Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998.

We describe 30 cases (1.7%) of community-acquired penicillin-susceptible Streptococcus agalactiae endocarditis among 1771 episodes of endocarditis diagnosed in 4 Spanish hospitals from 1975 through 1998. Endocarditis affected a native valve (most often the mitral valve) in 25 cases (83%). Surgical valve replacement was performed for 12 patients (40%). Fourteen patients (47%) died. Mortality rates for patients with native and prosthetic valve endocarditis were 36% and 100%, respectively (P=.01). The mortality rate for native valve endocarditis decreased during the last 6 years of the study (from 61% in 1975-1992 to 8% in 1993-1998; P<.05). Additionally, 115 cases in the literature from 1962-1998 were reviewed. During 1980-1998, the percentage of patients who underwent cardiac surgery increased from 24% (in the previous period, 1962-1979) to 43% (P=.05) and the mortality rate decreased from 45% to 34% (P=NS). S. agalactiae is an uncommon cause of endocarditis with a high mortality rate, although the prognosis of native valve endocarditis has improved in recent years, probably because of an increased use of cardiac surgery.

Anti-inflammatory activity of abietic acid, a diterpene isolated from Pimenta racemosa var. grissea.

The anti-inflammatory activity of abietic acid, a diterpene isolated from Pimenta racemosa var. grissea (Myrtaceae), was evaluated in-vivo and in-vitro. This compound significantly inhibited rat paw oedema induced by carrageenan in a time- and dose-dependent manner, and mouse ear oedema induced by 12-O-tetradecanoylphorbol acetate, after oral or topical administration. The inhibition of myeloperoxidase enzyme showed that its topical activity was influenced by neutrophil infiltration into the inflamed tissues (ears). In addition, the effect of abietic acid on some macrophage functions was analysed in-vitro. Non-toxic concentrations of abietic acid inhibited prostaglandin E2 (PGE2) production in lipopolysaccharide-treated macrophages, whereas nitrite, tumour necrosis factor alpha and interleukin-1beta production were only weakly affected by this diterpene. PGE2 production from A23187-stimulated macrophages was only inhibited at high doses (100 microM) and it failed to modify leukotriene C4 production. These results indicate that abietic acid exerts in-vivo anti-inflammatory activity after oral or topical administration and has partial ability to prevent the production of some inflammatory mediators.

Long term results of mechanical prostheses for treatment of active infective endocarditis.

OBJECTIVE: To analyse the long term results of mechanical prostheses for treating active infective endocarditis. DESIGN: Prospective cohort study of a consecutive series of patients diagnosed with infective endocarditis and operated on in the active phase of the infection for insertion of a mechanical prosthesis. SETTING: Tertiary referral centre in a metropolitan area. RESULTS: Between 1975 and 1997, 637 cases of infective endocarditis were diagnosed in the centre. Of these, 436 were left sided (with overall mortality of 20.3%). Surgical treatment in the active phase of the infection was needed in 141 patients (72% native, 28% prosthetic infective endocarditis). Mechanical prostheses were used in 131 patients. Operative mortality was 30.5% (40 patients). Ninety one survivors were followed up prospectively for (mean (SD)) 5.4 (4.5) years. Thirteen patients developed prosthetic valve dysfunction. Nine patients suffered reinfection: four of these (4%) were early and five were late. The median time from surgery for late reinfection was 1.4 years. During follow up, 12 patients died. Excluding operative mortality, actuarial survival was 86.6% at five years and 83.7% at 10 years; actuarial survival free from death, reoperation, and reinfection was 73.1% at five years and 59.8% at 10 years. CONCLUSIONS: In patients surviving acute infective endocarditis and receiving mechanical prostheses, the rate of early reinfection compares well with reported results of homografts. In addition, prosthesis dysfunction rate is low and long term survival is good. These data should prove useful for comparison with long term studies, when available, using other types of valve surgery in active infective endocarditis.

Heart failure after aortic valve replacement for aortic regurgitation: prospective 20-year study.

BACKGROUND: The objective of this study was to assess the probability of development of heart failure during a long-term follow-up in patients submitted for aortic valve replacement for aortic regurgitation on the basis of preoperative findings. METHODS AND RESULTS: Eighty-seven consecutive patients with pure aortic regurgitation and normal coronary arteries were submitted for aortic valve replacement and prospectively followed up. Clinical examination, echocardiography, and radionuclide ejection fraction were performed before surgery and at 1, 2, 5, and 10 years after surgery. Operative mortality rate was 2.2% (2 patients). The follow-up period was 1 to 12 years (mean 6 years). Overall survival rate was 87% at 5 years and 81% at 10 years. During follow-up, 19 patients had heart failure develop, and there were 14 deaths (6 caused by heart failure). Probability of heart failure was 16% at 5 years and 24% at 10 years. Age was the single independent preoperative predictor of both death and heart failure. Age >50 years (relative risk [RR] 10.4), preoperative ejection fraction <40% (RR 10.6), and end-systolic diameter >50 mm (RR 74) were independently related to the postoperative development of heart failure. CONCLUSIONS: Aortic valve replacement can be performed safely in patients with severe aortic regurgitation by following current recommendations. Age >50, end-systolic diameter >50 mm, and radionuclide ejection fraction <40% were independent preoperative predictors of postoperative heart failure. The only independent predictor of both postoperative death and heart failure was age >50 years.

Clinical outcome of severe asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study.

One hundred one patients with asymptomatic chronic severe aortic regurgitation and normal ejection fraction were monitored for up to 10 years (mean 55.4 +/- 33.5 months). Predefined surgical indications were the development of cardiac symptoms or the documentation of impaired basal left ventricular function. During the follow-up period there were no cardiac deaths; 14 patients needed surgery, 8 because of development of symptoms and 6 because of left ventricular impairment. The risk of surgery was 12% at 5 years and 24% at 10 years. Baseline end-systolic diameter > 50 mm and radionuclide ejection fraction < 60% were independent predictors or either cardiac symptoms or left ventricular dysfunction. In patients needing surgery, a pattern of progressive left ventricular dilatation was demonstrated. There were no deaths during surgery, and echocardiographic and radionuclide parameters normalized in the first year of follow-up. Our data confirm that the prognosis of severe aortic regurgitation in patients with no symptoms is good and that the occurrence of asymptomatic left ventricular dysfunction is an uncommon event. Surgery can be safely postponed until the appearance of cardiac symptoms or the documentation of left ventricular dysfunction at rest.

Long-term complications of native valve infective endocarditis in non-addicts. A 15-year follow-up study.

OBJECTIVE: To describe the incidence and clinical manifestations of long-term cardiac complications of endocarditis. DESIGN: Cohort study. SETTING: University-affiliated tertiary medical center. PATIENTS: One hundred twelve consecutive patients, survivors from a series of 140 non-addicted patients with a first episode of infective endocarditis on native valves hospitalized from 1975 to 1990. Thirty-two patients had had valve replacement during the active phase of the infection, and the remaining 80 patients received medical treatment alone. MEASUREMENTS: Relapse, recurrence, need for late cardiac surgery, and cardiac mortality. RESULTS: Relapses occurred in three patients (2.7%) and recurrences in five patients (4.5%, incidence density at 15 years, 0.0030 per patient-year). Late cardiac surgery was needed by 47% of the patients treated medically during the active phase, and most had surgery in the first 2 years of follow-up (incidence density, 0.25 per patient-year at 2 years). Aortic valve involvement (relative risk, 2.66; 95% CI, 1.15 to 6.17) and end-diastolic diameter greater than 60 mm (relative risk, 1.04; 95% CI, 1.03 to 2.43) were associated with the need for late surgery in univariate analysis. Multiple logistic regression analysis showed aortic valve involvement to be an independent predictor of the need for late surgery (relative risk, 3.04; CI, 1.23 to 7.54). Only 2 of the 32 patients who had surgery during the active infection needed a second operation during follow-up. At the end of follow-up, the number of patients who had surgery after the onset of the infection was 86 (60% of the whole series). Cardiac death occurred in 16 patients; most deaths were sudden or postoperative and occurred in the first 2 years of follow-up (incidence density, 0.047 per patient-year at 2 years). Independent predictors of death were not found. Survival was 90% at 2 years, 88% at 5 years, 81% at 10 years, and 61% at 15 years. CONCLUSIONS: Survival after infective endocarditis is fair (81% probability of survival at 10 years), and the most common types of cardiac death are sudden and postoperative. Aortic valve involvement is an independent predictor of the need for late cardiac surgery. The rate of recurrences is not negligible (incidence density at 15 years, 0.0030 per patient-year).

Clinical evaluation of a prospective protocol for the timing of surgery in chronic aortic regurgitation.

Out of 160 prospectively followed patients with aortic regurgitation, the clinical courses of 53 patients with pure, severe, and chronic aortic regurgitation and without coronary artery disease who were selected for surgery on the basis of predefined criteria is discussed. Surgical criteria were either unequivocal symptoms or documentation of impaired left ventricular dysfunction (defined as angiographic ejection fraction of less than 50% plus and end-systolic volume index greater than 60 ml/m2). According to preoperative status, patients were divided as follows: 11 asymptomatic patients (group A), 30 patients with moderate (classes II to III) symptoms (group B), and 12 patients with dyspnea at rest and pulmonary edema when first seen (group C). Surgical mortality was one patient (from group C). Late death occurred in four patients (one from group B, three from group C). At the end of follow-up (minimum 1 year, mean 3.6 years) 41 patients were in functional class I, four patients in class II, and one patient in class III. All patients except one in functional classes II and III belonged to group C. Before surgery, patients from groups A and B had similar ventricular dimensions and ejection fractions, whereas patients from group C had larger end-systolic diameters and volumes and lower ejection fractions. End-diastolic and end-systolic diameters decreased significantly at 1 and 2 years after surgery. Patients from group C continued to have dilated hearts as did those patients from groups A and B who had preoperative end-systolic diameters greater than 55 mm.(ABSTRACT TRUNCATED AT 250 WORDS)