrent PVE. A hemodynamic relevant paravalvular leak necessitating reoperation was seen in 2 patients within 6 months after operation. The rate of a minor paravalvular leak was 13% (4 of 31 patients). CONCLUSIONS: The SJM "Silzone" valve when implanted for active bacterial endocarditis does not give better results than other mechanical prostheses with regard to early recurrence of endocarditis. The rate of a hemodynamic relevant paravalvular leak requiring reoperation seems rather high during the early postoperative period, whereas the occurrence of minor paravalvular leaks is comparable with that of other mechanical prostheses. Routine observation, recommended for all patients with mechanical heart valves, is also sufficient for patients with the SJM "Silzone" valve.

Actuarial Analysis↗