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PubMed1988

Results of a prospective statewide reporting system for infective endocarditis.

To better understand the microbiology, anatomy, and demography of infectious endocarditis, we devised a prospective statewide reporting system to study these infections. Because our study design required accurate diagnosis, reliable case reporting, and a high probability of physician-to-case exposure, we enlisted the help of cardiologists, cardiovascular surgeons, and infectious disease specialists throughout Louisiana. All Louisiana members of the American College of Cardiology and the Infectious Diseases Society of America were invited to participate. Participants were supplied with a brief endocarditis report form and asked to complete the form as they saw patients with infective endocarditis. Seventy-five patients with infective endocarditis were reported for a case rate of 1.7 per 100,000 persons per year. This report analyzes the results from this one-year study.

Adolescent↗
PubMed1983

Prosthetic valve endocarditis.

During 1965 to 1982, 32 episodes of infective endocarditis on prosthetic valves in 30 patients were treated at this hospital. In early endocarditis (presenting within four months of operation) staphylococci were the organisms most commonly responsible. Early endocarditis appears to be declining in incidence and is largely preventable; sternal sepsis was the main predisposing factor, requiring urgent and effective treatment. Streptococci were the most common organisms in late onset disease, but as with natural valve endocarditis a wide range or organisms was responsible. All but one of the patients with early onset disease were treated conservatively, but mortality was high; prompt surgical replacement of infected prostheses is probably indicated in such patients. Medical management was effective in most patients with late onset disease, and for them early surgical intervention may not be justified.

Adult↗
PubMed1983

The preoperative evaluation in patients with endocarditis. Is cardiac catheterization necessary?

We retrospectively compared clinical assessment and cardiac catheterization to subsequent surgical findings with regard to specific valvular involvement, hemodynamic status, and presence of myocardial abscess in patients recommended for cardiac surgery for endocarditis. Of 105 consecutive patients with endocarditis, 19 met one or more of the following criteria suggesting the need for early surgery: congestive heart failure; systemic emboli; persistent infections or new conduction abnormalities. Of these 19 patients, seven had prosthetic cardiac valves. Clinical assessment was highly sensitive (95 percent) and specific (89 percent) for specific valvular involvement and was also highly sensitive and specific in evaluating myocardial abscess and congestive heart failure; however, clinical assessment could not identify the source of infection in one patient with multiple prosthetic valves, did not define the specific valve in one patient with right-sided endocarditis, and overestimated the severity of mitral regurgitation in one patient who had normal pressures and flows at catheterization. Catheterization incorrectly predicted multivalvular involvement in four patients. At catheterization, only one patient experienced evidence of clinical deterioration, and this was probably not related to the procedure. We conclude that although clinical assessment is correct in most patients, it may on occasion lead to an erroneous conclusion. Catheterization and angiograms are of value in the preoperative evaluation of patients with endocarditis, particularly in cases where the clinical assessment is ambiguous or uncertain. The procedures can be performed at low risk, and the information obtained may substantially influence management in some cases.

Adolescent↗
PubMed1999

Six-year experience with cryopreserved mitral homografts in the treatment of tricuspid valve endocarditis in HIV-infected drug addicts.

BACKGROUND AND AIM OF THE STUDY: In the past, valve homografts have been used in the treatment of aortic endocarditis. This report details our experience in tricuspid valve replacement using cryopreserved mitral homografts in HIV-positive drug addicts with infective endocarditis. METHODS: Five HIV-1-infected drug addicts with active uncontrollable tricuspid valve endocarditis underwent tricuspid valve replacement with a cryopreserved mitral homograft. RESULTS: There was no early mortality, and median follow up was 5 years (range: 1 to 6 years). One late mortality occurred as a result of heroin overdose. Three of the five patients developed six episodes of recurrent bacterial tricuspid endocarditis on the homograft; these were cured successfully with antibiotics. All survivors remain in NYHA functional class I. The latest transthoracic echocardiography examination showed mild, moderate or severe regurgitation in one, two and two patients, respectively. To date, neither homograft calcification nor rupture of the papillary muscle has been detected. CONCLUSIONS: This novel technique is considered to be an adequate approach to these cases of uncontrollable infectious disease. Further episodes of valvular infection can be managed medically.

Adult↗
PubMed1991

[Clinical aspects of endocarditis].

Considering the incidence of infectious endocarditis this disease is still an important clinical entity in internal medicine departments. Leading symptoms are fever, cardiac murmurs, embolic phenomena, skin alterations and also sometimes CNS-disturbances. Two different clinical endocarditis entities can be separated: an acute aggressive course of endocarditis and the subacute course (endocarditis lenta). Diagnostic procedures are mainly based on positive blood cultures and echocardiographic detection of cardiac vegetations. In case of a progressive development of cardiac insufficiency, non treatable infection, large vegetations on valve and embolic phenomena a prosthetic valve implantation is indicated.

Endocarditis, Bacterial↗
PubMed1990

[Surgical therapy for prosthetic heart valve endocarditis: immediate results and follow-up].

Between January 1980 and May 1990 17 patients underwent surgery for prosthetic valve endocarditis at Cardiosurgical Department of Bologna University. Ten patients were female and seven male, the average age was 33 years (range 19 to 67 years). The interval from valve replacement to onset of symptoms of prosthetic valve endocarditis was less than 2 months in 5 patients and longer than 2 months in 12 patients. Sixteen of 17 infected prostheses were mechanical and one biological. All patients were surgically treated and the infected prostheses replaced with new valve prostheses. The hospital mortality rate for early prosthetic valve endocarditis was 60%, for late endocarditis was 16.5%, global hospital mortality was 29.4%.

Adult↗
PubMed1983

[Antibiotic therapy in infectious endocarditis].

The most common causes of infective endocarditis, accounting for 65 to 85% of all cases, are viridans streptococci and other nonhemolytic streptococci. Enterococci are the offending microorganisms in 5 to 15%, staphylococci in 5 to 15% and gram-negative bacteria from the intestinal tract in 2 to 6%. In rare cases, infective endocarditis may be caused by any of a number of other pathogenic and nonpathogenic bacteria. Men over 60 years of age and women under 40 have a higher likelihood of contracting enterococcal endocarditis subsequent to febrile infections of the urogenital tract or after abortion; intravenous drug users tend to infections with gram-negative bacteria; patients with intravascular catheters who are administered cortisone, broad-spectrum antibiotics or cytostatic drugs are at risk of endocarditis from Candida or Aspergillus. At least two, but in general, five blood cultures should be drawn in short intervals. With the use of proper techniques for detection of aerobic and anaerobic microorganisms as well as fungi, positive blood cultures can be obtained in 95% of the patients. Antibiotics may be discontinued temporarily in pretreated patients. Bactericidal antibiotics are indicated. The following rule is valid as a guideline for adequate antibacterial chemotherapy: at maximal concentration after antibiotic administration, a bactericidal effect should still be demonstrated after 1:8 dilution of the patient's serum. Prior to receipt of blood culture findings, in forms tending to be subacute, treatment should be directed at streptococci and enterococci. If the course is more acute, in the presence of an intracardiac foreign body or in intravenous drug users, the antibiotic employed should also be effective against staphylococci.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1978

[The rheumatoid rosette test in bacterial endocarditis. A non-specific test for inflammation (author's transl)].

The rheumatoid rosette test was performed in 33 patients with febrile valvular cardiopathy. In 19 cases bacterial endocarditis was proved by blood culture or by histological examination. The test was positive in 3 cases out of 5 during the first ten days of the fever (group A1), in 6 cases out of 6 after the tenth day (group A2), and in 4 out of the 8 already treated patients (group A3). In 3 positive cases, successive measurements, before and during treatment, showed a rapid fall in rosette levels. In controls patients, the test was positive 8 out of 9 cases with febrile valvular cardiopathy without endocarditis (group B) and in 5 out of 5 cases in which bacterial endocarditis was probable but not proved (group C). The increase in rheumatoid rosette levels seems therefore to be non specific of bacterial endocarditis. Nevertheless it could be a good test for biological activity of the disease in treated patients. The origin and signification of the rheumatoid rosette forming cells are discussed.

Endocarditis, Bacterial↗
PubMed1983

Early valve replacement in active infective endocarditis. Results and late survival.

In the past 14 years, 42 patients with active infective endocarditis underwent early valve replacement for severe congestive heart failure, major prosthetic dehiscence, intramyocardial abscesses, sepsis, or major embolization. Blood cultures were positive in 40 patients and the valve tissues were positive in two others. All patients received antimicrobials for from 1 to 4 weeks. Drug addiction was noted in 24%, urinary tract manipulation in 7%, dental work in 5%, contaminated prosthesis in 2%, and unknown cause in 62%. Organisms were predominantly staphylococcal (43%) and streptococcal (41%); the remainder were gram-negative (9%) or fungal (7%). The aortic valve was involved in 72%, mitral in 14%, tricuspid in 7%, and both aortic and mitral in 7%. By the New York Heart Association (NYHA) functional classification, 90% (38/42) were in Class III or IV. Operative mortality was 10% (4/42) and all four patients had preexisting renal failure necessitating dialysis. No predominant organism correlated with early deaths. In aortic valve replacement (30 patients), operative mortality was 7%. Postoperatively, 95% (35/37) were Class I or II with one lost to follow-up. Subsequent reoperation was required in five patients (13%) for recurrent endocarditis, with an operative mortality of 20% (1/5). Late death occurred in 45% (17/38). Overall probability of survival was 0.53 at 5 years. For isolated aortic valve involvement, the 5 year survival was 0.58. Survival for native valve involvement was 0.58 and for prosthetic endocarditis, 0.55. This study shows that after at least 1 week of antibiotics, early operation in patients with active endocarditis has an acceptable operative mortality. Clinical improvement is excellent in 95% and more than half survived 5 years or longer.

Adult↗
PubMed1981

Diagnosis, management, and prevention of infective endocarditis.

The epidemiologic, clinical, and microbiologic patterns of infective endocarditis have been undergoing constant change. Prompt diagnosis of infective endocarditis requires clinical suspicion in proper clinical settings and appropriate laboratory tests. Once the infecting organism is identified in blood cultures, the majority of patients with infective endocarditis can be cured by prolonged, intensive antimicrobial therapy. Surgical intervention may be needed in certain patients. Infective endocarditis may be prevented in some patients by the elimination of predisposing factors. Patients with underlying heart diseases should receive antimicrobial prophylaxis immediately before undergoing surgical procedures that are associated with significant risks of bacteremia.

Endocarditis, Bacterial↗
PubMed1993

Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years experience.

During the past 25 years the authors have performed the following operations in the surgical treatment of intractable right-sided endocarditis in drug addicted patients: 1) Excision of the infected tricuspid valve and replacement with a mechanical or bioprosthetic valve during the same operation. In these patients the overall mortality was 100% due to: (a) inability to control the endocarditis in 80%; (b) re-infection due to a return to drug abuse and (c) fatal complications due to non-compliance with anticoagulant therapy. 2) Tricuspid valvulectomy in 53 patients, tricuspid and pulmonary valvulectomy without replacement in two patients. Six patients (11%) died within six weeks. Five due to the endocarditis and one due to low cardiac output. Ten patients (18%) died six months to 13 years later. In nine of these patients, death was related to continued drug abuse. At 22 years the actuarial survival is 64%. This experience supports the authors conclusion that among drug addicts with intractable right-sided endocarditis, tricuspid valvulectomy or tricuspid and pulmonary valvulectomy without replacement is/are the operation(s) of choice.

Adult↗
PubMed1993

Transesophageal echocardiography in endocarditis.

TEE plays a central role in the diagnosis and management of infective endocarditis. In experienced hands this technique is probably over 90% sensitive and specific for the detection of intracardiac lesions associated with endocarditis. TEE should be performed as soon as possible once endocarditis is suspected. A technically adequate negative study almost always means a low probability of endocarditis. Transesophageal imaging appears to be an accurate method of detecting leaflet perforation as well as abscess and fistula formation.

Aneurysm, Infected↗
PubMed1986

Coagulase-negative staphylococcal endocarditis. Occurrence in patients with mitral valve prolapse.

Although coagulase-negative staphylococci (CoNS) are frequent etiologic agents in prosthetic valve endocarditis, they rarely infect native heart valves. We report three cases of CoNS endocarditis in patients with mitral valve prolapse (MVP). Review of other reports of MVP-associated endocarditis and of the limited experience with CoNS infection of native heart valves suggests that our experience is not unique. Coagulase-negative staphylococcal endocarditis superimposed on MVP may be difficult to recognize and to treat. The cardiac dysfunction can be quite subtle, the clinical course indolent, the blood culture results difficult to interpret, and the response to antimicrobial agents suboptimal.

Adolescent↗
PubMed2003

Outcome and treatment of Bartonella endocarditis.

BACKGROUND: Endocarditis caused by Bartonella species is a potentially lethal infection characterized by a subacute evolution and severe valvular lesions. OBJECTIVES: To evaluate the outcome of patients with Bartonella endocarditis and to define the best antibiotic regimen using the following measures: recovery, relapse, or death. METHODS: We performed a retrospective study on 101 patients who were diagnosed in our laboratory as having Bartonella endocarditis between January 1, 1995, and April 30, 2001. Bartonella infection was diagnosed using immunofluorescence with a 1:800 cutoff, polymerase chain reaction amplification of DNA, and/or culture findings of Bartonella species from whole blood, serum, and/or valvular biopsy specimens. A standardized questionnaire was completed by investigators for each patient. RESULTS: Twelve of the 101 patients died and 2 relapsed. Patients receiving an aminoglycoside were more likely to fully recover (P =.02), and those treated with aminoglycosides for at least 14 days were more likely to survive than those with shorter therapy duration (P =.02). CONCLUSION: Effective antibiotic therapy for Bartonella endocarditis should include an aminoglycoside prescribed for a minimum of 2 weeks.

Adolescent↗
PubMed1975

Pneumococcal endocarditis in a 7-week-old infant. A case complicated by congenital heart malformation with mitral valve perforation.

A 7-week-old girl had pneumococcal endocarditis and perforation of the mitral valve. Pneumococcal endocarditis in children under 2 years of age is extremely rare, and is a prototype for endocarditis in general in infants less than 2 years of age. To our knowledge, this is the youngest reported patients with pneumococcal endocarditis in the penicillin era.

Endocarditis, Bacterial↗
PubMed1979

Infective endocarditis during the first decade of life. An autopsy review of 33 cases.

Twenty-six cases of infective endocarditis seen at autopsy during the first decade of life, between 1911 and 1944, are compared with seven fatal cases between 1944 and 1977. The incidence of infective endocarditis at autopsy in this age-group has decreased since 1944 (0.60% to 0.23%). Before 1944, Gram-positive cocci were most frequently responsible. Rheumatic heart disease (31%) more often predisposed to infective endocarditis than did congenital heart disease and left-sided valves were most frequently involved. Peripheral septic foci and penumonia were the most frequent sources of infection. The introduction of penicillin and advances in cardiology and cardiovascular surgery have had considerable impact of the spectrum and evolution of the diseases. Fungi and uncommon opportunistic bacteria are now frequently encountered. Rheumatic heart disease rarely predisposes to infective endocarditis in this age-group, congenital heart disease being the major underlying disease.

Age Factors↗
PubMed2003

Complicated left-sided native valve endocarditis in adults: risk classification for mortality.

CONTEXT: Complicated left-sided native valve endocarditis causes significant morbidity and mortality in adults. Lack of valid data regarding estimation of prognosis makes management of this condition difficult. OBJECTIVE: To derive and externally validate a prognostic classification system for adults with complicated left-sided native valve endocarditis. DESIGN, SETTING, AND PATIENTS: Retrospective observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals among 513 patients older than 16 years who experienced complicated left-sided native valve endocarditis and who were divided into derivation (n = 259) and validation (n = 254) cohorts. MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline. RESULTS: In the derivation and validation cohorts, the 6-month mortality rates were 25% and 26%, respectively. Five baseline features were independently associated with 6-month mortality (comorbidity [P =.03], abnormal mental status [P =.02], moderate to severe congestive heart failure [P =.01], bacterial etiology other than viridans streptococci [P<.001 except Staphylococcus aureus, P =.004], and medical therapy without valve surgery [P =.002]) and were used to create a prognostic classification system. In the derivation cohort, patients were classified into 4 groups with increasing risk for 6-month mortality: 5%, 15%, 31%, and 59% (P<.001). In the validation cohort, a similar risk among the 4 groups was observed: 7%, 19%, 32%, and 69% (P<.001). CONCLUSIONS: Adults with complicated left-sided native valve endocarditis can be accurately risk stratified using baseline features into 4 groups of prognostic severity. This prognostic classification system might be useful for facilitating management decisions.

Adult↗
PubMed2003

Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis.

CONTEXT: Complicated, left-sided native valve endocarditis causes significant morbidity and mortality in adults. The presumed benefits of valve surgery remain unproven due to lack of randomized controlled trials. OBJECTIVE: To determine whether valve surgery is associated with reduced mortality in adults with complicated, left-sided native valve endocarditis. DESIGN AND SETTING: Retrospective, observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances. PATIENTS: Of the 513 adults with complicated, left-sided native valve endocarditis, 230 (45%) underwent valve surgery and 283 (55%) received medical therapy alone. MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline. RESULTS: In the 6-month period after baseline, 131 patients (26%) died. In unadjusted analyses, valve surgery was associated with reduced mortality (16% vs 33%; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.29-0.63; P<.001). After adjustment for baseline variables associated with mortality (including hospital site, comorbidity, congestive heart failure, microbial etiology, immunocompromised state, abnormal mental status, and refractory infection), valve surgery remained associated with reduced mortality (adjusted HR, 0.35; 95% CI, 0.23-0.54; P<.02). In further analyses of 218 patients matched by propensity scores, valve surgery remained associated with reduced mortality (15% vs 28%; HR, 0.45; 95% CI, 0.23-0.86; P =.01). After additional adjustment for variables that contribute to heterogeneity and confounding within the propensity-matched group, surgical therapy remained significantly associated with a lower mortality (HR, 0.40; 95% CI, 0.18-0.91; P =.03). In this propensity-matched group, patients with moderate to severe congestive heart failure showed the greatest reduction in mortality with valve surgery (14% vs 51%; HR, 0.22; 95% CI, 0.09-0.53; P =.001). CONCLUSIONS: Valve surgery for patients with complicated, left-sided native valve endocarditis was independently associated with reduced 6-month mortality after adjustment for both baseline variables associated with the propensity to undergo valve surgery and baseline variables associated with mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Adult↗