Cardiac device infections: definition, classification, differential diagnosis, and management.

Cardiac device infections (CDIs) continue to be a serious clinical problem, with varying terminology and different classifications constituting one of the major diagnostic and therapeutic challenges in routine clinical practice. The problem invariably arises during an attempt to estimate the extent of the infection, which in consequence determines the choice of treatment strategy (duration of antibiotic therapy). The most serious form of CDI is lead-related infective endocarditis (LRIE). There are no clearly established diagnostic criteria for this disease; the available Duke University criteria are difficult to apply in patients with a suspicion of LRIE because of low sensitivity. As the treatment of LRIE is expensive and troublesome, there is a tendency to underdiagnose this condition and seek any intermediary forms between local pocket infection and definite LRIE. The present review includes suggestions for the systematization of CDIs with a clear definition of LRIE as a separate and most severe entity among CDIs.

Acute ischemic stroke patterns in infective and nonbacterial thrombotic endocarditis: a diffusion-weighted magnetic resonance imaging study.

BACKGROUND AND PURPOSE: Although infective endocarditis (IE) and nonbacterial thrombotic endocarditis (NBTE) are associated with cardioembolic stroke, differences in the nature of these conditions may result in differences in associated stroke patterns. We compared patterns of acute and recurrent ischemic stroke in IE and NBTE, using diffusion-weighted MRI (DWI). METHODS: Using ICD-9 diagnostic codes and medical record review, we identified 362 patients (387 episodes) with IE and 14 patients with NBTE. Thirty-five patients (with 27 episodes of IE, 9 NBTE) who underwent 36 initial and 29 follow-up DWI scans were selected for this study. DWI lesion size, number, and location were compared between groups and correlated with stroke syndromes and endocarditis features. RESULTS: DWI was abnormal in all but 2 patients. Four acute stroke patterns were identified: (1) single lesion, (2) territorial infarction, (3) disseminated punctate lesions, and (4) numerous small (<10 mm) and medium (10 to 30 mm) or large (>30 mm) lesions in multiple territories. All patients with NBTE exhibited pattern 4, whereas those with IE exhibited patterns 1, 2, 3, and 4 (6, 2, 8 and 9 episodes, respectively). Seventy-five percent of patients with pattern 3 exhibited the clinical syndrome of embolic encephalopathy. Vegetation size, valve, and organisms had no correlation with stroke patterns. CONCLUSION: DWI has utility in differentiating between IE and NBTE. Patients with NBTE uniformly have multiple, widely distributed, small and large strokes, whereas patients with IE exhibit a panoply of stroke patterns.

[Cardiomyopathies in tropical areas]. / Les cardiomyopathies en région tropicale.

Some particular features of the cardiomyopathies (CM) observed in the tropics, especially in Africa, are emphasized in this study. Chronic parietal endocarditis is excluded from the CM group. The author presents facts that justify the linking of that affection to endocardial diseases. Myocardiopathies are acute ailments presenting with congestive lesions, reversible under etiological therapy. Anemic and beri-beri myocardiopathies are not unusual in the tropics and present a hyperkinetic syndrome before the stage of advanced cardiac insufficiency. Infectious or parasitic myocarditis seem frequent in the tropics. The author recalls the characteristics of the myocarditis in the human african trypanosomiasis which he opposes, particularly, to the american trypanosomiasis. The reality of bilharzial myocarditis is more debatable while bilharzial pulmonary hypertension is well documented. Chronic congestive CM presents a few specific characteristics in the tropics. The features, well described in temperate regions, are found in the tropics with a particularly unfortunate prognosis. Some alcoholic myocardiopathies have been observed. The rare occurrence of hypertrophic CM in the tropics results, seemingly, from a lack of exploratory means. The author studies briefly a recent series of 31 cases in Abidjan. Post-partum myocardiopathy seems to be the clinical appearance of a latent myocardial insufficiency of the normal post-partum in women presenting with associated risks factors (anemia, malnutrition, overwork, excessive sodium intake, etc.). An early diagnosis enables a cure only by resting, but it is sometimes necessary to associate a medical treatment. Death by embolism or the passing to chronicity are however possible. Drepanocytic CM is debatable and in many cases, seems hardly differentiated from anemic myocardiopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evolution of protracted septic endocarditis]. / Evoliutsiia zatiazhnogo septicheskogo éndokardita

A study of 1000 cases of septic endocarditis served as a basis for an analysis of the natural history of the diseases (1939-1972): changes in its etiology, clinical course and therapy. The increasing frequency of hospital infection (endocarditis) is emphasized. The characteristics of Staphylococcal and fungal endocarditis are presented, those of the lesion developing on heart valve prostheses as well. The classification of septic endocarditis is analysed, the stages of its activeness are described (III, II, I) along with the clinical and laboratory signs. Schemes of etiotropic therapy are presented, as well as rational combinations of antibiotics. The role of surgery in the management of primary septic endocarditis is described, and the rationale of preventive employment of antibiotics is discussed.

Prognostic stratification of patients with left-sided endocarditis determined at admission.

BACKGROUND: The prognosis of patients with left-sided endocarditis remains poor despite the progress of surgical techniques. Identification of high-risk patients within the first days after admission to the hospital would permit a more aggressive therapeutic approach. METHODS: We designed a prospective multicenter study to find out the clinical, microbiologic, and echocardiographic characteristics available within 72 hours of admission that might define the profile of high-risk patients. Of 444 episodes, 317 left-sided endocarditis cases were included and 76 variables were assessed. Events were surgery in the active phase of the disease and in-hospital death. A stepwise logistic regression analysis was undertaken to determine variables predictive of events. RESULTS: Multivariate analysis of the clinical variables found to have statistical significance in the univariate analysis identified the following as predictive: patient referred from another hospital (odds ratio [OR]: 1.8; confidence interval [CI], 1.1-2.9), atrioventricular block (OR: 2.5; CI, 1.1-5.9), acute onset (OR: 1.7; CI, 1.1-2.9), and heart failure at admission (OR: 2.3; CI, 1.4-3.8). When the echocardiographic and microbiological variables statistically significant in the univariate analysis were introduced, the presence of heart failure at admission (OR: 2.9; CI, 1.8-4.8), periannular complications (OR: 1.8; CI, 1.1-3.1), and Staphylococcus aureus infection (OR: 2.0; CI, 1.1-3.8) retained prognostic power. Risk could be accurately stratified when combining the 3 variables with predictive power: 0 variables present: 25% of risk; 1 variable present: 38% to 49% of risk; 2 variables present: 56% to 66% of risk; and 3 variables present: 79% of risk. CONCLUSIONS: The risk of patients with left-sided endocarditis can be accurately stratified with the assessment of variables easily available within 72 hours of admission to the hospital.

Löffler's endocarditis and endomyocardial fibrosis--a nosologic entity?

The problem whether Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum or are separate entities is still under debate. Until recently it was believed that endomyocardial fibrosis was a disorder restricted to tropical areas. Three Danish patients are presented, two showing a continuous disease spectrum, one patient showing the fully developed endomyocardial fibrosis which is indistinguishable from endomyocardial fibrosis described from the tropical areas. Eosinophilia was present in all three patients. The findings described in these three patients lend support to the unitarian hypothesis that Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum, and that the eosinophilic granulocyte may be the underlying cause.

A comparative study of 48 host valve and 24 prosthetic valve endocarditis cases.

Forty-eight cases of host valve endocarditis and 24 cases of prosthetic valve endocarditis occurring during a concurrent period of time were analyzed to assess differences between the two groups. The over-all incidence of prosthetic valve endocarditis during this 40 month period was 4.4%. The symptoms and signs in both groups were similar, except that PVE patients had more frequent occurrences of changing heart murmurs and splenic and cerebral emboli. Spleen scans may be helpful in the diagnosis of selected cases of culture-negative prosthetic valve endocarditis. There was no significant difference between the two groups for the various infecting microorganisms. However, the culture-negative prosthetic valve group had a mortality rate of 77.7% compared to 46.2% for the host valve group. In the HVE patients the oral cavity or urinary tract was the probable source of infection in 50.0% of the patients. In about one third of HVE cases, there was strong evidence that the infection was related to a therapeutic procedure, whereas nearly half of the PVE patients had clinical evidence of an extracardiac infection at the time of open-heart surgery. We emphasize the need for good pre- and postoperative surveillance to eliminate possible predisposing infections and appropriate antibiotic prophylaxis in all patients with valvular disease at times of risk. The survival rate in patients with prosthetic valve endocarditis was highest in those patients who received "appropriate" antibiotics and, if significant congestive heart failure was present, surgical intervention was necessary.

Complicated left-sided native valve endocarditis in adults: risk classification for mortality.

CONTEXT: Complicated left-sided native valve endocarditis causes significant morbidity and mortality in adults. Lack of valid data regarding estimation of prognosis makes management of this condition difficult. OBJECTIVE: To derive and externally validate a prognostic classification system for adults with complicated left-sided native valve endocarditis. DESIGN, SETTING, AND PATIENTS: Retrospective observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals among 513 patients older than 16 years who experienced complicated left-sided native valve endocarditis and who were divided into derivation (n = 259) and validation (n = 254) cohorts. MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline. RESULTS: In the derivation and validation cohorts, the 6-month mortality rates were 25% and 26%, respectively. Five baseline features were independently associated with 6-month mortality (comorbidity [P =.03], abnormal mental status [P =.02], moderate to severe congestive heart failure [P =.01], bacterial etiology other than viridans streptococci [P<.001 except Staphylococcus aureus, P =.004], and medical therapy without valve surgery [P =.002]) and were used to create a prognostic classification system. In the derivation cohort, patients were classified into 4 groups with increasing risk for 6-month mortality: 5%, 15%, 31%, and 59% (P<.001). In the validation cohort, a similar risk among the 4 groups was observed: 7%, 19%, 32%, and 69% (P<.001). CONCLUSIONS: Adults with complicated left-sided native valve endocarditis can be accurately risk stratified using baseline features into 4 groups of prognostic severity. This prognostic classification system might be useful for facilitating management decisions.

Cambios en el perfil de la endocarditis sobre válvula protésica en un hospital de tercer nivel: 1986-2005 / The changing face of prosthetic valve endocarditis at a tertiary-care hospital: 1986-2005

Introducción y objetivos. Estudiar la evolución de las características clínicas, la etiología y el pronóstico de la endocarditis sobre válvula protésica en un hospital de tercer nivel. Métodos. Estudio de cohortes retrospectivo de todos los pacientes diagnosticados de endocarditis sobre válvula protésica desde 1986 a 2005 según los criterios de Duke modificados. Se analizaron dos periodos temporales: enero de 1986 a diciembre de 1995 (P1) y enero de1996 a diciembre de 2005 (P2).Resultados. Se estudiaron 133 episodios en 122 pacientes. En 73 episodios (54,9%) la endocarditis fue diagnosticada en el P1 y en 60 (45,1%), en el P2 (incidencia del 2,19 y el 2,18% respectivamente). La edad, media ± desviación estándar, fue de 52,6 ± 16,6 años en el P1 y 66,2 ± 11,5 años en el P2 (p = 0,0001). Las características clínicas fueron similares en ambos periodos de estudio. Fue llamativo el incremento de infecciones por enterococo (el 12,5% en el P2 y el 4,9% en elP1; riesgo relativo [RR] = 2,5; intervalo de confianza [IC]del 95%, 0,7-9,6) así como el descenso de las infecciones por estreptococos del grupo viridans (el 12,5% en el P2 y el 31,1% en el P1; RR = 0,4; IC del 95%, 0,2-0,9). Los pacientes intervenidos en el P1 fueron el 90,4%(63/73), mientras que en el P2 fueron el 68,3% (41/60),diferencias que resultaron estadísticamente significativas(RR = 0,8; IC del 95%, 0,6-0,9). La mortalidad intrahospitalaria fue del 28,8% en el P1 y el 30% en el P2 (RR = 1;IC del 95%, 0,6-1,7).Conclusiones. Durante los 20 años de estudio, se ha observado un cambio en la epidemiología y la etiología microbiológica de la endocarditis sobre válvula protésica. El abordaje diagnóstico y terapéutico también se ha modificado, aunque la mortalidad se ha mantenido elevada (AU)

Introduction and objectives. To investigate changes in the clinical characteristics, etiology and prognosis of prosthetic valve endocarditis at a tertiary-care hospital. Methods. Retrospective cohort study of all patients diagnosed with prosthetic valve endocarditis using modified Duke criteria between 1986 and 2005. The analysis covered two time periods: January 1986 to December 1995 (P1) and January 1996 to December 2005 (P2).Results. In total, 133 episodes of endocarditis occurred in 122 patients. Of these, 73 (54.9%) were diagnosed in P1and 60 (45.1%) in P2, with incidences of 2.19% and 2.18%,respectively. The patients’ mean age (SD) was 52.6±16.6years in P1 and 66.2±11.5 years in P2 (P=.0001). Clinical characteristics were similar in the two study periods. The increase in Enterococcus infection was remarkable (12.5%in P2 vs. 4.9% in P1; relative risk [RR]=2.5; 95% confidence interval [CI], 0.7-9.6), as was the decrease in viridans group Streptococcus infection (12.5% in P2 vs. 31.1% in P1;RR=0.4; 95% CI, 0.2-0.9). Some 90.4% of patients (63/73)underwent surgery in P1, while 68.3% (41/60) underwent surgery in P2. The difference was significant (RR=0.8; 95%CI, 0.6-0.9). The in-hospital mortality rate was 28.8% in P1and 30% in P2 (RR=1; 95% CI, 0.6-1.7).Conclusions. Changes in the epidemiology and microbiological etiology of prosthetic valve endocarditis were observed over the 20-year study period. Diagnostic and therapeutic approaches also changed, but mortality remained high (AU)