The use and effect of surgical therapy for prosthetic valve infective endocarditis: A propensity analysis of a multicenter, international cohort

doi:10.1016/j.ahj.2005.01.023

American Heart Journal

Volume 150, Issue 5, November 2005, Pages 1086-1091

https://doi.org/10.1016/j.ahj.2005.01.023 Get rights and content

Background

Although surgical intervention is often used in the treatment of prosthetic valve infective endocarditis (PVIE), an understanding of its effect on survival has been limited by the biases of observational studies and lack of controlled trials.

Methods

The International Collaboration on Endocarditis Merged Database is a large, multicenter, international registry of patients with definite endocarditis by Duke criteria, including 367 patients with PVIE. Clinical, microbiologic, and echocardiographic variables were analyzed to determine those factors associated with the use of surgery for PVIE. Logistic regression analysis was performed to create a propensity model of predictors of surgery use. Patients who underwent surgery during initial hospitalization were matched by propensity score with patients treated with medical therapy alone. Logistic regression analysis was performed to determine variables independently associated with inhospital mortality in this matched subset.

Results

Surgical therapy for PVIE was performed in 148 (42%) of 367 patients. Inhospital mortality was similar for patients treated with surgery compared with those treated with medical therapy alone (25.0% vs 23.4%, P = .729). Surgical therapy was independently associated with patient age, microorganism, intracardiac abscess, and congestive heart failure. After adjustment for these determinants, inhospital mortality was predicted by brain embolization (OR 11.12, 95% CI 4.16-29.73) and Staphylococcus aureus infection (OR 3.67, 95% CI 1.29-9.74), with a trend toward benefit for surgery (OR 0.56, 95% CI 0.23-1.36).

Conclusions

Despite the frequent use of surgery for the treatment of PVIE, this condition continues to be associated with a high inhospital mortality rate in the contemporary era. After adjustment for factors related to surgical intervention, brain embolism and S aureus infection were independently associated with inhospital mortality and a trend toward a survival benefit of surgery was evident.

Section snippets

Study population

Approval of research protocols by local institutional review boards were obtained at applicable sites. The methods used to create the International Collaboration on Endocarditis Merged Database (ICE-MD) have been described previously.13, 14 In brief, ICE investigators from 7 sites in 5 countries contributed prospectively collected data in an electronic format. The database from each center was provided to the coordinating center (Duke Clinical Research Institute) for characterization and

Results

Of 2212 patients in the merged database, definite PVIE was present in 355 (16.0%) patients without a history of injection drug use. Among these 355 patients with PVIE, 148 (42%) patients underwent cardiac surgery at a median time of 12 days from hospital admission. Clinical characteristics of this cohort and subgroups based on use of surgery are shown in Table I.

Inhospital complications of PVIE are depicted in Table II. Prosthetic valve infective endocarditis was associated with complications

Discussion

The present study, involving a large, multicenter, international cohort of patients with PVIE, offers important insights regarding the treatment and outcome of this condition. Despite contemporary diagnostic methods, including the Duke criteria16, 20 and use of transesophageal echocardiography, and modern surgical techniques at experienced centers, the inhospital mortality rate of PVIE remains high. In the current investigation, almost half of the patients with PVIE underwent cardiac surgery,

References (30)

F.L. Grover et al.
Determinants of the occurrence of and survival from prosthetic valve endocarditis. Experience of the Veterans Affairs Cooperative Study on Valvular Heart Disease
J Thorac Cardiovasc Surg
(1994)
C.H. Cabell et al.
Progress toward a global understanding of infective endocarditis. Early lessons from the International Collaboration on Endocarditis Investigation
Infect Dis Clin North Am
(2002)
C.H. Cabell et al.
Progress toward a global understanding of infective endocarditis. Lessons from the International Collaboration on Endocarditis
Cardiol Clin
(2003)
D.T. Durack et al.
New criteria for diagnosis of infective endocarditis: Utilization of specific echocardiographic findings. Duke Endocarditis Service
Am J Med
(1994)
A. Mugge et al.
Echocardiography in infective endocarditis: Reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach
J Am Coll Cardiol
(1989)
A.W. Karchmer et al.
Late prosthetic valve endocarditis: Clinical features influencing therapy
Am J Med
(1978)
W. Vongpatanasin et al.
Prosthetic heart valves
N Engl J Med
(1996)
P. Ghosh et al.
Cardiac surgery and catheter based coronary interventions in Europe 2002
Cardiovascular Forum Online
(2004)
F.E. Kloster
Complications of artificial heart valves
JAMA
(1979)
E.H. Blackstone et al.
Death and other time-related events after valve replacement
Circulation
(1985)

A.A. Vlessis et al.

Risk, diagnosis and management of prosthetic valve endocarditis: A review

J Heart Valve Dis

(1997)

E.F. Akowuah et al.

Prosthetic valve endocarditis: Early and late outcome following medical or surgical treatment

Heart

(2003)

M.B. Edwards et al.

Thirty-day mortality and long-term survival following surgery for prosthetic endocarditis: A study from the UK heart valve registry

Eur J Cardiothorac Surg

(1998)

R. Schulz et al.

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990's

Eur Heart J

(1996)

P. Tornos et al.

Clinical outcome and long-term prognosis of late prosthetic valve endocarditis: A 20-year experience

Clin Infect Dis

(1997)

Cited by (130)

Association of Surgical Treatment With Survival in Patients With Prosthetic Valve Endocarditis
2020, Annals of Thoracic Surgery
Prosthetic valve endocarditis (PVE) is a serious condition with high morbidity and mortality. This study investigated the association of surgical treatment with survival among patients with PVE.
A retrospective cohort study was done of patients with PVE hospitalized over 8 years in a large referral center. Association of surgery with survival was evaluated with multivariable Cox proportional hazards regression, adjusting for propensity to be accepted for surgery, and analyzing surgery as a time-dependent covariate. Survival was also compared separately in a 1:1 propensity score-matched cohort of patients accepted for surgery and control patients consigned to nonsurgical treatment.
Of 523 patients (mean [SD] age, 61 [14] years; 370 [71%] men; 393 [75%] initially accepted for surgery), 404 ultimately underwent surgery and 119 received nonsurgical treatment alone. Surgical treatment was associated with significantly lower hazard of death in the entire cohort (hazard ratio [HR] = 0.32; 95% confidence interval [CI]: 0.22-0.48; P < .001) and in the 1:1 matched cohort (HR = 0.33; 95% CI: 0.19-0.57; P < .001). Initial acceptance for surgery was associated with significantly lower odds of in-hospital death (odds ratio [OR] = 0.26; 95% CI: 0.11-0.59; P < .001), death or readmission within 90 days (OR = 0.17; 95% CI: 0.07-0.43; P < .001), and death within 1 year (OR = 0.16; 95% CI: 0.08-0.34; P < .001).
Surgical treatment is associated with a large survival benefit in PVE. A decision to pursue nonsurgical treatment in PVE should entail close follow-up for any development of an indication for surgery.
Treatment of infectious endocarditis
2019, Presse Medicale
L’antibiothérapie de l’EI doit s’intégrer dans la prise en charge globale du patient par une équipe multidisciplinaire (« Endocarditis team »).
L’antibiothérapie initiale de l’EI doit être parentérale et suivre les recommandations internationales en vigueur.
Il est possible d’envisager un relais oral de l’antibiothérapie en cas d’évolution clinique favorable après deux semaines d’antibiothérapie intraveineuse.
Les aminosides ne doivent plus être utilisés dans le traitement de première intention des endocardites à Staphylococcus aureus sur valve native.
La chirurgie cardiaque est nécessaire chez environ la moitié des patients.
Antibiotic treatment of infective endocarditis is part of a multidisciplinary patient management that should be conducted within an “Endocarditis team”
Initial antibiotic treatment of infective endocarditis should be parenteral and comply with current international guidelines.
A switch to an oral antibiotic regimen may be considered after 2 weeks of successful parenteral antibiotic treatment.
Aminoglycosides should no longer be used for the initial treatment of native valve Staphylococcus aureus endocarditis.
Valve surgery is required in almost half of the patients.
Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic
2019, Journal of Thoracic and Cardiovascular Surgery
To study mid-term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft.
Patients undergoing aortic root homograft replacement from 2011-2017 were studied retrospectively. Aortic root replacement was performed using a modified Bentall technique. Primary outcomes included both short-term and mid-term survival. Secondary outcomes included immediate postoperative complications.
A total of 138 patients underwent cryopreserved homograft replacement of the aortic root for aortic root abscesses. Eighty-five patients (61.6%) underwent reoperative sternotomy, and 12 patients (8.7%) underwent second or third reoperative sternotomy. Sixty-seven (48.5%) patients had severe aortic insufficiency preoperatively. Operative mortality was 12.3% (17 patients). Five patients (3.6%) sustained a permanent stroke. Twenty-one patients (15.2%) required dialysis for renal failure, and 21 patients (15.2%) had complete heart block necessitating a permanent pacemaker. Estimated 5-year mortality for the cohort was 43%.
Cryopreserved homograft replacement is a safe and desirable option for high-risk patients with infective endocarditis and aortic root abscess. Homograft accommodation for a widely debrided aortic annular bed provides a reasonable surgical strategy for patients needing aortic root replacement with annular abscess.
Infectious endocarditis: An update for emergency clinicians
2018, American Journal of Emergency Medicine
Infectious endocarditis (IE) is a potentially deadly disease without therapy and can cause a wide number of findings and symptoms, often resembling a flu-like illness, which makes diagnosis difficult.
This narrative review evaluates the presentation, evaluation, and management of infective endocarditis in the emergency department, based on the most current literature.
IE is due to infection of the endocardial surface, most commonly cardiac valves. Major risk factors include prior endocarditis (the most common risk factor), structural heart damage, IV drug use (IVDU), poor immune function (vasculitis, HIV, diabetes, malignancy), nosocomial (surgical hardware placement, poor surgical technique, hematoma development), and poor oral hygiene, and a wide variety of organisms can cause IE. Patients typically present with flu-like illness. Though fever and murmur occur in the majority of cases, they may not be present at the time of initial presentation. Other findings such as Roth spots, Janeway lesions, Osler nodes, etc. are not common. An important component is consideration of risk factors. A patient with IVDU (past or current use) and fever should trigger consideration of IE. Other keys are multiple sites of infection, poor dentition, and abnormal culture results with atypical organisms. If endocarditis is likely based on history and examination, admission for further evaluation is recommended. Blood cultures and echocardiogram are key diagnostic tests.
Emergency physicians should consider IE in the patient with flu-like symptoms and risk factors. Appropriate evaluation and management can significantly reduce disease morbidity and mortality.
Position paper for the evaluation and management of oral status in patients with valvular disease: Groupe de Travail Valvulopathies de la Société Française de Cardiologie, Société Française de Chirurgie Orale, Société Française de Parodontologie et d'Implantologie Orale, Société Française d'Endodontie et Société de Pathologie Infectieuse de Langue Française
2017, Archives of Cardiovascular Diseases
Citation Excerpt :
Cardiac conditions at the highest risk of IE do not all carry the same risk of IE (Table 1). Patients with previous IE have a risk of annual recurrence estimated at 20 to 60 per 1000 [29,30], while the incidence of IE is markedly lower in patients with a heart valve prosthesis, estimated at 3 to 12 per 1000 patient-years [5,54]. Therefore, the working group proposes to contraindicate dental implants in patients with a previous episode of IE.
Oral health is of particular importance in patients with heart valve diseases because of the risk of infective endocarditis. Recommendations for antibiotic prophylaxis before dental procedures have been restricted, but the modalities of oral evaluation and dental care are not detailed in guidelines. Therefore, a multidisciplinary working group reviewed the literature to propose detailed approaches for the evaluation and management of buccodental status in patients with valvular disease. Simple questions asked by a non-dental specialist may draw attention to buccodental diseases. Besides clinical examination, recent imaging techniques are highly sensitive for the detection of inflammatory bone destruction directly related to oral or dental infection foci. The management of buccodental disease before cardiac valvular surgery should be adapted to the timing of the intervention. Simple therapeutic principles can be applied even before urgent intervention. Restorative dentistry and endodontic and periodontal therapy can be performed before elective valvular intervention and during the follow-up of patients at high risk of endocarditis. The detection and treatment of buccodental foci of infection should follow specific rules in patients who present with acute endocarditis. Implant placement is no longer contraindicated in patients at intermediate risk of endocarditis, and can also be performed in selected high-risk patients. The decision for implant placement should follow an analysis of general and local factors increasing the risk of implant failure. The surgical and prosthetic procedures should be performed in optimal safety conditions. It is therefore now possible to safely decrease the number of contraindicated dental procedures in patients at risk of endocarditis.
L’hygiène buccodentaire revêt une importance particulière chez les patients présentant une cardiopathie valvulaire en raison du risque d’endocardite infectieuse. Les indications d’antibioprophylaxie ont été restreintes mais les modalités de l’évaluation et des soins buccodentaires ne sont pas détaillées dans les recommandations. Ceci a conduit à un groupe de travail multidisciplinaire à analyser la littérature afin de proposer des approches détaillées pour l’évaluation et la prise en charge buccodentaire chez les patients ayant une cardiopathie valvulaire. Des questions simples posées par un non-spécialiste peuvent attirer l’attention sur de possibles lésions buccodentaires. En plus de l’examen clinique, des techniques d’imagerie récentes sont très sensibles pour la détection de destructions osseuses inflammatoires d’origine infectieuse orales ou dentaires. Avant une intervention valvulaire, la prise en charge de lésions buccodentaires doit être adaptée à la chronologie de l’intervention. Des traitements simples peuvent être appliqués même avant une intervention urgente. Des soins dentaires conservateurs et endodontiques peuvent être effectués avant une intervention valvulaire élective et durant le suivi de patients à haut risque d’endocardite. La détection et le traitement des foyers infectieux buccodentaires doit suivre des règles spécifiques chez les patients présentant une endocardite aiguë. La mise en place d’implants n’est plus contre-indiquée chez les patients à risque intermédiaire d’endocardite et peut être effectuée aussi chez certains patients à haut risque. La décision de mise en place d’un implant dentaire doit suivre une analyse des facteurs généraux et locaux augmentant le risque d’echec implantaire. Les procédures chirurgicales et prothétiques doivent être réalisées dans des conditions optimales de sécurité. Il est donc désormais possible de réduire le nombre de procédures dentaires contre-indiquées chez les patients à risque d’endocardite.
Paravalvular abcess in bacterial endocarditis: Influence in postoperative prognosis
2017, Cirugia Cardiovascular
El absceso paravalvular (AbP) aumenta la mortalidad, la complejidad y las complicaciones asociadas a la cirugía de endocarditis infecciosa (EI). Analizamos la influencia del AbP en las distintas formas de presentación de endocarditis bacteriana.
Estudio retrospectivo, observacional, incluyendo a todos los pacientes intervenidos de EI entre 2002 y 2015, y realizando seguimiento clínico tras el alta.
Se intervino a 169 pacientes, presentando AbP el 33% de los casos.
El AbP se asoció a un incremento de la mortalidad perioperatoria (el 30,9% frente al 23,4%) e implante de marcapasos definitivo (el 15,2% frente al 9,3%).
El absceso resultó significativamente más frecuente en endocarditis aórtica (50,0%) que en mitral (20,3%), así como en endocarditis protésica (44,4%) que nativa (26,2%).
La existencia de AbP incrementó significativamente la mortalidad en la EI aórtica (el 21,4% frente al 3,6%; p = 0,043), pero no la modificó en EI mitral (el 25,5% frente al 25%; p = 0,970). Además, se asoció a mayor mortalidad en endocarditis nativa (el 29,6% frente al 19,7%), sin modificarla en el caso de EI protésica (el 32,1% frente al 31,4%).
Tras el alta hospitalaria (seguimiento mediano 51 meses), la supervivencia global (el 70,6% con AbP frente al 75,7% sin AbP) y la reinfección (el 13,3% frente al 10,2%) fueron similares entre los pacientes con y sin AbP.
La presencia de AbP ensombrece el pronóstico de la EI, especialmente en casos de afectación aórtica y sobre válvula nativa. En el caso de indicación quirúrgica, la intervención precoz podría ser beneficiosa para intentar evitar la formación de abscesos. Tras el alta hospitalaria, los pacientes tienen un pronóstico similar a largo plazo.
Paravalvular abscess (PAb) increases mortality, complexity and complications associated with infectious endocarditis (IE) surgery. We analysed the impact of PAb in different clinical presentations of IE.
Retrospective, observational study that included all patients undergoing heart surgery because of EI between 2002 and 2015 in one center. Clinical follow-up was performed after discharge.
169 patients were operated, and there was a PAb present in the 33% of them. Abscess was associated with increased perioperative mortality (30.9% vs. 23.4%)) and permanent pacemaker implantation (15.2% vs. 9.3%).
PAb was significantly more frequent in aortic (50.0%) than in mitral (20.3%) surgery, as well as in native (44.4%) versus prosthetic (26.2%) IE.
The presence of abscess significantly increased surgical mortality in aortic IE (21,4% vs. 3.6%; P=.043), with no significant differences in mitral IE (25,5% vs. 25%; P=.97). It was also associated with higher but no significantly increased mortality in native endocarditis (29.6% vs. 19.7%), with similar results in prosthetic IE (32,1% vs. 31,4%).
After a median follow-up of 51 months after discharge, survival (70.6% with PAb vs. 75.7% without PAb) and re-infection (13.3% vs. 10,2%) were similar among patients with and without PAb.
The presence of PAb was associated with poor prognosis in IE, especially in aortic and native valve involvement. When indicated, early surgery could be beneficial in these patients to prevent abscess formation. After discharge patients had a similar long-term prognosis.

View all citing articles on Scopus

: Guest editor of this manuscript is Lawrence H. Cohn, MD.

: This study was supported in part by the following: American Heart Association GIA 0455802U (AW) and BGIA 0265405U (CHC); National Institutes of Health K23 AI-01647 (VGF) and K23 HL70861-01 (CHC); Tenet Healthcare Foundation (Santa Barbara, Calif) (EA); Red Española de Investigación en Patología Infecciosa (V-2003-REDC14A-O) (JMM); Fundación Privada Máximo Soriano Jiménez (Barcelona, Spain) (JMM); and Institut d'Investigacions Biomèdiques August Pii Sunyer (Barcelona, Spain) (JMM).

: Guest editor of this manuscript is Lawrence H. Con, MD. This study was supported in part of the following: American Heart Association GIA 0455802U (AW) and BGIA 0265405U (CHC), National Institutes of Health K23 AI-01647 (VGF) and K23 HL70861-01 (CHC), Tenet Healthcare Foundation (Santa Barbara, CA) (EA), Red Española de Investigación en Patología Infecciosa (V-2003-REDC14A-O) (JMM), Fundación Privada Máximo Soriano Jiménez (Barcelona, Spain) (JMM), and Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS, Barcelona Spain) (JMM).

^g: The International Collaboration on Endocarditis Merged Database (ICE-MD) Study Group (see Appendix).

View full text

Clinical InvestigationValvular and Congenital Heart DiseaseThe use and effect of surgical therapy for prosthetic valve infective endocarditis: A propensity analysis of a multicenter, international cohort

Background

Methods

Results

Conclusions

Section snippets

Study population

Results

Discussion

J Thorac Cardiovasc Surg

Infect Dis Clin North Am

Cardiol Clin

Am J Med

J Am Coll Cardiol

Am J Med

Prosthetic heart valves

N Engl J Med

Cardiac surgery and catheter based coronary interventions in Europe 2002

Cardiovascular Forum Online

Complications of artificial heart valves

JAMA

Death and other time-related events after valve replacement

Circulation

Risk, diagnosis and management of prosthetic valve endocarditis: A review

J Heart Valve Dis

Prosthetic valve endocarditis: Early and late outcome following medical or surgical treatment

Heart

Thirty-day mortality and long-term survival following surgery for prosthetic endocarditis: A study from the UK heart valve registry

Eur J Cardiothorac Surg

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990's

Eur Heart J

Clinical outcome and long-term prognosis of late prosthetic valve endocarditis: A 20-year experience

Clin Infect Dis

Clinical Investigation
Valvular and Congenital Heart Disease
The use and effect of surgical therapy for prosthetic valve infective endocarditis: A propensity analysis of a multicenter, international cohort