Early and Late Survival After Surgical Treatment of Culture-Positive Active Endocarditis

doi:10.4065/70.6.517

Mayo Clinic Proceedings

Volume 70, Issue 6, June 1995, Pages 517-525

https://doi.org/10.4065/70.6.517 Get rights and content

Objective

To describe a 30-year experience with surgically treated culture-positive active endocarditis.

Design

We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991.

Results

The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62 % of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71 % and 60%, respectively.

Univariate determinants of an adverse longterm survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively.

Conclusion

Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.

Section snippets

PATIENTS AND METHODS

Inclusion Criteria.— For this study, a patient was considered as having culture-positive active endocarditis at the time of the surgical procedure when the following criteria were fulfilled: (1) a blood culture was positive within 3 weeks preoperatively or a valve or tissue culture was positive at the time of the surgical procedure and (2) operative macroscopic evidence of endocarditis was noted. The presence of an abscess, valve perforations, or vegetations with evidence of active inflammation

RESULTS

The 110 male (73%) and 41 female patients had a mean age of 49.8 ± 20.3 years. The youngest patient was 3 years of age, and the oldest was 86 years.

Previous Surgical Procedures.—Of the 151 study patients, 70 (46%) had undergone prior surgical procedures (Table 1). Of these patients, two had previous coronary artery bypass grafting, one had a Potts anastomosis, one had an aortic commissurotomy, and one had both mitral and aortic valve repair. The other 65 patients (43%) were considered to have

DISCUSSION

Infective endocarditis still remains a formidable problem, both for diagnosis and for clinical management. On review of the literature and comparison of the results of various treatment strategies, however, the definition of endocarditis and the nature of the patients treated were of paramount importance. Therefore, we clearly defined our current patient population to include only those with positive blood or valve cultures within 3 weeks of the operative intervention and with macroscopic

CONCLUSION

Clearly, important lessons can be learned from this longterm follow-up of a large series of patients after surgical treatment of active endocarditis. Although endocarditis, with multiorgan involvement, is a serious or even fatal condition if left untreated, surgical intervention—despite its high associated mortality-is effective in salvaging a substantial number of patients who would otherwise die. The important surgical principles include early and aggressive operation when heart failure

ACKNOWLEDGMENT

We thank Steven L. Wallrichs for expert assistance in statistical analysis, Kathleen M. Distad for careful preparation of the manuscript, and Drs. Dwight C. McGoon, John W. Kirklin, F. Henry Ellis, Jr., Robert B. Wallace, James R. Pluth, and Jeffrey M. Piehler for their clinical contributions.

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Cited by (98)

Neurologic complications of infective endocarditis
2022, Infective Endocarditis: A Multidisciplinary Approach
The clinical course of acute infective endocarditis (IE) is one that is frequently disrupted by neurologic complications. Cerebrovascular complications, specifically, ischemic stroke, intracranial hemorrhage, and infectious intracranial aneurysms, are perhaps the most feared of all neurologic complications. They typically occur in left-sided IE as a result of septic emboli. Early initiation of the appropriate antibiotics reduces embolism risk, yet the prevalence of cerebrovascular complications in IE populations remains high. Exact numbers vary between studies owing to differences in population and methodology. Cerebrovascular complications present their own set of diagnostic and therapeutic challenges. They also have major implications for surgical planning and patient outcome. Optimal surgical timing after an acute stroke has been at the center of much debate. The purpose of this chapter is to summarize and provide contemporary insights on neurologic complications of IE, with focus on unresolved diagnostic and therapeutic dilemmas.
The Epidemiology of Endocarditis in Manitoba: A Retrospective Study
2021, CJC Open
Recently, anecdotal evidence suggested an increase in infective endocarditis (IE) in Manitoba driven by an increasing proportion of patients with intravenous drug use (IVDU)-associated endocarditis. This study aimed to characterize the observed changing incidence and epidemiology of IE.
This retrospective study evaluated consecutive patients >18 years old with an International Classification of Disease–10 diagnosis of IE who presented to a tertiary referral center in Winnipeg, Manitoba between January 1, 2004 and December 31, 2018. Data were obtained by individual review of paper and electronic medical records and entered into the Research Electronic Data Capture database. Mortality and hospital readmission data were acquired by linking Research Electronic Data Capture data to the Manitoba Centre for Health Policy, which prospectively maintains a comprehensive population-based health database.
A total of 612 cases of IE were identified. The incidence of IE increased from 2.03 per 100,000 in 2004 to 5.16 per 100,000 in 2018, with IVDU-associated cases increasing from 0.11 to 2.87 per 100,000. Left heart vegetations were most common in the non-IVDU group, whereas right-sided vegetations dominated in the IVDU group. All-cause mortality did not differ between IVDU and non-IVDU IE, despite a significantly younger age in patients with IVDU. The IVDU group showed a higher rate of endocarditis recurrence.
In this first study to examine the longitudinal incidence of IE in Manitoba, we showed that the incidence of IE has significantly increased over the last 15 years, with a contribution of IVDU-associated IE that has a high rate of mortality and disease recurrence.
Des données anecdotiques récentes montraient une augmentation de l’endocardite infectieuse (EI) au Manitoba attribuable à la proportion accrue de patients atteints d’une endocardite associée à l’usage de drogues par voie intraveineuse (UDVI). La présente étude avait pour but de caractériser les changements observés dans l’incidence et l’épidémiologie de l’EI.
Cette étude rétrospective a permis d’évaluer les patients consécutifs > 18 ans qui avaient un diagnostic d’EI conformément à la Classification internationale des maladies, 10^e révision, et qui s’étaient présentés dans un centre d’aiguillage en soins tertiaires de Winnipeg, au Manitoba, entre le 1^er janvier 2004 et le 31 décembre 2018. Nous avons obtenu les données par l’examen du dossier individuel et des dossiers médicaux électroniques de la base de données Research Electronic Data Capture. Nous avons obtenu les données sur la mortalité et les réadmissions à l’hôpital par la liaison des données de la Research Electronic Data Capture au Manitoba Centre for Health Policy, qui maintient de manière prospective une base de données exhaustive sur la santé de la population.
Nous avons trouvé un total de 612 cas d’EI. L’incidence de l’EI est passée de 2,03 par 100 000 en 2004 à 5,16 par 100 000 en 2018, et l’incidence des cas d’EI associée à l’UDVI, de 0,11 à 2,87 par 100 000. Les végétations du cœur gauche étaient plus fréquentes dans le groupe de patients atteints d’une EI non associée à l’UDVI, alors que les végétations du cœur droit dominaient dans le groupe de patients atteints d’une EI associée à l’UDVI. La mortalité toutes causes confondues ne différait pas entre les patients atteints d’une EI associée à l’UDVI ou non associée à l’UDVI, en dépit de l’âge significativement plus jeune des patients atteints d’une EI associée à l’UDVI. Le groupe de patients atteints d’une EI associée à l’UDVI montrait un taux plus élevé de récurrence de l’endocardite.
Dans cette première étude, qui portait sur l’incidence longitudinale de l’EI au Manitoba, nous avons montré que l’incidence de l’EI avait considérablement augmenté au cours des 15 dernières années, puisque l’EI associée à l’UDVI a contribué à l’augmentation du taux de mortalité et de récurrence de la maladie.
Prevalence and characteristics of tricuspid valve endocarditis among patients presented to Ain Shams Hospital echocardiography lab; one year study
2018, Egyptian Heart Journal
Isolated Tricuspid valve infective endocarditis is an infrequent diagnosis, the incidence of Tricuspid valve infective endocarditis accounts for 5% and up to 15% of IE cases.
To assess the prevalence and the echocardiographic characteristics of tricuspid valve endocarditis among patients presented to the echo lab of Ain Shams hospital from 1-1-2016 to 1-1-2017.
This is a retrospective study which included all patients presented to the echo lab of Ain Shams university hospital from 1st January 2016 to 1st January 2017, the total number of patients were 8376, patients with infective endocarditis were 278, and patients with tricuspid valve endocarditis were 51 patients respectively. Complete transthoracic echocardiography was done for all patients and data was retrieved from a locally designed electronic database of cardiology department at Ain shams hospitals.
The incidence of TVIE was (17.7%) of all cases of IE, and (0.67%) of all cases attending the echo lab during the study period. The mean age group in our study was (31.1 ± 7.8) and about 84.3% of patient’s age was between 20 and 40 years. Higher incidence of IE was in males (90.2%) than in females (9.8%) with a ratio of 9:1. The vegetations were detected in one leaflet in 33 patients (64.7%), two leaflets in 9 patients (17.6%) and in the three TV leaflets in 7 patients (13.7). The most affected leaflet was the anterior leaflet that was affected in 38 patients constituting about 74.5% of patients. The size of vegetations was large >15 mm in 40 patients (78.4%).
The most encountered echocardiographic complication was severe TR, detected in 40 patients (78.4%) and abscess formation was the least present, detected in only 2 patients (3.9%).
The incidence of TV IE is increasing with male gender predominance, and affects mainly young age groups. TV IE represented 0.6% of all patients, and 17.7% of IE cases. The main echocardiographic feature of TV IE is vegetations which were characterized by being large, highly mobile, and affecting mainly anterior TV leaflet. The main echocardiographic complication is severe TR, but abscess formation was infrequent.
Early postoperative paravalvular leak among Egyptian population: An observational study
2017, Journal of the Saudi Heart Association
Several reports described the incidence of postoperative paravalvular leakage (PVL) early after valve replacement surgery, however, there is a paucity of data regarding the outcomes and complications correlated to the severity of PVL. The aim of the current study was to evaluate the incidence, causes, and short term outcome of early postoperative PVL.
Data were collected from patients presenting to the cardiovascular department at Cairo University Hospital for aortic and/or mitral valve replacement surgery from May 2014 to May 2015. Transthoracic echocardiography (TTE) was done for all patients early postoperative. Transesophageal echocardiography (TEE) was done if diagnosis was not confirmed by TTE. All patients with detected PVL were subjected to TTE and TEE after a 3 month follow-up period.
Two hundred patients were enrolled in the study. Seventy five percent of patients were known to have rheumatic heart disease, while 16.5% had infective endocarditis. The mitral valve was replaced in 40% of patients, the aortic valve was replaced in 36%, and other patients had both valves replaced. Early postoperative period PVL was detected in 25 patients. The most common underlying etiologies were rheumatic heart disease and infective endocarditis. PVL was common in patients with both valves replaced compared with either mitral or aortic valve replacement. Infective endocarditis as underlying valve disease was significantly high in patients with PVL compared with those without (p < 0.001).
The incidence of PVL was high in patients with both valves replaced compared with either mitral or aortic valve replacement. Moreover, every patient with PVL should be properly investigated for infective endocarditis. Surgical intervention, although associated with high morbidity and mortality, reduces PVL recurrence.
2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary
2017, Journal of Thoracic and Cardiovascular Surgery
Infective Endocarditis
2014, Heart Lung and Circulation
Infective endocarditis continues to pose a therapeutic challenge to treating clinicians. We believe that the successful management of endocarditis mandates a thorough understanding of the risk factors for adverse outcomes and a co-ordinated team approach.
Between the years 2000 and 2009, 85 patients required surgery for infective endocarditis, with a total of 112 infected valves being treated surgically. Data was analysed to determine factors significantly associated with morbidity and mortality.
The mean age was 50.5 years. Nine (10.5%) of these patients had Prosthetic Valve Endocarditis, the remaining 76 (89.5%) had Native Valve Endocarditis.
Twenty-nine percent of patients were NYHA 4 pre-operatively, 15% of patients were haemodynamically unstable requiring inotropic support, 34% were persistently febrile despite antibiotic therapy, and 48% had suffered any embolic event, 20% suffered cerebral emboli.
The commonest causative organism in our series was Staphylococcus Aureus (54.1%) with 2.3% of cases being due to MRSA. The second commonest organism isolated was Streptococcus spp. at 21.1%.
Operative mortality was 12.9%, of which on-table mortality was 2.2%. Mean follow-up was 56 months (range 1-151). Early recurrence rates (<3 months) were 2.3%. Late recurrence was 7.0%. The pre-operative factors associated with increased mortality were age over 65, inotropic requirement, uncontrolled sepsis and cerebral emboli. We summarise our experience and recommendations for a team approach to the management of infective endocarditis.

View all citing articles on Scopus

^*: Current address: Singapore General Hospital, Singapore.

View full text

Early and Late Survival After Surgical Treatment of Culture-Positive Active Endocarditis

Objective

Design

Results

Conclusion

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

ACKNOWLEDGMENT

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Med

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Treatment of acute bacterial endocarditis by valve excision and replacement

Circulation

Fungal endocarditis

Prosthetic valve endocarditis

Ann Intern Med