A pragmatic approach for mortality prediction after surgery in infective endocarditis: optimizing and refining EuroSCORE.

OBJECTIVE: To simplify and optimize the ability of EuroSCORE I and II to predict early mortality after surgery for infective endocarditis (IE). METHODS: Multicentre retrospective study (n = 775). Simplified scores, eliminating irrelevant variables, and new specific scores, adding specific IE variables, were created. The performance of the original, recalibrated and specific EuroSCOREs was assessed by Brier score, C-statistic and calibration plot in bootstrap samples. The Net Reclassification Index was quantified. RESULTS: Recalibrated scores including age, previous cardiac surgery, critical preoperative state, New York Heart Association >I, and emergent surgery (EuroSCORE I and II); renal failure and pulmonary hypertension (EuroSCORE I); and urgent surgery (EuroSCORE II) performed better than the original EuroSCOREs (Brier original and recalibrated: EuroSCORE I: 0.1770 and 0.1667; EuroSCORE II: 0.2307 and 0.1680). Performance improved with the addition of fistula, staphylococci and mitral location (EuroSCORE I and II) (Brier specific: EuroSCORE I 0.1587, EuroSCORE II 0.1592). Discrimination improved in specific models (C-statistic original, recalibrated and specific: EuroSCORE I: 0.7340, 0.7471 and 0.7728; EuroSCORE II: 0.7442, 0.7423 and 0.7700). Calibration improved in both EuroSCORE I models (intercept 0.295, slope 0.829 (original); intercept -0.094, slope 0.888 (recalibrated); intercept -0.059, slope 0.925 (specific)) but only in specific EuroSCORE II model (intercept 2.554, slope 1.114 (original); intercept -0.260, slope 0.703 (recalibrated); intercept -0.053, slope 0.930 (specific)). Net Reclassification Index was 5.1% and 20.3% for the specific EuroSCORE I and II. CONCLUSIONS: The use of simplified EuroSCORE I and EuroSCORE II models in IE with the addition of specific variables may lead to simpler and more accurate models.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines.

OBJECTIVE: The management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy. METHODS: Thirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015. RESULTS: The global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical 'consensus', local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%-62%) or in blood-culture-negative endocarditis (0%-15%) that requires adaptation to clinical and epidemiological data. CONCLUSION: Worldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy.

BACKGROUND: The use of anticoagulant therapy in patients with infective endocarditis (IE) is a controversial issue. OBJECTIVE: To study the impact of anticoagulant therapy on the clinical outcome, mortality, and cause of death in a series of patients with native and prosthetic left-sided Staphylococcus aureus IE. METHODS: This report is based on all consecutive cases of IE diagnosed at our hospital between 1975 to 1997. Clinical data, including the use of anticoagulant therapy at the time of diagnosis, were prospectively obtained, and antibiotic treatment and surgical indications were uniform throughout the study period. Computed tomographic scans of all clinical records were reviewed. RESULTS: Of 637 consecutive patients with IE, 56 had left-sided S aureus IE affecting native valves in 35 patients and prosthetic valves in 21 patients. Of the patients with prosthetic valve IE, 19 (90%) were taking oral anticoagulant therapy at the time of diagnosis while no patient with native valve IE was receiving such treatment. There were no differences between native valve IE and prosthetic valve IE in age, sex, embolic episodes, and number of central nervous system complications. Mortality was higher in prosthetic valve IE than in native valve IE (71% vs 37%; P=.02). No patient with native valve IE died due to central nervous system complications, while 73% (11 of 15 patients) with prosthetic valve IE died due to central nervous system complications. The difference in the distribution of the type of death (stroke vs other) was significant (P<.007). CONCLUSIONS: Our results suggest that in left-sided S aureus IE anticoagulant therapy is closely associated with death due to neurologic damage. According to our data, as soon as the clinical diagnosis of S aureus IE is indicated the use of anticoagulant therapy should be immediately stopped until the septic phase of the disease is overcome.

Cardiac complications during pregnancy are better predicted with the modified WHO risk score.

BACKGROUND/OBJECTIVE: Several risk scores (RSs) have been used to stratify risk of cardiac complications (CCs) in pregnant patients with heart disease. We aimed to compare and contrast the accuracy of several RSs for predicting CC in this population. METHODS: Prospective inclusion of all consecutive pregnant patients with heart disease, and follow-up until 6 months postpartum. CCs were defined as primary if admission was required due to heart failure, arrhythmia or thromboembolic events, and secondary if the decline in NYHA class compared with baseline was >2 or urgent invasive cardiac procedures were needed. The discriminatory power of each RS was assessed by the area-under-the receiver-operating characteristic (ROC) curve (AUC). RESULTS: 179 patients, mean age: 32 years, accounted for 13.4% of CC (primary 11.7%, secondary 1.7%); the main diagnosis was congenital heart disease (CHD) in 68% followed by valvulopathies in 16%, arrhythmia in 7% and myocardiopathies in 5%. 22% (n=40) were classified as mWHO=1, 59% (n=105) mWHO=2 including subgroup 2-3, 14% (n=26) mWHO=3 and 4%(n=7) mWHO=4; 1 patient was unclassifiable. mWHO showed a better AUC (0.763) than CARPREG (0.67). For the CHD population, ZAHARA RS showed an AUC of 0.74, and Khairy an AUC of 0.632. CONCLUSIONS: mWHO was better at predicting CC than CARPREG; mWHO was also better at predicting CC than the specific CHD RS in the CHD subgroup. PRACTICE: There are an increasing number of pregnant women with HD. IMPLICATIONS: Improved prediction of CC risk during pregnancy can provide better preconception assessment in women with HD.

Late prosthetic valve endocarditis. Immediate and long-term prognosis.

From 1975 to 1989, 307 consecutive episodes of infective endocarditis were diagnosed in our hospital. Of those, 35 were cases of late prosthetic valve endocarditis, defined as those occurring after 12 months of valvular replacement. Blood cultures grew streptococci in 15 patients (43 percent), staphylococci in seven (20 percent), enterococci in five (14 percent), Gram-negative bacilli of HACEK group in four (11.5 percent), and Candida in one. Blood cultures were negative in three cases (prosthetic infection was confirmed at surgery). Heart failure due to prosthetic dysfunction occurred in seven patients (20 percent) and emboli in 12 (34 percent). Early valvular replacement was performed in six patients (17 percent). Complications and mortality were dependent on the infective agent. Overall mortality was 23 percent, no death occurred from streptococcal infection, whereas mortality with endocarditis by organisms of the HACEK group and Staphylococcus was 50 percent and 43 percent, respectively. During a mean follow-up of five years, 11 patients (those with prosthetic leaks diagnosed during the active infection and patients with biologic prostheses) required surgery. There was one relapse in a patient with staphylococcal endocarditis and one recurrence, six years after the initial episode. We conclude that immediate prognosis of late prosthetic valve endocarditis depends on the infective agent. Although the immediate prognosis of streptococcal infections is good, the need for early reoperation during follow-up due to progressive perivalvular leak is high. Also, it appears that deterioration of bioprostheses proceeds swiftly after the cure of infection.

Ventricular arrhythmias in aortic valve disease: a further marker of impaired left ventricular function.

One hundred and twenty stable patients with pure and severe aortic valve disease and without coronary lesions (aortic stenosis, 43 patients; aortic regurgitation, 45 patients; combined aortic stenosis and regurgitation, 32 patients) who had been submitted to haemodynamic studies were prospectively studied with standard electrocardiograms, M-mode echocardiograms, and 24-hour ambulatory electrocardiography (Holter recording). The frequency and complexity of ventricular arrhythmias were related to clinical parameters such as functional class, type of lesion and presence of syncope, and to parameters of left ventricular hypertrophy and function. Ventricular arrhythmias were present in 92% of patients. A high number of ventricular premature beats was directly correlated with parameters of complexity of the arrhythmia. A significant relation was found between electrocardiographic left ventricular hypertrophy and Ryan class (P less than 0.05), and an inverse relation between maximal number of ventricular premature beats in any hour and left ventricular ejection fraction (P less than 0.05). The group of patients with aortic regurgitation showed a higher total number of ventricular premature beats per 24 hours (P less than 0.001), a higher maximal number of these in any hour (P less than 0.01), a higher number of patients with pairs (P less than 0.001), and a higher number of patients in Ryan classes 3, 4A, 4B (P less than 0.01). This study shows a high incidence of ventricular arrhythmias in aortic valve disease, and especially in aortic regurgitation, with a significant relation between left ventricular hypertrophy and function, and number and complexity of arrhythmias.

[New aspects in aortic valve disease]. / Nuevos aspectos de la valvulopatía aórtica.

Renewed interest for aortic valve disease has evolved in recent years. Aortic valve replacement has become the second most frequent cause of cardiac surgery, following coronary bypass surgery. In addition, the etiologic and physiopathologic knowledge of this disorder has improved. In the present paper we analyze three aspects of the disease which are, at present, the subject of study and controversy: first, we discuss the possible relationship between degenerative aortic stenosis and atherosclerosis; second, the involvement of the aortic root in cases of bicuspid aortic valve; and third, the surgical indications in asymptomatic patients with either aortic stenosis or regurgitation.

[The ergonovine test: an episode of hallucinations]. / Prueba de la ergonovina: un episodio de alucinaciones.

The ergonovine maleate provocation test for the diagnosis of coronary spasm is widely used in patients with rest angina. A patient who developed an episode of psychotomimetic symptoms after the administration of intravenous ergonovine is presented. This side effect of ergonovine maleate had not been previously reported.

[Practice guidelines of the Spanish Society of Cardiology on endocarditis]. / Guías de práctica clínica de la Sociedad Española de Cardiología en endocarditis.

Infectious endocarditis is a disease which mainly involves the cardiac valves. It has a bad prognosis and is caused by a great variety of microorganisms. Prophylaxis is important although the effectiveness and the best way to achieve it remain unclear. Recommendations are herein presented. The diagnosis is based on clinical, bacteriological, and echocardiographic findings mainly based on Duke's criteria. Transthoracic and transesophageal echography are not only of diagnostic value but are also a tool to determine the therapy to follow. Antibiotic therapy should be selected according to the organisms isolated and their in vitro susceptibility. Guidelines for empirical antibiotic therapy in cases of negative cultures are also included. Lastly, indications and time for surgery are discussed.

[Apical hypertrophic myocardiopathy: differential diagnosis with ischemic cardiopathy]. / Miocardiopatía hipertrófica apical: diagnóstico diferencial con la cardiopatía isquémica.

A 53-year-old patient was admitted to our hospital because of exertional angina and electrocardiographic changes suggesting ischemic heart disease. The echocardiogram and cardiac catheterization demonstrated apical hypertrophic cardiomyopathy with normal coronary angiogram. We review the clinical features, treatment and prognosis of this condition. We insist on the importance of clinically suspecting it in any asymptomatic patient, or with any type of cardiac symptoms, and giant negative T waves with electrocardiographic features of left ventricular hypertrophy.

[Infectious endocarditis in drug addicts: a study of 71 cases]. / Endocarditis infecciosa en drogadictos: estudio de 71 casos.

Infective endocarditis (IE) is a severe and relatively common condition in parenteral drug abusers (PDA). Seventy-one IE episodes in 59 PDAs admitted to the Hospital General Vall d'Hebron from August 1978 to December 1988 were evaluated. The disease basically involved young males, with a progressively increasing incidence throughout the decade and a higher frequency during August. Fever was a constant symptom, with a duration of less than 10 days before admission in 73% of cases. Staphylococcus aureus was the most common pathogen (85% of episodes). Vegetations were detected by echocardiography in 70% of cases. In 82% of episodes the right side of the heart was involved, particularly the tricuspid valve. The initial chest X-ray film was abnormal in 57.5% of episodes. In 7 patients features of heart failure were present at admission; most had left heart endocarditis. Three patients with left heart endocarditis required surgical therapy. Overall mortality was 13%; it was 6% in patients with only tricuspid involvement and 27% when the left heart was involved.

Immediate and long-term outcome of left-sided infective endocarditis. A 12-year prospective study from a contemporary cohort in a referral hospital.

The aim of this study was to describe the immediate and long-term prognosis of a contemporary cohort of patients with left-sided infective endocarditis (LSIE). A prospective observational cohort study was conducted in a referral centre. Between January 2000 and December 2011, all consecutive adult patients with LSIE were followed-up until death, relapse, recurrence, need for late surgery, or last control. During the active phase of IE, 174 of 438 patients underwent surgery (40% overall; 43% native valve (NVIE), 30% prosthetic valve (PVIE)) and 125 died (29% overall; 26% NVIE, 39% PVIE). The median follow-up in survivors was 3.2 years (interquartile range (IQR) 1.0-6.0 years). Relapses occurred in seven patients (2.2%; 95% CI, 1.1-4.5) and recurrences in eight (2.6%; 95% CI, 1.3-5.0), with an incidence density of 0.0067 per patient-year (95% CI, 0.0029-0.0133) and high mortality (75% of recurrences). Only four of 130 survivors (3.1%; 95% CI, 1.2-7.6) who were treated surgically during the active phase of the disease, and 14/183 (7.7%; 95% CI, 4.6-12.4) of those not undergoing surgery needed operation during follow-up (p 0.09). In the 313 survivors, actuarial survival was 86% at 1 year (87% NVIE, 83% PVIE), 79% at 2 years (81% NVIE, 72% PVIE) and 68% at 5 years (71% NVIE, 57% PVIE). At 1 year, 115 of 397 patients (29.0%; 95% CI, 24.7-33.6) remained alive, with no surgery requirement, relapse or recurrence. LSIE is associated with considerable in-hospital and long-term mortality, especially PVIE. However, relapses, recurrences and the need for late surgery are uncommon.

Prognosis of left-sided infective endocarditis in patients transferred to a tertiary-care hospital--prospective analysis of referral bias and influence of inadequate antimicrobial treatment.

The aims of this study were to compare the characteristics of adult patients with left-sided infective endocarditis (LSIE) diagnosed and treated in a tertiary-care hospital with those of patients referred from a second-level community hospital, and to establish the accuracy of diagnosis and adequacy of treatment in referred patients and the influence of this factor on outcome. A prospective observational cohort study was conducted at Hospital Universitari Vall d'Hebron, a 1000-bed teaching hospital in Barcelona (Spain) and a referral centre for cardiac surgery. One hundred and fourteen of 337 (34%) episodes of LSIE treated in our hospital occurred in transferred patients. As compared with patients diagnosed in our hospital, transferred patients acquired LSIE within the healthcare system less often (16.7% vs. 38.1%, p <0.001), were in better health (Charlson index 3 (interquartile range (IQR)) 1-4) vs. 4 (IQR 2-6), p <0.001), had more complications (94.7% vs. 78.9%, p <0.001), underwent more operations (69.3% vs. 22.1%, p <0.001), and experienced similar mortality (22.8% vs. 31.4%, p 0.100). Only 52 of 114 (45.6%) referred patients received an antimicrobial regimen included in the American, European or Spanish guidelines at the hospital of origin. After adjustment for congestive heart failure and staphylococcal infection in multivariate logistic regression, inadequate or no antimicrobial treatment at origin was a risk factor for in-hospital mortality (OR 3.3, 95% CI 1.1-10.0, p 0.030). Errors in the initial antimicrobial treatment prescribed for LSIE are associated with greater mortality.

Therapeutic strategies after coronary stenting in chronically anticoagulated patients: the MUSICA study.

OBJECTIVES: To identify the therapeutic regimens used at discharge in patients receiving oral anticoagulant therapy (OAT) who undergo stenting percutaneous coronary intervention and stent implantation (PCI-S), and to assess the safety and efficacy associated with different therapeutic regimens according to thromboembolic risk. DESIGN: A prospective multicentre registry. SETTING: In hospital, after discharge and follow-up by telephone call. PATIENTS AND METHODS: 405 patients (328 male/77 female; mean (SD) age 71 (9) years) receiving OAT who underwent PCI-S between November 2003 and June 2006 from nine catheterisation laboratories of tertiary care teaching hospitals in Spain and one in the United Kingdom were included. RESULTS: Three therapeutic regimens were identified at discharge: triple therapy (TT) -- that is, any anticoagulant (AC) plus double antiplatelet therapy (DAT; 278 patients (68.6%); AC and a single antiplatelet (AC+AT; 46 (11.4%)) and DAT only (81 (20%)). At 6 months, patients receiving TT showed the greatest rate of bleeding events. No patients receiving DAT at low thromboembolic risk presented a bleeding event (14.8% receiving TT, 11.8% receiving AC+AT and 0% receiving DAT, p = 0.033) or cardiovascular event (6.7% receiving TT, 0% receiving AC+AT and 0% receiving DAT, p = 0.126). The combination of AC+AT showed the worst rate of adverse events in the whole cohort, especially in patients at moderate-high thromboembolic risk. CONCLUSIONS: In patients receiving OAT, TT was the most commonly used regimen after PCI-S. DAT was associated with the lowest rate of bleeding events and a similar efficacy to TT in patients at low thromboembolic risk. TT should probably be restricted to patients at moderate-high thromboembolic risk.

Coagulase-negative staphylococcal prosthetic valve endocarditis--a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study.

OBJECTIVE: To describe the contemporary features of coagulase-negative staphylococcal (CoNS) prosthetic valve endocarditis (PVE). DESIGN: Observational study of prospectively collected data from a multinational cohort of patients with infective endocarditis. Patients with CoNS PVE were compared to patients with Staphylococcus aureus and viridans streptococcal (VGS) PVE. SETTING: The International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) is a contemporary cohort of patients with infective endocarditis from 61 centres in 28 countries. PATIENTS: Adult patients in the ICE-PCS with definite PVE and no history of injecting drug use from June 2000 to August 2005 were included. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Heart failure, intracardiac abscess, death. RESULTS: CoNS caused 16% (n = 86) of 537 cases of definite non-injecting drug use-associated PVE. Nearly one-half (n = 33/69, 48%) of patients with CoNS PVE presented between 60 days and 365 days of valve implantation. The rate of intracardiac abscess was significantly higher in patients with CoNS PVE (38%) than in patients with either S aureus (23%, p = 0.03) or VGS (20%, p = 0.05) PVE. The rate of abscess was particularly high in early (50%) and intermediate (52%) CoNS PVE. In-hospital mortality was 24% for CoNS PVE, 36% for S aureus PVE (p = 0.09) and 9.1% for VGS PVE (p = 0.08). Meticillin resistance was present in 68% of CoNS strains. CONCLUSIONS: Nearly one-half of CoNS PVE cases occur between 60 days and 365 days of prosthetic valve implantation. CoNS PVE is associated with a high rate of meticillin resistance and significant valvular complications.

Enoxaparin as bridging anticoagulant treatment in cardiac surgery.

OBJECTIVE: To assess enoxaparin as bridging anticoagulant treatment in cardiac surgery. METHODS: Prospective registry of those patients who underwent cardiac surgery in our centre between December 2003 and June 2004 and required long-term anticoagulation. Subcutaneous enoxaparin was used as bridging anticoagulant treatment according to a pre-established protocol. The global thromboembolic risk was carefully assessed in all patients. All patients were followed up for 3 months. RESULTS: Of 140 patients who were included (mean (SD) age 66 (11); 49% female), 51 were already receiving long-term acenocumarol treatment before the index intervention. 50% of the patients were at high or very high risk for thromboembolic events in the postoperative period. The mean (SD) number of days between surgery and the first dose of anticoagulant was 2.01 (7) for acenocumarol and 1 (1.01) for enoxaparin. The mean (SD) daily dose of enoxaparin was 1.1 (0.27) mg/kg. Six thromboembolic events (4.3%; 95% CI 1.6 to 9.1) occurred, but only four of them were plausibly related to enoxaparin (2.9%; 95% CI 0.8 to 7.1). Six major haemorrhagic events (4.3%; 95% CI 1.6 to 9.1) occurred, but only three were plausibly related to enoxaparin (2.1%; 95% CI 0.4 to 6.1). CONCLUSIONS: These findings show a reasonable rate of adverse events using enoxaparin as bridging anticoagulant treatment in cardiac surgery. Randomised studies are necessary to evaluate the real efficacy and safety of enoxaparin as bridging anticoagulant treatment in cardiac surgery.

Candida infective endocarditis.

Candida infective endocarditis (IE) is uncommon but often fatal. Most epidemiologic data are derived from small case series or case reports. This study was conducted to explore the epidemiology, treatment patterns, and outcomes of patients with Candida IE. We compared 33 Candida IE cases to 2,716 patients with non-fungal IE in the International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS). Patients were enrolled and the data collected from June 2000 until August 2005. We noted that patients with Candida IE were more likely to have prosthetic valves (p < 0.001), short-term indwelling catheters (p < 0.0001), and have healthcare-associated infections (p < 0.001). The reasons for surgery differed between the two groups: myocardial abscess (46.7% vs. 22.2%, p = 0.026) and persistent positive blood cultures (33.3% vs. 9.9%, p = 0.003) were more common among those with Candida IE. Mortality at discharge was higher in patients with Candida IE (30.3%) when compared to non-fungal cases (17%, p = 0.046). Among Candida patients, mortality was similar in patients who received combination surgical and antifungal therapy versus antifungal therapy alone (33.3% vs. 27.8%, p = 0.26). New antifungal drugs, particularly echinocandins, were used frequently. These multi-center data suggest distinct epidemiologic features of Candida IE when compared to non-fungal cases. Indications for surgical intervention are different and mortality is increased. Newer antifungal treatment options are increasingly used. Large, multi-center studies are needed to help better define Candida IE.

Infective endocarditis in Europe: lessons from the Euro heart survey.

OBJECTIVES: To describe the characteristics, treatment, and outcomes of active infective endocarditis (IE) in Europe. DESIGN: Prospective survey of medical practices in Europe. SETTING: 92 centres from 25 countries. PATIENTS: The EHS (Euro heart survey) on valvar heart disease (VHD) enrolled 5001 adult patients between April and July 2001. Of those, 159 had active IE. RESULTS: 118 patients (74%) had native IE and 41 (26%) had prosthetic IE. Mean (SD) age was 57 (16) years. Blood cultures were obtained for 113 patients (71%) before antibiotic treatment was started. Surgery was performed in 52% of patients. Reasons for surgery were heart failure in 60%, persistent sepsis in 40%, vegetation size in 48%, or embolism in 18%. Surgery was for implantation of mechanical prosthesis in 63%, bioprosthesis in 21%, aortic homograft in 5%, and valve repair in 11%. In-hospital mortality was 12.6%, being 10.4% in the medical group and 15.6% in the surgical group. Among the total population of 5001 patients, only 50% of those with native VHD had been educated on endocarditis prophylaxis and only 33% regularly attended dental follow up. Of patients with IE who had had a procedure at risk during the preceding year only 50% had received adequate prophylaxis. CONCLUSIONS: The EHS on VHD shows that patients with active IE have a high risk profile and often undergo surgery. However, there are deficiencies in obtaining blood cultures and applying prophylaxis. Mortality remains high, which is a justification for the improvement of patient management through education and the implementation of guidelines.