Comparison of long term outcome in patients with or without aortic ring abscess treated surgically for aortic valve infective endocarditis.

OBJECTIVE: To assess the long term prognostic significance of aortic valve ring abscess in patients with aortic endocarditis. PATIENTS: A consecutive series of 75 patients who had surgery for aortic infective endocarditis between 1981 and 1989; 35 had aortic ring abscesses (group 1) and 40 did not (group 2). Mean age did not differ between the two groups. Prosthetic valve endocarditis was present in 17% of group 1 and 5% of group 2. Pneumococcal or beta haemolytic streptococcal endocarditis was more common in patients with native valve endocarditis who had aortic ring abscesses (20% v 5%). DESIGN: Cohort analysis. RESULTS: In-hospital mortality (11.4% v 7.5%) and 10 year survival (56% v 66%) were not significantly different between groups 1 and 2. In patients with native valve endocarditis, 10 year survival was 62% and 66%, respectively for patients with or without ring abscess, and 10 year reintervention-free survival was 38% v 58% (p = 0.11). In these patients, the presence of an intercurrent illness, severe congestive heart failure before surgery, and use of valved conduits for surgical treatment were predictors of poorer long term survival. At follow up residual aortic regurgitation was documented in 72% of patients in group 1 and 26% in group 2 (p < 0.01). CONCLUSIONS: Aortic valve ring abscess is not an independent marker of poor long term outcome in patients with infective endocarditis. However, as residual aortic regurgitation appears frequent at follow up, specific surgical techniques should be considered in patients with paravalvar abscesses.

[Coxiella burnetii endocarditis on a mechanical valvular prosthesis. Apropos of 2 cases]. / Endocardite à Coxiella burnetii sur prothèse valvulaire mécanique. A propos de deux cas.

The authors report two cases of prosthetic valve endocarditis due to Coxiella burnetii. The histories were chronic and complex suggesting an auto-immune disease: prolonged recurrent fever despite antibiotic therapy with a biological inflammatory syndrome whilst blood cultures remained negative. The first patient presented with prosthetic valve dehiscence and acute glomerulonephritis. The second patient had coagulation defects with prosthetic valve thrombosis, mesenteric adenopathy and congestive cardiac failure without prosthetic valve dysfunction. In suspected endocarditis with negative blood cultures, serological tests should be extended to intracellular pathogens difficult to identify and justifying specific and prolonged bactericidal therapy (fluoroquinolones, cyclines, rifampincine). Long-term serological surveillance is essential even when the outcome could have led to the termination of antibiotic therapy. Usually, antibiotic therapy provides a bacteriological cure, but treatment has to be continued for at least 3 years, and, in some patients, all their lives. Valve replacement is reserved for haemodynamic complications of the pathology which determine the ultimate prognosis.

[Comparative outcome of aortic valve endocarditis with or without annular abscess]. / Profil évolutif comparé des endocardites aortiques avec ou sans abcès de l'anneau.

Annular abscess is a not uncommon but serious complication of aortic valve endocarditis. The aim of this retrospective study was to evaluate the prognosis of aortic valve endocarditis with and without annular abscess. Between January 1981 and 1989, 122 consecutive cases of aortic endocarditis fulfilling the diagnostic criteria of Duke University were admitted to hospital. Group I included 40 cases with aortic ring abscess confirmed at surgery, in 35 patients; group II comprised 43 cases of operated aortic valve endocarditis without annular abscess in 41 patients and group III comprised 38 cases of aortic valve endocarditis treated medically without echocardiographic or angiographic signs of annular abscess in 36 patients. The patients in group III were significantly older than those in group I (57 +/- 14 years vs 44 +/- 17 years; p < 0.001). From the clinical point of view, endocarditis of prosthetic valves was slightly more common, but without reaching statistical significance, in group I, but the abscess was associated with more severe cardiac failure. Systemic embolism, atrioventricular block and pericardial effusion were equally common in the three groups. On the other hand, endocarditis with annular abscess was more often the result of infection with streptococci A, B, C or pneumoniae, than forms without abscess (22.5% vs 5% and 3% respectively in the 3 groups; p < 0.05). Of the patients treated surgically, destructive lesions of the valves were more common in cases of abscess (57.5% vs 35%; p < 0.05): the hospital mortality was higher in cases of abscess (17.5% vs 7%).(ABSTRACT TRUNCATED AT 250 WORDS)