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PubMed1986

Cardiac conduction abnormalities complicating native valve active infective endocarditis.

Two hundred eleven episodes of native valve active infective endocarditis treated at the Massachusetts General Hospital between 1975 and 1983 were reviewed. The aortic (36%) and mitral (33%) valves were most frequently involved, but in 21% of the cases the site of infection could not be localized. Streptococcal (50%) and staphylococcal (35%) species were the most frequently isolated pathogens. New or changing ("unstable") conduction abnormalities developed in 9% of the patients, while an additional 7% had conduction abnormalities of "indeterminate" age. Unstable conduction block was more likely to develop in patients with aortic valve infective endocarditis than in those with mitral infection. Surgery was performed in 23% of the patients. Unstable conduction abnormalities were significantly associated with valve replacement, but in a multivariate analysis, this effect could be explained by the site of valvular infection. The mortality rate was 20%. Patients with unstable conduction abnormalities had a significantly higher mortality rate, even after other significant predictors of death (age, type of causative organism) were taken into account. Patients whose conduction changes persisted had a worse prognosis than those with transient conduction abnormalities. Although more hemodynamically compromised, patients with unstable conduction block who underwent valve replacement did at least as well as those given medical therapy alone. Patients with native valve active infective endocarditis in whom persistent, unstable conduction abnormalities develop without other identifiable cause, especially in the presence of aortic valve infection, should be considered for valve replacement.

Adolescent↗
PubMed1979

Right-sided infective endocarditis: an echocardiographic study.

Echocardiographic observations are described in 10 patients with right-sided bacterial endocarditis. Six of the nine patients with tricuspid regurgitation had shaggy echoes on the tricuspid valve, which were confirmed to be vegetations on autopsy in two patients. In six patients, right ventricular dilatation was present, and paradoxic septal motion was seen in four. In one of the patients with pulmonic valve endocarditis, the pulmonic valve and right ventricular outflow tract revealed the shaggy echoes in diastole, along with systolic fluttering of the pulmonic valve, right ventricular dilatation and paradoxic septal motion. When the findings are supplemented to the clinical picture, echocardiography is found to be a useful noninvasive adjunct in the diagnosis of acute vegetative bacterial endocarditis involving the right side of the heart, especially if other clinical features, e.g., fever, leukocytosis and positive blood cultures are absent.

Adult↗
PubMed1982

Association between serum inhibitory and bactericidal concentrations and therapeutic outcome in bacterial endocarditis.

Several recent reviews on the therapy of bacterial endocarditis have recommended that a serum inhibitory and/or bactericidal concentration (SIC/SBC) of 1:8 or more be achieved to ensure successful therapeutic outcome. We conducted a methodologic and statistical analysis of the available literature on endocarditis to determine the association between SIC/SBC titers of 1:8 or more and therapeutic outcome. We reviewed 17 studies published between 1948 and 1980 in which both SIC/SBC and therapeutic outcome were available. Factors that affect outcome, such as age, duration of symptoms, organism, and valve status, varied widely among the 226 patients. The methods used to measure SIC/SBC differed with respect to the time of obtaining the blood specimen relative to the antibiotic dose, size of the bacterial inoculum, type of broth, and definition of the bactericidal end-point. None of the 17 studies showed a significant association between SIC/SBC titers of 1:8 or more and survival or bacteriologic cure. Fifteen of the 17 also failed to demonstrate a significant association between SIC/SBC titers of 1:8 or more and medical cure. However, each of the studies that failed to demonstrate an association between SIC/SBC titers of 1:8 or more and improved therapeutic outcome had an insufficient sample size to confidently exclude a false-negative result. Analysis of the published data reveals insufficient evidence to demonstrate that SIC and SBC titers are of prognostic value in the therapy of patients with bacterial endocarditis.

Anti-Bacterial Agents↗
PubMed1982

Q fever endocarditis.

Despite a worldwide distribution of Coxiella burnetii, only single cases of Q fever endocarditis have been reported outside Great Britain and Australia. We present 10 patients; five were female, only four had a history of environmental exposure, and the mitral valve was involved as commonly as the aortic stenosis, and three patients had a prosthetic valve. We confirm the importance of hepatic involvement, thrombocytopenia and hypergammaglobulinemia as diagnostic features. Diagnosis was established by finding and elevated complement-fixing antibody to Phase I C. burnetii antigen. Tetracycline, with or without lincomycin or cotrimoxazole, was used in nine patients, and one patient received cotrimoxazole as as the sole antibiotic agent. Optimal duration of therapy is unknown. In one patient, relapse followed when treatment was stopped after 18 months. Valve replacement was necessary in five patients, because of hemodynamic problems. Five patients died, and the means survival is 36 months with a range of five to 66 months. We suggest that Q fever endocarditis is frequently missed, and we recommend clinicians to consider the diagnosis in all cases of culture-negative endocarditis.

Adult↗
PubMed1984

Optimal therapy for enterococcal endocarditis.

Enterococcal endocarditis accounts for an increasing proportion of cases of endocarditis in recent years. The combination of a penicillin and an aminoglycoside has become an accepted standard of treatment for this disease. However, the optimal choice of antibiotics, duration of therapy, and timing of surgical intervention remain controversial. This study reviews the presentation, clinical course, treatment, and outcome in 37 patients with 42 separate episodes of enterococcal endocarditis at four Yale University hospitals. Patients treated with aminoglycosides and penicillins or vancomycin had significantly better outcomes than those who did not receive aminoglycosides. However, the duration of aminoglycoside therapy (more than four versus less than four weeks) did not appear to affect outcome significantly. These results suggest that excellent cure rates may be achieved after treatment for less than four weeks with an aminoglycoside in combination with penicillin or vancomycin, thus potentially avoiding significant renal and vestibular toxicity.

Aminoglycosides↗
PubMed1986

Influence of vegetation size on clinical outcome of right-sided infective endocarditis.

Endocarditis involving right-sided valvular structures is largely a disease of intravenous drug abusers. The majority of these patients respond to antibiotic therapy with clearing of their bacteremia and preservation of their hemodynamic status. This study evaluated the prognostic value of echocardiographically determined vegetation size in 23 episodes of right-sided valvular endocarditis in 21 patients. Right-sided vegetations were visualized in 19 of 23 episodes (83 percent). Of these, a vegetation of 1.0 cm or greater was found in 11. No patient with an echocardiographically determined vegetation size of less than 1.0 cm required surgery, whereas four of 11 (36 percent) of those episodes in which the vegetation size was 1.0 cm or greater required surgery for persistent pyrexia (p less than 0.05). In all patients requiring surgery, a bioprosthetic tricuspid valve was placed at the time of initial surgery and in no patient did early reinfection occur. This study reconfirms the benign prognosis of right-sided valvular endocarditis. Further, although vegetations of less than 1.0 cm identify those patients who will respond to medical therapy, echocardiographically documented vegetations of 1.0 cm or greater are associated with a significantly lower response rate to appropriate medical therapy. The association of fever that persists for more than three weeks in the absence of another source of infection with an echocardiographically demonstrable right-sided vegetation of 1 cm or more identifies those patients who will require surgical intervention. Finally, tricuspid valve replacement can be performed at the time of initial surgery without undue concern for early reinfection or valve dysfunction.

Adult↗
PubMed1986

Group G streptococcal endocarditis and bacteremia.

This report describes fifteen recent cases of group G streptococcal bacteremia in patients with acute illnesses. Seven patients had acute endocarditis (47 percent). Four deaths occurred, and four patients had significant clinical complications during prolonged stormy courses. This series indicates a relatively high incidence of infective endocarditis in patients with group G streptococcal bacteremia, which is at variance with recent reports. Group G streptococcal bacteremia (with or without endocarditis) is a serious infection that often follows a hectic course with significant morbidity and mortality. The need for prompt recognition and aggressive treatment of this infection is underscored.

Adult↗
PubMed1990

Does prophylaxis prevent postdental infective endocarditis? A controlled evaluation of protective efficacy.

PURPOSE: Despite the American Heart Association's (AHA) recommendations for antibiotic prophylaxis to prevent infective endocarditis, no controlled clinical evidence exists for the effectiveness of this intervention. The purpose of this case-control study was to determine whether antibiotic prophylaxis for a dental procedure reduces the risk of infective endocarditis in persons with high-risk cardiac lesions. PATIENTS AND METHODS: Cases consisted of eight subjects with high-risk lesions (six mitral, one aortic, one uncorrected tetralogy) whose first-time, native-valve infective endocarditis occurred within 12 weeks of a dental procedure and was diagnosed between 1980 and 1986. For each case subject, three control subjects were chosen from patients who underwent echocardiographic evaluation between 1980 and 1986, and who were matched for the specific high-risk lesion and age. Use of antibiotic prophylaxis, which was determined by interviews with patients and supplemented by the dentists, was defined as antibiotic taken both before and after the dental procedure. RESULTS: Antibiotic prophylaxis was used by only one of eight (13%) case subjects compared with 15 of 24 (63%) control subjects, for an odds ratio of 0.09, which is clinically impressive (indicating 91% protective efficacy) and statistically significant (p = 0.025). CONCLUSION: Although this report does not specifically assess the value of antibiotic prophylaxis for the current AHA recommendations, the use of antibiotic prophylaxis in persons with high-risk cardiac lesions is supported by the magnitude of protective efficacy observed in this study.

Adult↗
PubMed1989

Candida endocarditis with saddle embolism: a successful surgical intervention.

A 43-year-old woman who had Candida endocarditis with saddle embolism underwent mitral valve replacement and resection of infected aorta. Only 7 persons with fungal endocarditis with saddle embolism have been reported in the literature, and all of them died. We report a case of successful treatment of this lethal complication of Candida endocarditis.

Adult↗
PubMed1991

Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve "recycling".

Tricuspid valve endocarditis traditionally has been treated with either valve excision or valve replacement. To avoid implantation of foreign material in an infected field, we have applied the principles of mitral valve repair to 4 patients with tricuspid valve endocarditis. On preoperative echocardiography, all patients had 3 to 4+ tricuspid regurgitation, evidence of progressive right ventricular enlargement, and mobile vegetations. In each case, up to three quarters of the anterior leaflet was excised en bloc with infected chordae and papillary muscle heads. Surgical procedures included standard quadrangular resection, conversion to a bicuspid valve, and pericardial patch replacement of the anterior leaflet with mobilization of basal chordae to replace resected marginal chordae. On postoperative echocardiography, tricuspid regurgitation and right ventricular dimensions were reduced in 2 of 4 patients in spite of loss of leaflet tissue. All excised valve tissue demonstrated bacteria on Gram stain or culture. Nonetheless, all repaired valves were successfully sterilized without recurrent infections. Tricuspid valve repair can allow eradication of infection with potential for improving valve competency in complicated tricuspid valve endocarditis.

Echocardiography↗
PubMed1991

Valve replacement in patients with endocarditis and cerebral septic emboli.

Cerebral septic emboli complicate the cases in 20% to 40% of patients with left-sided endocarditis but the management of these patients who require a valvar operation remains unclear. From 1980 to 1988, the incidence of cerebral septic embolus was 42% (n = 45) among 106 patients with endocarditis who underwent valve replacement at the University of Illinois Hospital in Chicago. Of these 45 patients, 69% (n = 31) had symptomatic cerebral septic infarctions and 31% (n = 14) were asymptomatic. Findings on cerebral computed tomographic scans included ischemic infarcts (n = 36, 80%), hemorrhagic infarcts (n = 5, 11%), normal studies (n = 2, 4%), and unknown (n = 2, 4%). Neurological complications after valve replacement included postoperative strokes (n = 6, 6%), cerebral abscesses (n = 2, 2%), and seizure (n = 1, 1%). The presence of a hemorrhagic infarct preoperatively predisposed to a perioperative stroke (p less than 0.05). In conclusion, cerebral septic infarctions, both symptomatic and asymptomatic, are common among patients with endocarditis referred for valvar operation. In the absence of a hemorrhagic infarct, valve replacement can be performed with minimal risk of a perioperative stroke.

Adolescent↗
PubMed1994

Animal models of endocarditis.

Bacterial endocarditis is a difficult infection to cure, due to poor penetration of antibiotics into infected vegetations, altered metabolic state of bacteria within the lesion, and absence of adequate host-defense cellular response which could cooperate with antibiotic action. The contribution of animal models to a better understanding of the pathophysiology of the infection and to definition and improvement of therapeutic regimens of endocarditis in humans remains of great importance due to the difficulties encountered in clinical trials. The advantage of the experimental model is that besides the fact that it closely simulates the characteristics of the infection in humans, it provides clear endpoints which allow statistical comparisons among different therapeutic regimens: number of bacteria per gram of tissue, frequency of emergence of resistance, positivity of blood cultures, death vs. survival rates, and percentage of relapses after treatment has been stopped. All these parameters are more sensitive and more easy to study than in humans. The animal model has definitively established that bactericidal therapy is warranted and that in vitro susceptibility tests, especially those evaluating the killing rate, have a good predictive value on the therapeutic outcome. Two main aspects are discussed for their relevance to human therapy: (i) the kinetics of antibiotic diffusion into vegetations, with special reference to data obtained with autoradiography; and (ii) the specificity of some pharmacodynamic aspects of antibiotics in endocarditis, including the clinical consequences of these two parameters with respect to antibiotic dosing regimens and length of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1984

Infective endocarditis: a review and update.

Infective (bacterial) endocarditis has presented a "changing face" over the previous years but remains a disease with potentially serious complications. Surveys have indicated that up to 92% of cases of infective endocarditis could be attributed to a dental origin; yet most susceptible persons do not understand their condition or the precautions necessary prior to dental treatment. Up to 80% of infective endocarditis patients received no protection prior to dental or genitourinary manipulation. Dental practitioners, therefore, play an important role in the prevention of this disease and must be familiar with recent developments on the subject. This article provides an in-depth review of the disease and outlines and stresses the dental practitioner's responsibility in its prevention.

Adult↗
PubMed1986

New concept in chemoprophylaxis of bacterial endocarditis resulting from dental treatment.

Bacteremia following dental procedures may lead to bacterial endocarditis in susceptible patients. Traditional methods of chemoprophylaxis with a parenteral loading dose of penicillin followed by oral penicillin have proved impractical outside the hospital. In 1978, it was suggested in England that amoxicillin be substituted as the drug of choice in the prophylaxis of bacterial endocarditis. The recommended mode of treatment was a single oral dose of 3 g amoxicillin administered 1 hour before onset of the dental procedure. Amoxicillin is absorbed to a greater extent and more rapidly than penicillin V. It maintains its effectiveness throughout the critical postoperative period at concentrations well over the minimum necessary to combat Streptococcus viridans. Amoxicillin has two mechanisms of protection: bactericidal and inhibition of bacterial adherence to the thrombotic vegetation on injured heart valves. Data obtained from 206 susceptible patients undergoing dental treatment under chemoprophylaxis with amoxicillin showed that in no case did infective endocarditis occur. Only in 13.1% of the patients could very mild side effects of this drug be observed. With this new method, there is a higher incidence of patient compliance and administration is easier to supervise.

Adult↗
PubMed1990

Pathogenesis, management, and prevention of infective endocarditis in the elderly dental patient.

Aortic stenosis and mitral valve insufficiency are common precipitating causes of infectious endocarditis in older persons. These degenerative cardiac valvular lesions may result from an exaggerated calcification process seen in association with aging. Mitral valve prolapse, especially when noted in an older man, may predispose the person to infectious endocarditis. Infectious endocarditis is harder to diagnosis and treat in older persons, and about half of patients die of the disease or its complications. Prophylactic antibiotics must be prescribed for patients with degenerative cardiac or atherosclerotic valvular defects having dental procedures likely to produce a bacteremia.

Aged↗
PubMed1994

Dens in dente associated with infective endocarditis.

This article describes an 11-year-old patient in whom infective endocarditis developed after the occurrence of a dental abscess associated with a dens in dente affecting the maxillary left lateral incisor. Dens in dente has not been reported in the literature previously as a source of infection associated with infective endocarditis. A prolonged period of hospitalization was required to control the infective endocarditis, which was caused by a strain of nutritionally deficient streptococci.

Child↗
PubMed1990

Infective endocarditis caused by Streptococcus suis serotype 2.

Infective endocarditis caused by Streptococcus suis serotype 2 is not uncommon in pigs but is rare in human beings. We describe the case of a pig-farmer with endocarditis due to S. suis serotype 2 and in whom prolapse of the mitral valve was the predisposing cardiac lesion. Streptococcus suis, a possible cause of infective endocarditis in endemic areas, may be confused with other group D streptococci. In suspected cases a history of contact with pigs or raw pork should be sought.

Agricultural Workers' Diseases↗
PubMed1984

Endocarditis in patients with bioprostheses: pathology and clinical correlations.

We studied 13 porcine bioprostheses removed from patients with endocarditis at our institute during the last 4.5 years. All bioprostheses had been removed at reoperation and were analyzed using anatomical and histological techniques. Each bioprosthesis was found to have developed rather constant lesions which were not related to the type of bioprosthesis. The stage of infection was not related to the duration of implantation. The presence of perivalvular abscesses was an ominous finding, often being the seat of persistent endocarditis. Our good clinical results of reoperation lead us to suggest that this be performed early once valvular or prosthetic malfunction is detected. Bioprostheses are, in our experience, the best choice in the surgical treatment of prosthetic valve endocarditis.

Adult↗