The three-noes right-sided infective endocarditis: An unrecognized type of right-sided endocarditis.

The "3 noes right-sided infective endocarditis" (3no-RSIE: no left-sided, no drug users, no cardiac devices) was first described more than a decade ago. We describe the largest series to date to characterize its clinical, microbiological, echocardiographic and prognostic profile. Eight tertiary centers with surgical facilities participated in the study. Patients with right-sided endocarditis without left sided involvement, absence of drug use history and no intracardiac electronic devices were retrospectively included in a multipurpose database. A total of 53 variables were analyzed in every patient. We performed a univariate analysis of in-hospital mortality to determine variables associated with worse prognosis. the study was comprised of 100 patients (mean age 54.1 ± 20 years, 65% male) with definite 3no-RSIE were included (selected from a total of 598 patients with RSIE of all the series, which entails a 16.7% of 3no-RSIE). Most of the episodes were community-acquired (72%), congenital cardiopathies were frequent (32% of the group of patients with previous known predisposing heart disease) and fever was the main manifestation at admission (85%). The microbiological profile was led by Staphylococci spp (52%). Vegetations were detected in 94% of the patients. Global in-hospital mortality was 19% (5.7% in patients operated and 26% in patients who received only medical treatment, P < .001). Non-community acquired infection, diabetes mellitus, right heart failure, septic shock and acute renal failure were more common in patients who died. the clinical profile of 3no-RSIE is closer to other types of RSIE than to LSIE, but mortality is higher than that reported on for other types of RSIE. Surgery may play an important role in improving outcome.

Infective endocarditis in patients with aortic grafts.

BACKGROUND: Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients. METHODS: Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group. RESULTS: Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03). CONCLUSIONS: In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients.

Modelo predictivo de mortalidad hospitalaria en endocarditis infecciosa izquierda / Predictive model of in-hospital mortality in left-sided infective endocarditis

INTRODUCCIÓN Y OBJETIVOS: La endocarditis infecciosa (EI) es una enfermedad compleja con elevada mortalidad. La evaluación pronóstica es esencial en el tratamiento de la enfermedad; sin embargo, las guías internacionales no aportan una evaluación objetiva del riesgo individual. Se desarrolló un modelo predictivo de mortalidad hospitalaria en EI izquierda combinando las variables pronósticas propuestas por la guía europea. MÉTODOS: Se utilizaron 2 cohortes prospectivas de pacientes con EI izquierda. La cohorte 1 (n=1.002) se aleatorizó 2:1 para obtener 2 muestras: muestra de derivación (n=688) y muestra de validación interna (n=314). La cohorte 2 (n=133) se utilizó para la validación externa. RESULTADOS: El modelo incluyó edad, endocarditis protésica, comorbilidades, insuficiencia cardiaca, insuficiencia renal, shock séptico, Estafilococo aureus, hongos, complicaciones perianulares, disfunción ventricular y vegetaciones como predictores independientes de mortalidad hospitalaria. El modelo mostró buena capacidad discriminativa (área bajo la curva ROC=0,855; IC95%, 0,825-0,885) y calibración (p valor test Hosmer-Lemeshow=0,409) que se ratificaron en la validación interna (área bajo curva ROC=0,823; IC95%, 0,774-0,873) y externa (área bajo curva ROC=0,753; IC95%, 0,659-0,847). Para la muestra de validación interna (mortalidad 29,9%) el modelo predijo una mortalidad de 30,7% (IC95%, 27,7-33,7) y para la muestra de validación externa (mortalidad 27,1%) 26,4% (IC95%, 22,2-30,5). CONCLUSIONES: Se presenta un modelo predictivo de mortalidad hospitalaria en EII basado en las variables pronósticas propuestas por la guía europea de EI y con alta capacidad discriminativa

INTRODUCTION AND OBJECTIVES: Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines. METHODS: Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n=1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n=688), and a validation sample for internal validation (n=314). Cohort 2 (n=133) was used for external validation. RESULTS: The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve=0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test=0.409), which were ratified in the internal (area under the ROC curve=0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve=0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5). CONCLUSIONS: A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability

Short-course antibiotic regimen compared to conventional antibiotic treatment for gram-positive cocci infective endocarditis: randomized clinical trial (SATIE).

BACKGROUND: Most serious complications of infective endocarditis (IE) appear in the so-called "critical phase" of the disease, which represents the first days after diagnosis. The majority of patients overcoming the acute phase has a favorable outcome, yet they remain hospitalized for a long period of time mainly to complete antibiotic therapy. The major hypothesis of this trial is that in patients with clinically stable IE and adequate response to antibiotic treatment, without signs of persistent infection, periannular complications or metastatic foci, a shorter antibiotic time period would be as efficient and safe as the classic 4 to 6 weeks antibiotic regimen. METHODS: Multicenter, prospective, randomized, controlled open-label, phase IV clinical trial with a non-inferiority design to evaluate the efficacy of a short course (2 weeks) of parenteral antibiotic therapy compared with conventional antibiotic therapy (4-6 weeks). SAMPLE: patients with IE caused by gram-positive cocci, having received at least 10 days of conventional antibiotic treatment, and at least 7 days after surgery when indicated, without clinical, analytical, microbiological or echocardiographic signs of persistent infection. Estimated sample size: 298 patients. INTERVENTION: Control group: standard duration antibiotic therapy, (4 to 6 weeks) according to ESC guidelines recommendations. Experimental group: short-course antibiotic therapy for 2 weeks. The incidence of the primary composite endpoint of all-cause mortality, unplanned cardiac surgery, symptomatic embolisms and relapses within 6 months after the inclusion in the study will be prospectively registered and compared. CONCLUSIONS: SATIE will investigate whether a two weeks short-course of intravenous antibiotics in patients with IE caused by gram-positive cocci, without signs of persistent infection, is not inferior in safety and efficacy to conventional antibiotic treatment (4-6 weeks). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04222257 (January 7, 2020). EudraCT 2019-003358-10.

Predictive model of in-hospital mortality in left-sided infective endocarditis.

INTRODUCTION AND OBJECTIVES: Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines. METHODS: Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n=1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n=688), and a validation sample for internal validation (n=314). Cohort 2 (n=133) was used for external validation. RESULTS: The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve=0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test=0.409), which were ratified in the internal (area under the ROC curve=0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve=0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5). CONCLUSIONS: A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.

Contemporary epidemiology and outcomes in recurrent infective endocarditis.

OBJECTIVE: Recurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large contemporary cohort. METHODS: 1335 consecutive episodes of IE were recruited prospectively in three tertiary care centres in Spain between 1996 and 2015. Episodes were categorised into group I (n=1227), first-IE episode and group II (n=108), recurrent IE (8.1%). After excluding six patients, due to lack of relevant data, group II was subdivided into IIa (n=87), reinfection (different microorganism), and IIb (n=15), relapse (same microorganism within 6 months of the initial episode). RESULTS: The cumulative burden and incidence of recurrence was slightly lower in the second decade of the study (2006-2015) (7.17 vs 4.10 events/100 survivors and 7.51% vs 3.82, respectively). Patients with reinfections, compared with group I, were significantly younger, had a higher frequency of HIV infection, were more commonly intravenous drug users (IVDU) and prosthetic valve carriers, had less embolic complications and cardiac surgery, with similar in-hospital mortality. IVDU was found to be an independent predictor of reinfection (HR 3.92, 95% CI 1.86 to 8.28).In the relapse IE group, prosthetic valve endocarditis (PVE) and periannular complications were more common. Among patients treated medically, those with PVE had a higher relapse incidence (4.82% vs 0.43% in native valve IE, p=0.018). Staphylococcus aureus and PVE were independent predictors of relapse (HR 3.14, 95% CI 1.11 to 8.86 and 3.19, 95% CI 1.13 to 9.00, respectively) and in-hospital-mortality was similar to group I. Three-year all-cause mortality was similar in recurrent episodes compared with single episodes. CONCLUSION: Recurrent IE remains a frequent late complication. IVDU was associated with a fourfold increase in the risk of reinfection. PVE treated medically and infections caused by S. aureus increased the risk of relapse. In-hospital and long-term mortality was comparable among groups.

"A contemporary description of staphylococcus aureus prosthetic valve endocarditis. Differences according to the time elapsed from surgery".

Staphylococcus aureus prosthetic valve endocarditis (SAPVE) has a poor prognosis. There are no large series that accurately describe this entity.This is a retrospective observational study on a prospective cohort from 3 Spanish reference hospitals for cardiac surgery, including 78 definitive episodes of left SAPVE between 1996 and 2016.Fifty percent had a Charlson Index score >5; 53% were health care-related. Twenty percent did not present fever. Complications at diagnosis included: severe heart failure (HF, 29%), septic shock (SS, 17.9%), central nervous system abnormalities (19%), septic metastasis (4%). Hemorrhagic stroke was not higher in anticoagulated patients. Twenty-seven percent were methicilin-resistant SA (MRSA). Fifteen of 31 had positive valve culture; it was related to surgery within first 24 hours. At diagnosis, 69% had vegetation (>10 mm in 75%), 21.8% perianular extension, and 20% prosthetic dehiscence. Forty-eight percent had persistent bacteremia, related to nonsurgical treatment. Perianular extension progressed in 18%. Surgery was performed in 35 episodes (12 with stroke). Eleven uncomplicated episodes were managed with medical therapy, 8 survived. In-hospital mortality was 55%, higher in episodes with hemorrhagic stroke (77.8% vs 52.2%, odds ratio 3.2 [0.62-16.55]). Early SAPVE was nosocomial (92%), presented as severe HF (54%), patients were diagnosed and operated on early, 38% died. In intermediate SAPVE (9 weeks-1 year) diagnosis was delayed (24%), patients presented with constitutional syndrome (18%), renal failure (41%), and underwent surgery >72 hours after indication; 53% died. Late SAPVE (>1 year) was related with health care, diagnosis delay, and 60% of deceases.Left SAPVE frequently affected patients with comorbidity and health care contact. Complications at diagnosis and absence of fever were frequent. Presence of MRSA was high. Positive valve culture was related to early surgery. Paravalvular extension was frequent; vegetations were large, but its absence at diagnosis was common. Some uncomplicated SAPVE episodes were safety treated with medical therapy. Surgery was feasible in patients with stroke. Mortality was high. There were differences in some clinical characteristics and in evolution according to the time elapsed from valve replacement. Prognosis was better in early SAPVE.

Impact of Valve Culture in the Prognosis of Active Left-sided Infective Endocarditis.

BACKGROUND: The culture of removed cardiac tissues during cardiac surgery of left-sided infective endocarditis (LSIE) helps to guide antibiotic treatment. Nevertheless, the prognostic information of a positive valve culture has never been explored. METHODS: Among 1078 cases of LSIE consecutively diagnosed in 3 tertiary centers, we selected patients with positive blood cultures who underwent surgery during the active period of infection and in whom surgical biological tissues were cultured (n = 429). According to microbiological results, we constructed 2 groups: negative valve culture (n=218) and concordant positive valve culture (CPVC) (n=118). We compared their main features and performed a multivariable analysis of in-hospital mortality. RESULTS: Patients with CPVC presented more nosocomial origin (32% vs 20%, P = .014), more septic shock (21% vs 11%, P = .007), and higher Risk-E score (29% vs 21%, P = .023). Their in-hospital mortality was higher (35% vs 19%, P = .001), despite an earlier surgery (3 vs 11 days from antibiotic initiation, P < .001). Staphylococcus species (61% vs 42%, P = .001) and Enterococcus species (20% vs 9%, P = .002) were more frequent in the CPVC group, whereas Streptococcus species were less frequent (14% vs 42%, P < .001). Independent predictors for in-hospital mortality were renal failure (odds ratio [OR], 2.6 [95% confidence interval {CI}, 1.5-4.4]), prosthesis (OR, 1.9 [95% CI, 1.1-3.5]), Staphylococcus aureus (OR, 1.8 [95% CI, 1.02-3.3]), and CPVC (OR, 2.3 [95% CI, 1.4-3.9]). CONCLUSIONS: Valve culture in patients with active LSIE is an independent predictor of in-hospital mortality.

Surgery changes prognosis in infective endocarditis: The importance of post-surgical clinical evolution.

BACKGROUND: Left-sided infective endocarditis (LSIE) bears a grim prognosis and surgery is needed in more than half of the patients to improve survival. Our hypothesis has been that clinical complications developing after surgery impact prognosis. METHODS: Among 1075 consecutive episodes of LSIE, 654 (60.7%) underwent cardiac surgery. Of them, 41 patients (6.3%) died the same day of surgery, 112 (17.2%) died after the first day of surgery during hospital stay and 500 (76.5%) were successfully discharged. We compared the last two groups and performed a multivariable analysis of in-hospital mortality. RESULTS: Age (OR 1.02, 95% CI 1.01-1.04), periannular complications (OR 1.9, 95% CI 1.2-3.2) renal failure after surgery (OR 2.4, 95% CI 1.3-4.4) but not before surgery, and septic shock after surgery (OR 9.6, 95% CI 5.4-17.1) but not before surgery are predictive of in-hospital death among LSIE patients who underwent cardiac surgery. CONCLUSION: A thorough clinical assessment with prognostic purposes in infective endocarditis after surgery is mandatory. In-hospital mortality of patients with infective endocarditis who undergo surgery depends mainly on the clinical evolution after surgery.

Early surgery for acute-onset infective endocarditis.

OBJECTIVES: Acute onset of infective endocarditis has been previously linked to the development of septic shock and a worse prognosis. The purpose of this study was to analyse the clinical features and in-hospital evolution of patients with acute-onset endocarditis as well as the potential role of early surgery in the treatment of these patients. METHODS: From 1996 to 2014, 1053 consecutive patients with left-sided endocarditis were prospectively included. Patients were classified into 2 groups according to the clinical presentation: patients with acute-onset endocarditis (n = 491) and patients with non-acute endocarditis (n = 562). Acute-onset endocarditis was considered when the time between the appearance of symptoms and diagnosis was <15 days. RESULTS: At admission, acute renal failure, septic shock and cerebral embolism predominated among patients with acute-onset endocarditis. Staphylococcus aureus was more frequently isolated in patients with an acute onset (27.7% vs 7.8% P < 0.001). During hospitalization, patients with acute onset developed systemic embolism and septic shock more frequently. Death was much more common in this group (42.7 vs 30.1%, P < 0.001). Paravalvular complications, nosocomial infection, heart failure, S. aureus and septic shock were predictors of mortality. Acute-onset presentation of endocarditis was strongly associated with increased mortality. Among patients with acute-onset endocarditis, early surgery, performed within the first 2 days after diagnosis, was associated with a 64% of reduction in mortality. CONCLUSIONS: Patients with endocarditis and acute onset of symptoms are at high risk of septic in-hospital complications and mortality. Early surgery, performed within the first 2 days after diagnosis, plays a central role in the treatment of these patients.

Endocarditis infecciosa derecha en portadores de dispositivos cardiacos: perfil clínico y pronóstico / Right-sided infective endocarditis in cardiac device carriers: Clinical profile and prognosis

Antecedentes y objetivos: Debido al aumento en las indicaciones de implante de dispositivos cardiacos y el envejecimiento de la población, la epidemiología de la endocarditis infecciosa derecha (EID) ha cambiado drásticamente, siendo hoy en día los portadores de dispositivos cardiacos el principal grupo afectado. El objetivo de este trabajo es describir la epidemiología, el perfil clínico y los resultados de la EID en portadores de dispositivos cardiacos. Pacientes y métodos: Se incluyeron episodios de endocarditis infecciosa definitiva diagnosticados consecutivamente en 3 centros terciarios entre marzo de 1995 y septiembre de 2014. Se realizó un análisis retrospectivo de 85 variables, seguimiento de un año y análisis univariante de la mortalidad hospitalaria. Resultados: Entre 1.182 episodios, 100 portadores de dispositivos cardiacos presentaron EID (8,5%). La edad media±DE fue de 67±14 años. Los estafilococos fueron los principales microorganismos responsables (coagulasa negativos 44%, aureus 31%), y de ellos, el 37% eran resistentes a meticilina. Los dispositivos cardiacos fueron retirados en el 95% de los pacientes. La mortalidad hospitalaria y al año fue del 8 y el 4%, respectivamente. El análisis univariante demostró que la insuficiencia renal al ingreso (OR 6,2; IC 95% 1,3-30,3), el shockséptico (OR 8,9; IC 95% 1,7-47,9) y la infección persistente durante la evolución (OR 19,4; IC 95% 3-125,7) aumentan la mortalidad hospitalaria, mientras que la retirada del dispositivo es un factor protector (OR 0,08; IC 95% 0,02-0,39). Conclusiones: La EID sobre dispositivos cardiacos tiene una baja mortalidad intrahospitalaria y al año. Los estafilococos coagulasa negativos son responsables de casi la mitad de los episodios y la incidencia de resistencia a meticilina es elevada. La retirada de los dispositivos disminuye la mortalidad hospitalaria (AU)

Background and objectives: Due to the widespread indications for device implants and the population aging, right-sided infective endocarditis (RSIE) epidemiology has dramatically changed, being nowadays, cardiac device carriers the main affected group. The aim of this work is to describe the epidemiology, clinical profile and outcomes of RSIE in cardiac device carriers. Patients and methods: We included definitive infective endocarditis episodes consecutively diagnosed in 3 tertiary centers from March 1995 to September 2014. A retrospective analysis of 85 variables, one-year follow up and univariate analysis of in-hospital mortality was conducted. Results: Among 1,182 episodes, 100 cardiac device carriers presented with RSIE (8.5%). Mean age±SD was 67±14 years. Staphylococcus spp. were the main causative microorganisms (coagulase-negative 44%, aureus 31%) and 37% were methicillin-resistant. Cardiac devices were removed in 95% of patients. In-hospital mortality was 8% and one-year mortality was 4%. Univariate analysis demonstrated that renal failure at admission (OR 6.2; 95% CI 1.3-30.3), septic shock (OR 8.9; 95% CI 1.7-47.9) and persistent infection during clinical course (OR 19.4; 95% CI 3-125.7) increase in-hospital mortality while device removal is a protective factor (OR 0.08; 95% CI 0.02-0.39). Conclusions: RSIE have low in-hospital and one-year mortality. Coagulase-negative Staphylococci is responsible of almost half of the episodes and methicillin-resistant incidence is high. Device removal is mandatory since it decreases in-hospital mortality (AU)

Right-sided infective endocarditis in cardiac device carriers: Clinical profile and prognosis. / Endocarditis infecciosa derecha en portadores de dispositivos cardiacos: perfil clínico y pronóstico.

BACKGROUND AND OBJECTIVES: Due to the widespread indications for device implants and the population aging, right-sided infective endocarditis (RSIE) epidemiology has dramatically changed, being nowadays, cardiac device carriers the main affected group. The aim of this work is to describe the epidemiology, clinical profile and outcomes of RSIE in cardiac device carriers. PATIENTS AND METHODS: We included definitive infective endocarditis episodes consecutively diagnosed in 3 tertiary centers from March 1995 to September 2014. A retrospective analysis of 85 variables, one-year follow up and univariate analysis of in-hospital mortality was conducted. RESULTS: Among 1,182 episodes, 100 cardiac device carriers presented with RSIE (8.5%). Mean age±SD was 67±14 years. Staphylococcus spp. were the main causative microorganisms (coagulase-negative 44%, aureus 31%) and 37% were methicillin-resistant. Cardiac devices were removed in 95% of patients. In-hospital mortality was 8% and one-year mortality was 4%. Univariate analysis demonstrated that renal failure at admission (OR 6.2; 95% CI 1.3-30.3), septic shock (OR 8.9; 95% CI 1.7-47.9) and persistent infection during clinical course (OR 19.4; 95% CI 3-125.7) increase in-hospital mortality while device removal is a protective factor (OR 0.08; 95% CI 0.02-0.39). CONCLUSIONS: RSIE have low in-hospital and one-year mortality. Coagulase-negative Staphylococci is responsible of almost half of the episodes and methicillin-resistant incidence is high. Device removal is mandatory since it decreases in-hospital mortality.

Risk score for cardiac surgery in active left-sided infective endocarditis.

OBJECTIVE: To develop and validate a calculator to predict the risk of in-hospital mortality in patients with active infective endocarditis (IE) undergoing cardiac surgery. METHODS: Thousand two hundred and ninety-nine consecutive patients with IE were prospectively recruited (1996-2014) and retrospectively analysed. Left-sided patients who underwent cardiac surgery (n=671) form our study population and were randomised into development (n=424) and validation (n=247) samples. Variables statistically significant to predict in-mortality were integrated in a multivariable prediction model, the Risk-Endocarditis Score (RISK-E). The predictive performance of the score and four existing surgical scores (European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and II), Prosthesis, Age ≥70, Large Intracardiac Destruction, Staphylococcus, Urgent Surgery, Sex (Female) (PALSUSE), EuroSCORE ≥10) and Society of Thoracic Surgeons's Infective endocarditis score (STS-IE)) were assessed and compared in our cohort. Finally, an external validation of the RISK-E in a separate population was done. RESULTS: Variables included in the final model were age, prosthetic infection, periannular complications, Staphylococcus aureus or fungi infection, acute renal failure, septic shock, cardiogenic shock and thrombocytopaenia. Area under the receiver operating characteristic curve in the validation sample was 0.82 (95% CI 0.75 to 0.88). The accuracy of the other surgical scores when compared with the RISK-E was inferior (p=0.010). Our score also obtained a good predictive performance, area under the curve 0.76 (95% CI 0.64 to 0.88), in the external validation. CONCLUSIONS: IE-specific factors (microorganisms, periannular complications and sepsis) beside classical variables in heart surgery (age, haemodynamic condition and renal failure) independently predicted perioperative mortality in IE. The RISK-E had better ability to predict surgical mortality in patients with IE when compared with other surgical scores.

Endocarditis infecciosa por Listeria monocytogenes: a propósito de 4 casos / Infective endocarditis due to listeria monocytogenes: a report of 4 patients

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Usefulness of New-Onset Atrial Fibrillation, as a Strong Predictor of Heart Failure and Death in Patients With Native Left-Sided Infective Endocarditis.

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and has been independently related to increased morbidity and mortality. AF is a frequent arrhythmia in infective endocarditis (IE). Nevertheless, there are no data on how AF affects the clinical outcome of patients with endocarditis. Our purpose was to investigate patient characteristics, microbiology, echocardiographic findings, in-hospital course, and prognosis of patients with IE who develop new-onset AF (NAF) and compare them with those who remained in sinus rhythm (SR) or had previous AF (PAF). From 1997 to 2014, 507 consecutive patients with native left-sided IE were prospectively recruited at 3 tertiary care centers. We distinguished 3 groups according to the type of baseline heart rhythm during hospitalization and previous history of AF: NAF group (n = 52), patients with no previous history of AF and who were diagnosed as having NAF during hospitalization; SR group (n = 380), patients who remained in SR; and PAF group (n = 75), patients with PAF. Patients with NAF were older than those who remained in SR (68.3 vs 59.6 years, p <0.001). At admission, heart failure was more common in NAF group (53% vs 34.3%, p <0.001), whereas stroke (p = 0.427) was equally frequent in all groups. During hospitalization, embolic events occurred similarly (p = 0.411). In the multivariate analysis, NAF was independently associated with heart failure (odds ratio 3.56, p <0.01) and mortality (odds ratio 1.91, p = 0.04). In conclusion, the occurrence of NAF in patients with IE was strongly associated with heart failure and higher in-hospital mortality independently from other relevant clinical variables.

Streptococcus bovis endocarditis: Update from a multicenter registry.

BACKGROUND: Infective endocarditis (IE) due to Streptococcus bovis has been classically associated with elderly patients, frequently involving >1 valve, with large vegetations and high embolic risk, which make it a high-risk group. Our aim is to analyze the current clinical profile and prognosis of S bovis IE episodes, in comparison to those episodes caused by viridans group streptococci and enterococci. METHODS: We analyzed 1242 consecutive episodes of IE prospectively recruited on an ongoing multipurpose database, of which 294 were streptococcal left-sided IE and comprised our study group. They were classified into 3 groups: group I (n = 47), episodes of IE due to S bovis; group II (n = 134), episodes due to viridans group streptococci; and group III (n = 113), those episodes due to enterococci. RESULTS: The incidence of enterococci IE has significantly increased in the last 2 decades (6.4% [1996-2004] vs 11.1% [2005-2013]; P = .005), whereas the incidence of IE due to S bovis and viridans streptococci have remained stable (4% and 10%, respectively). Gender distribution was similar in the 3 groups. Patients with S bovis and enterococci IE were older than those from group II. Nosocomial acquisition was more frequent in group III. Concerning comorbidity, diabetes mellitus (36.7% vs 9.2% vs 26.8%; P < .001) was more common in groups I and III. Chronic renal failure was more prevalent in patients from group III (4.2% vs 1.5% vs 19%; P < .001). Prosthetic valve IE was more frequent in enterococcal IE. Infection upon normal native valves was more frequent in S bovis IE. Colorectal tumors were found in 69% of patients from this group. Vegetation detection was similar in the 3 groups. However, vegetation size was smaller in S bovis IE. During hospitalization, in-hospital complications and in-hospital mortality were higher in enterococci episodes. CONCLUSIONS: S bovis IE accounts for 3.8% of all IE episodes in our cohort; it is associated with a high prevalence of colonic tumors, with predominance of benign lesions, and affects patients without preexisting valve disease. It is related to small vegetations and a low rate of in-hospital complications, including systemic embolisms. In-hospital mortality is similar to that of viridans group streptococci.