RESUMO
The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.
Assuntos
Valva Aórtica/microbiologia , Endocardite Bacteriana/complicações , Doenças das Valvas Cardíacas/microbiologia , Abscesso/epidemiologia , Abscesso/microbiologia , Abscesso/terapia , Adulto , Idoso , Análise de Variância , Anti-Infecciosos/uso terapêutico , Valva Aórtica/cirurgia , Ecocardiografia , Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/terapia , Feminino , Seguimentos , Doenças das Valvas Cardíacas/epidemiologia , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia , Fístula Vascular/epidemiologia , Fístula Vascular/microbiologia , Fístula Vascular/terapiaRESUMO
The periannular extension of infection in prosthetic valve endocarditis (PVE) is a serious complication of infective endocarditis associated with high mortality. Periannular lesions in PVE occasionally rupture into adjacent cardiac chambers, leading to aortocavitary fistulae and intracardiac shunting. It is unknown whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinctive clinical characteristics of patients with PVE and either aortocavitary fistulization or nonruptured abscesses. In a retrospective multicenter study of >872 PVE episodes, 150 patients (17%) with periannular complications in PVE in the aortic position were identified (29 with aortocavitary fistulization and 121 with nonruptured abscesses). Early-onset PVE was present in 73 patients (49%). Rates of heart failure (p = 0.09), ventricular septal defect (p <0.01), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 128 patients (83%). In-hospital mortality in the overall population was 39%. Multivariate analysis identified heart failure (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6 to 6.8), renal failure (OR 2.5, 95% CI 1.2 to 5.2), and co-morbidity (OR 2.4, 95% CI 1.1 to 5.1) as independent risk factors for death. Fistulous tract formation was not associated with increased in-hospital mortality (OR 1.6, 95% CI 0.7 to 3.7). The actuarial 5-year survival rate in surgical survivors was 100% in patients with fistulae and 78% in patients with nonruptured abscesses (log-rank p = 0.14). In conclusion, aortocavitary fistulous tract formation in PVE complicated with periannular complications is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscesses. Despite the frequent complications, fistulous tract formation in the current era of infective endocarditis is not an independent risk factor for mortality.
Assuntos
Endocardite Bacteriana/etiologia , Infecções Relacionadas à Prótese/complicações , Abscesso/epidemiologia , Abscesso/etiologia , Abscesso/terapia , Adulto , Idoso , Anti-Infecciosos/uso terapêutico , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/microbiologia , Valva Aórtica/cirurgia , Fatores de Confusão Epidemiológicos , Ecocardiografia , Endocardite Bacteriana/epidemiologia , Endocardite Bacteriana/terapia , Feminino , Seguimentos , Doenças das Valvas Cardíacas/epidemiologia , Doenças das Valvas Cardíacas/microbiologia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Prognóstico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/terapia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Fístula Vascular/epidemiologia , Fístula Vascular/etiologia , Fístula Vascular/terapiaRESUMO
Four patients infected with human immunodeficiency virus receiving antiretroviral treatment and high doses of methadone (>200 mg/day) presented with several syncopal episodes. A significant prolongation of the QTc interval was detected in all of them, and in 3 patients, > or =1 episode of Torsades de Pointes was recorded. The sequence of events in these cases suggests that high doses of methadone caused QT prolongation and provided the substrate for syncope and Torsades de Pointes.
Assuntos
Analgésicos Opioides/efeitos adversos , Síndrome do QT Longo/induzido quimicamente , Metadona/efeitos adversos , Torsades de Pointes/induzido quimicamente , Adulto , Analgésicos Opioides/administração & dosagem , Terapia Antirretroviral de Alta Atividade , Relação Dose-Resposta a Droga , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Humanos , Masculino , Metadona/administração & dosagemAssuntos
Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/secundário , Neoplasias Cardíacas/diagnóstico , Taquicardia Ventricular/diagnóstico , Diagnóstico Diferencial , Eletrocardiografia , Reações Falso-Positivas , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Tonsilares/diagnósticoRESUMO
AIMS: To investigate the clinical features, echocardiographic characteristics, management, and prognostic factors of mortality of aorto-cavitary fistulization (ACF) in infective endocarditis (IE). Extension of infection in aortic valve IE beyond valvular structures may result in peri-annular complications with resulting necrosis and rupture, and subsequent development of ACF. Aorto-cavitary communications create intra-cardiac shunts, which may result in further clinical deterioration and haemodynamic instability. METHODS AND RESULTS: In a retrospective multi-centre study over 4681 episodes of IE, a total of 76 patients with ACF [1.6%, confidence interval (CI) 95%: 1.2-2.0%] diagnosed by echocardiography or during surgery were identified. Fistulae were found in 1.8% of cases of native valve IE and in 3.5% of cases of prosthetic valve IE from the general population and in 0.4% of drug abusers. PVE was present in 31 (41%) cases of ACF. Transthoracic and transoesophageal echocardiography detected the fistulous tracts in 53 and 97% of cases, respectively. Peri-annular abscesses were detected in 78% of cases, fistulae originated in similar rates from the three sinuses of Valsalva, and the four cardiac chambers were equally involved in the fistulous tracts. Heart failure (HF) developed in 62% of cases and surgery was performed in 66 (87% CI 95% 77-93%) patients with a mortality of 41% (95% CI 30-53%) in the overall population. Multivariate analysis identified HF (OR 3.4, CI 95% 1.0-11.5), prosthetic IE (OR 4.6, CI 95% 1.4-15.4) and urgent or emergency surgical treatment (OR 4.3, CI 95% 1.3-16.6) as variables significantly associated with an increased risk of death. Major complications during follow-up (death, re-operation, or re-admission for HF) among the five operative survivors with residual fistulae occurred in 20 and 100% of patients at 1 and 2 years, respectively. CONCLUSION: Aorto-cavitary fistulous tract formation is an uncommon but extremely serious complication of IE. In-hospital mortality was exceptionally high despite aggressive management with surgical intervention in the majority of patients. Prosthetic IE, urgent surgery, and the development of HF identify the subgroup of patients with IE and ACF that have significantly increased risk of in-hospital death.
Assuntos
Doenças da Aorta/complicações , Valva Aórtica , Cardiopatias/complicações , Seio Aórtico , Fístula Vascular/complicações , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/mortalidade , Ecocardiografia/métodos , Endocardite Bacteriana/complicações , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/mortalidade , Feminino , Cardiopatias/diagnóstico por imagem , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Micoses/mortalidade , Estudos Retrospectivos , Fatores de Risco , Infecções Estafilocócicas/mortalidade , Infecções Estreptocócicas/mortalidade , Fístula Vascular/diagnóstico por imagemRESUMO
A 73-year-old woman with dilated cardiomyopathy presented with heart failure. The ECG showed sinus rhythm with left bundle branch block, left-axis deviation and prolonged QRS duration and frequent ventricular premature complexes from the left ventricular septal wall were present. Ventricular premature beats had narrower QRS duration than sinus node beats conducted through the His-purkinje fibers consistent with resynchronizing beats. The mechanisms of narrowing of the QRS complex produced by premature beats in cases of impaired intra and interventricular conduction are discussed.