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PubMed1984

[Clinical demonstrations: Heart rupture in acute myocardial infarct. Infectious endocarditis. Wolff-Parkinson-White syndrome].

This clinical demonstration includes three topics of clinical cardiology: myocardial rupture in acute myocardial infarction, infective endocarditis, and WPW-syndrome with paroxysmal supraventricular tachycardia. In the first part three cases with septal perforation or papillary muscle rupture are demonstrated. Our experience with myocardial rupture (free wall, septum, papillary muscle) during the last six years is summarized with special reference to the significance and the differential diagnosis of systolic regurgitant murmurs after myocardial infarction. Special features of acute mitral incompetence (papillary muscle dysfunction) in myocardial infarction are outlined and diagnostic guidelines for differentiation between septal perforation and papillary muscle rupture are discussed. In the second part two patients with aortic (e.g. mitral) valve rupture in the course of infective endocarditis are presented. The synoptic comparison of these two patients is related to the results of our own clinical studies on the changing pattern of infective endocarditis (epidemiologically, clinically) during the last three decades. The clinical picture of acute aortic valve rupture is outlined and the bedside signs indicating catastrophic complications of infective endocarditis are summarized. In the third part the odyssey of a patient with WPW-syndrome and consecutive paroxysmal supraventricular tachycardia is described. Progress in electrophysiological analysis of the re-entry circles in preexcitation syndromes is outlined.

Adult↗
PubMed1984

[Characteristics of acute infectious endocarditis in various types of hospitals].

The study has revealed that active forms of infectious endocarditis constitute 30-50% of all septic diseases in hospitals. It is the normal cusps of the valvular apparatus of the left cardiac portion that are predominantly damaged, deformed or destroyed. Endocardial involvement of the right portion of the heart and the pulmonary artery occurs very rarely. Infectious patients develop sepsis more frequently than patients with non-infectious diseases but it takes the form of acute infectious endocarditis less commonly. Currently the clinical course of acute infectious endocarditis is characterized by predominantly ulcerous thrombotic damage of the normal valves with the formation of heart disease, the development of congestive insufficiency of the circulation and thromboembolic complications and the lethal outcome in the first weeks of hospitalization in 95.6% of patients with acute endocarditis in infectious and 56.6% in non-infectious hospitals.

Acute Disease↗
PubMed1978

Q fever endocarditis: a report of 2 cases.

Two patients with Q fever endocarditis are described. Both patients demonstrated some of the characteristic features of Q fever endocarditis, i.e. the long course of the disease before diagnosis, persistently negative blood cultures, resistance to conventional antibiotic therapy and a dramatic response to tetracycline therapy. Complications included arteriovenous thrombo-embolism and hepatic enlargement, and 1 patient developed an immune complex form of glomerulonephritis. The possibility of Q fever endocarditis should be considered in all patients with infective endocarditis in whom blood cultures are negative and who fail to respond to conventional antibiotic therapy.

Adult↗
PubMed1983

Antibiotic treatment of staphylococcal septicaemia and endocarditis in a Swedish hospital.

In a retrospective study covering the years 1977 to 1981, the results of antibiotic treatment in 123 patients with staphylococcal septicaemia with or without endocarditis have been analysed. 80 patients (mean age 60 years) were non-drug addicts (Group I) and 43 (mean age 28 years) were drug addicts (Group II). Underlying conditions other than drug abuse were noted in 74 patients in Group I and in only 7 in Group II.S. aureus was isolated from 117 patients and S. epidermidis in 6, all of them in Group I. 91 strains were penicillinase producers, but all susceptible to isoxazolyl-penicillins. In Group I verified or highly suspected endocarditis was registered in 12 patients (15%), always left-sided, as against in 31 (72%) in Group II, of whom 25 had tricuspid valve engagement. In the multivariate pattern of antibiotic treatment 3 groups may be discerned; 1) Cloxacillin, alone (35 patients) or in a combination (57), 2) Penicillin G, alone (6) or in a combination (12), and 3) Lincomycin or clindamycin, a cephalosporin or co-trimoxazole, alone (4) or in combination (9). Additive agents were mostly an aminoglycoside or fusidic acid. Out of the 45 patients in the whole material who received single therapy 9 patients (20%) died, and out of the 78 patients who received combined therapy 13 patients (16.6%) died. In the cloxacillin group 11.8% died, compared to 35% who initially received other antibiotics. In 70 patients the initial therapy had to be changed, in 39 due to adverse drug reactions and in 31 due to therapeutic failures or for unexplained reasons. In these cases linco- or clindamycin, more rarely rifampicin or vancomycin, were used. In Group I, 20 patients (25%) died, 8 of them with endocarditis. Sequels, relapses or reinfections were noted in 21 (25%), and 39 (50%) had an uneventful course. In Group II, 2 patients (5%) died, both with endocarditis. Sequels, relapses or reinfections occurred in 11 (25%), and 30 (70%) had an uneventful course. From this unstructured material no definite conclusions can be drawn. However, the lower mortality rate in the cloxacillin group suggests this regimen to be superior. The addition of other antibiotics did not appear to influence the clinical outcome. There was a more favourable outcome in addicts than in non-addicts, despite the same general principles of antibiotic treatment. Thus, for the outcome the characteristics of the patient group seemed to have more influence than the choice of antibiotic treatment.

Adolescent↗
PubMed1983

Serological diagnosis of Staphylococcus aureus septicaemia and endocarditis by means of crossed immuno-electrophoresis.

The diagnostic sensitivity and specificity were determined for serological diagnosis of Staphylococcus aureus endocarditis and septicaemia by means of crossed immuno-electrophoresis with intermediate gel. The antibody responses to S. aureus antigens in sera from 19 patients with S. aureus endocarditis and 51 patients with S. aureus septicaemia were compared with findings in 30 patients with non-S. aureus endocarditis and 30 patients with non-S. aureus septicaemia. Two of 55 S. aureus antigens, no. 18 (cross-react serologically with cell wall teichoic acid) and no. 46 of the reference pattern, were useful for serological diagnosis. The precipitin score, taking into account both the total number of precipitins and their titres, was the most useful diagnostic criterion. The present method can be used in selected cases to discriminate between S. aureus and non-S. aureus endocarditis. In cases with septicaemia only a positive test is of clinical value.

Adolescent↗
PubMed1983

Right-sided endocarditis complicating peritoneovenous shunting for ascites.

We describe two patients with alcoholic cirrhosis in whom staphylococcal right-sided endocarditis developed after insertion of a peritoneovenous shunt (PVS). Massive pulmonary embolism caused early death in one patient. In the other patient, staphylococcal septicemia was cured after shunt removal and antibiotic treatment; recurrent endocarditis due to Corynebacterium xerosis ultimately caused the patient's death. No clinical manifestation of tricuspid valve dysfunction was noted in either patient, and right-sided endocarditis was recognized only at autopsy. The protracted contact of the tip of the venous line of PVS with the atrial wall is likely to be a major factor in the development of right-sided endocarditis in these patients.

Adult↗
PubMed1983

Bacterial endocarditis complicating systemic lupus erythematosus.

Culture proven bacterial endocarditis occurred in 6 of 571 patients with systemic lupus erythematosus (SLE) admitted to the National Institutes of Health (NIH). Although 4 of the patients had a murmur noted on examination prior to developing endocarditis, only one of the 6 had a recognized valvular abnormality. Bacterial endocarditis followed dental procedures in 2 of the 6 patients; no precipitating events were recorded in the remaining 4. M-mode and 2-D echocardiography of 20 unselected SLE patients did not reveal previously unrecognized cardiac disease. There was an unexpectedly high frequency of bacterial endocarditis among SLE patients relative to all other connective tissue disease patients seen at the NIH.

Adult↗
PubMedDate not supplied

[Immunologic studies in active rheumatic fever and infectious endocarditis].

We compared clinical and immunological characteristics of acute rheumatic fever (19 cases) and infectious endocarditis (7 cases), because these two diseases can be confused easily with each other and their differential diagnosis is not simple. In this small series we had cases of acute rheumatic fever with splenomegaly and/or vasculitis, as well as infectious endocarditis with subcutaneous nodules, which exemplifies the diagnostic problem. Using laboratory tests we were able to point out differences which are statistically significant, such as: rheumatoid factor by passive agglutination of IgG sensitized latex particles (X2 4.27 p less than 0M05), and tests which reflects the presence of circulating immune complexes, hemolytic capacity of antigammaglobulin antibodies (X2 3.79 p less than 0.05) and the presence of circulating C3 degradation products (X2 5.92 p less than 0.01), which occurs preferentially or exclusively in infectious endocarditis. Although in the standard patient the clinical assessment is usually sufficient to establish a diagnosis, when differentiation between acute rheumatic fever and infectious endocarditis is not clear, immunologic tests are helpful.

Adolescent↗
PubMed1983

Staphylococcus aureus endocarditis: clinical manifestations in addicts and nonaddicts.

Data collected from a prospective multicenter study of endocarditis caused by S. aureus were analyzed to contrast the clinical presentation of the disease between a group of 46 intravenous drug addicts and a group of 35 nonaddicts. Two-thirds of the patients in each group were men. The duration of illness before diagnosis was similar (mean, 9.3 days). Intravenous-drug addicts were younger and had less underlying disease (30% versus 80%) than the non-addicts. When first seen, the drug addicts had signs and symptoms of sepsis and pulmonary embolism, but only 40% had pathologic murmurs. Seventy-six percent had evidence of tricuspid valve infection only. Congestive heart failure and neurologic manifestations were uncommon in addicts. Nonaddicts had infection involving predominantly the left side of the heart (14 mitral valves, 8 aortic valves, 4 both aortic and mitral valves) and 80% had underlying medical diseases. Only half of these patients had pathologic murmurs when first examined, but another 30% developed them later. Congestive heart failure, involvement of the central nervous system, and peripheral embolic or septic complications each occurred in over half of the nonaddicts. Eighty percent of these patients had peripheral stigmas of endocarditis. One intravenous drug addict (2%) and seven nonaddicts (20%) died. Six patients required cardiac valve replacement either during or after a course of antibiotics. Outcome was not related to the titer of peak serum bactericidal tests. Endocarditis caused by S. aureus presents as two distinct clinical syndromes depending on the patient population (intravenous drug user or nonaddict) and the location of infection (right-sided or left-sided). The disease is distinguished from endocarditis due to other causes by its acute onset and its fulminant course manifested by a multitude of septic and embolic complications and its ability to cause heart failure. Medical management alone is often successful but in certain subsets of patients, notably those with infection of aortic or multiple valves, early operation may be necessary.

Endocarditis, Bacterial↗
PubMed1982

Management of complications of infective endocarditis.

Complications of infective endocarditis may be considered as those that involve the heart and adjacent structures or those that are extracardiac. Congestive heart failure is the most common serious complication of infective endocarditis and is the leading cause of death among patients with this infection. In patients with severe heart failure unresponsive to medical therapy after 24 to 48 hours, prompt cardiac valve replacement should be considered, irrespective of the duration of preoperative antimicrobial therapy. We believe that all patients with bacterial infective endocarditis who are stable hemodynamically and who have not had multiple large emboli should receive at least one course of antimicrobial therapy in an attempt to sterilize the infected valve before cardiac valve replacement is considered. Most patients with multiple major embolic events should undergo cardiac valve replacement or debridement of the infected valve. The technical limitations and the experience with two-dimensional echocardiography in patients with infective endocarditis who have valve vegetations demonstrated by echocardiography are not yet sufficient to justify cardiac valve replacement solely on the basis of echocardiographic findings. The highest frequency of major embolic events occurs in association with infections that produce large mobile valve vegetations, such as those caused by Haemophilus parainfluenzae and other slow-growing fastidious gram-negative bacilli, fungi (especially Aspergillus), and nutritionally variant viridans streptococci.

Aneurysm, Infected↗
PubMedDate not supplied

Nursing management of the parenteral drug abuser with infective endocarditis.

Caring for the parenteral drug abuser with infective endocarditis is a challenge. In many ways, the nursing care needed for these patients differs from that needed by other patients with infective endocarditis. This article has identified some of the important considerations: maximizing the effectiveness of the treatment regimen, fostering patient adaptation to hospitalization, and planning for discharge to minimize the risk of recurrence. By understanding the nature of drug abuse and of infective endocarditis, and by understanding how they interact to create a particular set of problems in the parenteral drug abuser with infective endocarditis, the nurse can provide optimal nursing management for these patients.

Adult↗
PubMed1981

Infective endocarditis update experience from a heart hospital.

In a retrospective study of 50 patients with infective endocarditis (IE), we found an overall mortality of 44%: among the 26 patients with natural valves (NV) the mortality was 19%; among the 24 with prosthetic valves (PV) it was 71%. Congenital heart disease was recognized in 17 of our cases, with a significant clustering in the NV group (50% vs 17%, p = 0.029); the most frequently encountered malformation was the bicuspid aortic valve. The incidence of rheumatic heart disease was 46% in the NV group and 83% in the PV group (p = 0.015). Manifestations of IE were protean and multisystemic. We calculated an average of 4.6 symptoms and 4.7 signs for each patient. Although sepsis was abated with appropriate antibiotics, death often ensued from multiple complications: congestive heart failure, arrhythmia, stroke, embolic myocardial infarction, valvular destruction or dehiscence, coagulopathy. New features of natural valve infective endocarditis are a rising incidence in the elderly and a survival rate seemingly at its peak. Features of prosthetic valve infective endocarditis include overwhelmingly frequent embolization to the central nervous system (p = 0.004), spleen (p = 0.009) and kidney (p = 0.010). Advances in therapy for this disease may come from early surgery in late prosthetic valve endocarditis and from future prospective studies to define how the host response influences the outcome.

Adult↗
PubMed1982

Staphylococcal infective endocarditis.

Staphylococcus aureus causes an acute endocarditis, often involving previously normal valves. The criteria used for diagnosis of subacute bacterial endocarditis are frequency absent, and distinguishing acute endocarditis from bacteremia without valvular involvement is difficult. In vitro studies, including teichoic acid antibody assay and bactericidal tolerance, have been developed to aid in making the diagnosis and planning the treatment. Cases of native valve, prosthetic valve, and addict-associated endocarditis are considered separately because of differences in prognosis and approach. Use of two synergistic antibiotics has not been proved clinically superior to use one agent, and surgical intervention during treatment may be necessary in some cases. Despite prompt treatment recognition of complications, the morbidity and mortality associated with this infection remain high.

Anti-Bacterial Agents↗
PubMed1982

Cardiac operation during active infective endocarditis: results of aortic, mitral, and double valve replacement in 94 patients.

Cardiac valve replacement was performed in 94 patients (95 operations) in the presence of active infective endocarditis. Most of the patients were extremely ill. The operation was performed as an emergency or semiemergency lifesaving procedure in 88% of them, and more than half received little or no antibiotic treatment prior to the operation. The hospital mortality was 16%--14% for aortic valve replacement (AVR) and 11% for double valve replacement (DVR) but 31% for isolated mitral valve replacement (MVR). The mortality was not higher in patients operated on urgently (emergency or semiemergency), nor was it higher in patients who had aortic annular abscesses or aneurysms. Prosthetic valve endocarditis (PVE) (in each case occurring more than 60 days after the previous valve operation) carried a higher mortality (33%) than native valve endocarditis (NVE) (14%). The relatively high early mortality for MVR may have been related to the fact that we operated upon MVR patients after intensive medical treatment had failed. The late results were good: Sixty-six patients are alive and well, 51 of them in Functional Class I. Six patients were reoperated upon for aortic periprosthetic leaks, and five are now well. Eight patients died late (9%), one of them because of a periprosthetic leak and one because of a clotted valve. In seven of the eight deaths, the cause of death was probably not related to the timing of the original operation. We recommend early valve replacement for patients with infective endocarditis. We believe that early operation reduces mortality, prevents emboli, and is associated with excellent long-term results.

Adolescent↗
PubMed1982

Failure of erythromycin in preventing bacterial endocarditis.

Use of oral erythromycin to prevent bacterial endocarditis has been accepted in the treatment of penicillin-allergic patients who required oral or sinusal surgery. A case of Streptococcus sanguis endocarditis, however, developed in a patient following intravenous erythromycin administration during surgery on the maxillary sinus. The organism isolated proved resistant to erythromycin. This isolation of an erythromycin-resistant organism, together with previous reports of the drug's failure in preventing endocarditis in animal models, and recognition of the bacteriostatic action of erythromycin, argue for caution in our current practice of using erythromycin as a single drug therapy to prevent endocarditis in the patient who is allergic to penicillin.

Adult↗
PubMed1982

Infective endocarditis due to anaerobic and microaerophilic bacteria.

Seven cases of infective endocarditis (IE) due to anaerobic or microaerophilic bacteria were seen in a period of 42 months at Rancho Los Amigos Hospital (Downey, California), representing 10.6 percent of the total number of 66 cases that carried the diagnosis of IE. Five of the 66 patients had polymicrobial endocarditis. Three of five patients with polymicrobial endocarditis had at least one anaerobic or microaerophilic microorganism isolated from the blood, and all five patients practiced intravenous drug abuse. Six of the seven patients with anaerobic or microaerophilic IE were women. The three patients who had anaerobic Gram-negative bacillary endocarditis were drug abusers. None of the isolated organisms were Bacteroides fragilis. The following heart valves were involved in the seven patients with anaerobic or microaerophilic IE: tricuspid (three), mitral (two), aortic (one) and tricuspid plus aortic (one). Three of the seven patients had preexistent valvular disease, and two required tricuspid valvulectomy. Only one patient had serious systemic embolism (cerebral), but all four drug abusers had septic pulmonary embolism. All seven patients recovered with appropriate antimicrobial therapy.

Adult↗
PubMed1978

[The association of a digestive carcinoma and subacute endocarditis. 4 cases (author's transl)].

Attention has recently been drawn to the association of digestive carcinoma and streptococcus bovis endocarditis. The authors studied 130 records of patients with endocarditis and an association with a digestive tumour (3 neoplasms, one villous tumour) was found in four. Streptococcus bovis was demonstrated in one case, streptococcus faecalis in two and streptococcus durans in one. The association of carcinoma and subacute endocarditis would thus seem to not solely relate to digestive commensual organisms. The question of common factors favourising carcinoma and endocarditis is raised.

Adenocarcinoma↗
PubMed1982

[Etiology and clinical course of bacterial endocarditis, 1971-1980].

Etiology and clinical course of infective endocarditis were analyzed in 31 patients seen at this institution between 1971 and 1980. The follow-up period averaged 60 (1-180) months. The infection relapsed 9 times (relapse rate 31-38%). The etiologic agent isolated from blood cultures in 26/42 infective episodes. Penicillin-sensitive streptococci were by far the most frequent cause of infective endocarditis (46%), followed by Staphylococcus aureus in 23%. A predisposing cardiac lesion existed in 26/31 patients (84%), aortic valve disease and a prolapsing mitral valve being the most frequent. In the 31 patients there were 5 deaths, 2 of which occurred acutely within a few days following the onset of endocarditis (mortality rate 6%), 2 suddenly after completion of antimicrobial therapy and 1 from another cause during the observation period. Surgery was necessary in 18 patients, emergency valve replacement being required in 3 cases (10%). In 15 patients (52%) cardiac surgery was performed electively after healing of the endocarditis. The indication for surgery was onset of heart failure due to valvular incompetence in 16 patients and recurrent systemic embolization in 2 patients. All patients survived surgery. At restudy no difference was observed in overall cardiac function, physical working capacity and employment activities among the surviving patients whether operated upon or not.

Adolescent↗