The changing pattern of infective endocarditis in childhood

Unusual large mass on aortic valve in an infant

Mass on the aortic valve is extremely rare in children, and the differential diagnosis includes vegetation, thrombus, and primary cardiac tumors. A rise in infective endocarditis in infants is seen due to increasing survival of children with congenital heart diseases and sick newborn infants with prolonged hospitalization. We report a 4-month-old infant born prematurely with early-onset sepsis requiring prolonged antibiotic treatment and valvular aortic stenosis presenting with sudden hemodynamic compromise due to aortic vegetation extending into the ascending aorta eroding through its posterior wall. The report details management of our case and a brief description of available alternative treatment strategies.

Infective endocarditis by HACEK: a review

Infective endocarditis (IE) is a severe disease that is still associated with high mortality despite recent advances in diagnosis and treatment. HACEK organisms (Haemophilus spp., Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) are gram-negative bacteria that are part of the normal flora of the mouth and upper respiratory tract in humans. These organisms cause a wide range of infections, of which IE is one of the most notable. In order to control and prevent endocarditis caused by HACEK, measures such as oral hygiene and the use of prophylactic drugs should be used for people at risk, including people with underlying heart disease and people with artificial valves. This review is a summary of the main aspects of IE focusing on HACEK organisms.

Infective Endocarditis in Childhood: a Single-Center Experience of 18 Years

Introduction

We aimed to present the risk factors, clinical and laboratory findings, treatment management, and risk factors for morbidity and mortality of infective endocarditis (IE) as well as to relate experiences at our center.

Method

We retrospectively analyzed data of 47 episodes in 45 patients diagnosed with definite/possible IE according to the modified Duke criteria between May 2000 and March 2018.

Results

The mean age of all patients at the time of diagnosis was 7.6±4.7 years (range: 2.4 months to 16 years). The most common symptoms and findings were fever (89.3%), leukocytosis (80.8%), splenomegaly (70.2%), and a new heart murmur or changing of pre-existing murmur (68%). Streptococcus viridans (19.1%), Staphylococcus aureus (14.8%), and coagulase-negative Staphylococci (10.6%) were the most commonly isolated agents. IE-related complications developed in 27.6% of the patients and the mortality rate was 14.8%.

Conclusion

We found that congenital heart disease remains a significant risk factor for IE. The highest risk groups included operated patients who had conduits in the pulmonary position and unoperated patients with a large ventricular septal defect. Surgical intervention was required in most of the patients. Mortality rate was high, especially in patients infected with S. aureus, although the time between the onset of the first symptom and diagnosis was short. Patients with fever and a high risk of IE should be carefully examined for IE, and evaluation in favor of IE until proven otherwise will be more accurate. In high-risk patients with prolonged fever, IE should be considered in the differential diagnosis.

Pediatric Infective Endocarditis and Stroke: A 13-Year Single-Center Review

OBJECTIVE

We explored the relationship between pediatric infective endocarditis and stroke.

PATIENTS AND METHODS

All children encountered with infective endocarditis from January 2002 to December 2015 were included as our sample, and their medical records were comprehensively reviewed.

RESULTS

Sixty children with infective endocarditis were identified, including 30 boys and 30 girls aged eight months to 18 years (mean ± SD: 10.3 ± 5.6), and om 43 (71.6%) of these individuals had congenital heart disease. Left-sided endocarditis occurred in 25 patients (41.7%), and vegetations were found in 58 individuals (96.6%). The most often encountered microorganisms were Streptococcus viridans and Staphylococcus aureus, which were identified in five and four patients, respectively. Postendocarditis stroke occurred in nine patients, including five with cerebral infarction, two with intracerebral hemorrhage, and one with subarachnoid hemorrhage. The remaining child experienced cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage simultaneously. The incidence of stroke in children with left-sided endocarditis was significantly higher than that of which in those who had right-sided endocarditis (32% versus 2.8%, P < 0.01). The most common manifestation of stroke was hemiparesis (55.5%). Two girls died of stroke, and the mortality rate in the patients who had stroke was significantly higher than that in those without stroke (22.2 % versus 3.9 %, P < 0.05).

CONCLUSIONS

Our data indicate that stroke is common among children with infective endocarditis, especially in those with left-sided endocarditis, and major stroke may increase their risk of death. Congenital heart disease is the main underlying disease in children with infective endocarditis in China.

Incidence, predictors and outcomes of infective endocarditis in a contemporary adult congenital heart disease population

BACKGROUND

The prevalence of congenital heart disease (CHD) in the adult population is steadily increasing. A substrate of prosthetic material and residual lesions, constantly evolving as surgical techniques change over time, predispose these patients to the potentially devastating complication of infective endocarditis (IE).

METHODS

We retrospectively reviewed 2935 patients in our adult CHD database for all cases of endocarditis between 1991 and 2016. Incidence, clinical course and predictors of outcomes were analysed.

RESULTS

We document 74 episodes in 62 patients, with an incidence of 0.9 cases/1000 patient years (py). IE was more common in complex CHD (1.4 cases/1000py) and ventricular septal defects (VSDs) (1.9 cases/1000py). Prosthetic material was involved in 47% and left-sided infection predominated (66%). The incidence in bicuspid aortic valves post aortic valve replacement (AVR) was significantly higher than in unoperated valves, being 1.8 and 1.1 cases/1000 patient years respectively. Streptococcus was the most frequently implicated causative organism (37%). Emboli occurred in 34% of cases with a cerebral predilection. 46% of patients required surgery during the admission for IE, most frequently to replace a severely regurgitant bicuspid aortic valve. Early endocarditis-related mortality was 15%, associated with cerebral emboli and acute renal failure.

CONCLUSIONS

In a contemporary adult CHD cohort, those with complex underlying lesions, VSDs or an AVR were at higher risk for IE. Mortality remains substantial and is more likely in patients with cerebral emboli and/or acute renal failure.

Subarachnoid haemorrhage from undiagnosed mycotic aortic aneurysm in a child

We report a case of subarachnoid haemorrhage resulting from a mycotic aortic aneurysm in a child with CHD. The patient previously underwent operations for CHD and had a subarachnoid haemorrhage of unknown cause before the scheduled re-operation. During the re-operation, a sealed rupture of an undiagnosed mycotic ascending aortic aneurysm was identified, and the causative organism was later identified as Streptococcus. A postoperative MRI indicated a partially thrombosed cerebral aneurysm. This case demonstrates that a mycotic aortic aneurysm can be a cause of intracranial haemorrhage in children.

Trends, microbiology, and outcomes of infective endocarditis in children during 2000-2010 in the United States

BACKGROUND

We studied the incidence, trend, underlying conditions, microbiology, and outcomes of infective endocarditis (IE) in children during 11 years using Nationwide Inpatient Sample (NIS) database. This is the largest all-payer inpatient care database in the United States containing data for more than 8 million hospital stays from over 1000 hospitals.

METHODS

NIS data from 2000 to 2010 of primary discharge diagnosis of IE in children aged ≤19 years old were studied. Children with underlying congenital heart defects and acquired heart conditions were identified. Microbiological causative agents were recorded. Linear regression was used to assess trend of incidence over time.

RESULTS

An estimated 3,840 (95% CI: 3,395-4,285) children had a discharge diagnosis of IE. The overall incidence was 0.43 per 100 000 children. The incidence was stable over the study period (P = .4 for trend). The majority of patients 56.2% were ≥11 years old and 15.4% were ≤ 1 year. Underlying cardiac conditions were present in 53.5% of patients. Overall 30.2% of cases were culture-negative. Among those with identified pathogens, Staphylococcus species were most common (43.1%) followed by Streptococcus species (39.5%). Viridans Streptococcus group was most common in those with underlying heart disease (32.7%) and S. aureus was most common in those without heart disease (46.9%). Among culture-positive patients, there was a decline in proportion of Staphylococcal IE (P = .03) and an increase in proportion of Streptococcal IE (P = .04). Overall mortality was 2.8%. Patients with Staphylococcal IE had longer median length of stay (12 vs. 9 days; P < .01) and the highest mortality (4.7%).

CONCLUSION

The incidence of IE in children has remained unchanged in the United States during the 11-year study period. Among culture-positive patients there was a significant decrease in Staphylococcal IE and a significant increase of Streptococcal IE. Staphylococcal IE was associated with increased LOS and highest mortality.

Infective Endocarditis in Children With Congenital Heart Disease

Background—

The American Heart Association guidelines for prevention of infective endocarditis (IE) in 2007 reduced the groups of congenital heart disease (CHD) patients for whom antibiotic prophylaxis was indicated. The evidence base in CHD patients is limited. We sought to determine the risk of IE in children with CHD.

Methods and Results—

We performed a population-based analysis to determine the cumulative incidence and predictors of IE in children (0–18 years) with CHD by the use of the Quebec CHD Database from 1988 to 2010. In 47 518 children with CHD followed for 458 109 patient-years, 185 cases of IE were observed. Cumulative incidence of IE was estimated in the subset of 34 279 children with CHD followed since birth, in whom the risk of IE up to 18 years of age was 6.1/1000 children (95% confidence interval, 5.0–7.5). In a nested case-control analysis, the following CHD lesions were at highest risk of IE in comparison with atrial septal defects (adjusted rate ratio, 95% confidence interval): cyanotic CHD (6.44, 3.95–10.50), endocardial cushion defects (5.47, 2.89–10.36), and left-sided lesions (1.88, 1.01–3.49). Cardiac surgery within 6 months (5.34, 2.49–11.43) and an age of <3 years (3.53, 2.51–4.96; reference, ages 6–18) also conferred an elevated risk of IE.

Conclusions—

In a large population-based cohort of children with CHD, we documented the cumulative incidence of IE and associated factors. These findings help identify groups of patients who are at the highest risk of developing IE.

Infective endocarditis in the pediatric patient: a 60-year single-institution review

OBJECTIVE

To determine the epidemiology of infective endocarditis (IE) presenting in pediatric patients during a 60-year period at our institution.

PATIENTS AND METHODS

In this retrospective medical record review, we extracted demographic characteristics, diagnostic variables, and outcomes for patients less than 20 years of age diagnosed with IE from January 1, 1980, to June 30, 2011. We compared this cohort with a previously reported cohort of pediatric patients with IE from our institution diagnosed from 1950 to 1979.

RESULTS

We identified 47 patients (24 males; mean ± SD age at diagnosis, 12.3±5.5 years [range, 1 day to 18.9 years]) who had 53 episodes of IE. The most common isolated organisms were viridans streptococci (17 of 53 episodes [32%]) and Staphylococcus aureus (12 of 53 episodes [23%]). Of the 47 patients, 36 (77%) had congenital heart disease, 24 of whom had cardiac surgery before their first episode of IE (mean ± SD time to IE diagnosis after surgery, 4.2±3.2 years [range, 64 days to 11.3 years]). Fourteen patients (30%) required valve replacement because of valvular IE, and 16 (34%) had complications, including mycotic aneurysm, myocardial abscess, or emboli. Vegetations were identified using echocardiography in 37 of the 53 unique episodes of IE (70%). Endocarditis-related mortality occurred in 1 patient. Compared with the historical (1950-1979) cohort, there were no differences in patient demographic characteristics, history of congenital heart disease, or infecting organisms. One-year mortality was significantly lower in the modern cohort (4%) compared with the historical cohort (38%) (P<.001).

CONCLUSION

Most pediatric episodes of IE occur in patients with congenital heart disease. Mortality due to endocarditis has decreased in the modern era.

Surgical treatment of infective valve endocarditis in children with congenital heart disease

OBJECTIVE

This study assesses surgical procedures, operative outcome, and early and intermediate-term results of infective valve endocarditis in children with congenital heart disease.

METHODS

Seven consecutive children (five females, two males; mean age, 10.8 years) who underwent surgery for infective valve endocarditis between 2006 and 2010 were included in the study. The aortic and mitral valves were affected in two and tricuspid in five patients. Indications for operation included cardiac failure due to atrioventricular septal rupture, severe tricuspid valve insufficiency, and septic embolization in one, moderate valvular dysfunction with vegetations in three (two tricuspid, one mitral), and severe valvular dysfunction with vegetations in the other three patients (two tricuspid, one mitral). The pathological microorganism was identified in five patients. Tricuspid valve repair was performed with ventricular septal defect (VSD) closure in five patients. Two patients required mitral valve repair including one with additional aortic valve replacement.

RESULTS

There were no operative deaths. Actuarial freedom from recurrent infection at one and three years was 100%. Early echocardiographic follow-up showed four patients to have mild atrioventricular valve regurgitation (three tricuspid and one mitral) and three had no valvular regurgitation. No leakage from the VSD closure or any valvular stenosis was detected postoperatively.

CONCLUSIONS

Mitral and tricuspid valve repairs can be performed with low morbidity/mortality rates and satisfactory intermediate-term results in children with infective valve endocarditis.

Infective endocarditis in congenital heart disease

Congenital heart disease (CHD) has become the leading risk factor for pediatric infective endocarditis (IE) in developed countries after the decline of rheumatic heart disease. Advances in catheter- and surgery-based cardiac interventions have rendered almost all types of CHD amenable to complete correction or at least palliation. Patient survival has increased, and a new patient population, referred to as adult CHD (ACHD) patients, has emerged. Implanted prosthetic material paves the way for cardiovascular device-related infections, but studies on the management of CHD-associated IE in the era of cardiovascular devices are scarce. The types of heart malformation (unrepaired, repaired, palliated) substantially differ in their lifetime risks for IE. Streptococci and staphylococci are the predominant pathogens. Right-sided IE is more frequently seen in patients with CHD. Relevant comorbidity caused by cardiac and extracardiac episode-related complications is high. Transesophageal echocardiography is recommended for more precise visualization of vegetations, especially in complex type of CHD in ACHD patients. Antimicrobial therapy and surgical management of IE remain challenging, but outcome of CHD-associated IE from the neonate to the adult is better than in other forms of IE.

CONCLUSION

Primary prevention of IE is vital and includes good dental health and skin hygiene; antibiotic prophylaxis is indicated only in high-risk patients undergoing oral mucosal procedures.

Pediatric infective endocarditis: Has Staphylococcus aureus overtaken viridans group streptococci as the predominant etiological agent?

BACKGROUND

Viridans group streptococci (VGS) have traditionally been the most common etiological agents of infective endocarditis (IE). Advances in cardiovascular surgery and the increasing use of long-term central venous catheters may have altered the epidemiology of pediatric IE.

METHODS

A chart review of children younger than 17 years of age with IE was completed at the Stollery Children's Hospital (Edmonton, Alberta) between 1985 and 2004. The literature was reviewed to look for changes over time in the most common etiological agents of pediatric IE.

RESULTS

There were 31 cases of definite IE and nine cases of possible IE at the Stollery Children's Hospital, 19 of which were nosocomial. Thirty cases (75%) had congenital heart disease. The etiological agents were Staphylocccus aureus (n=16), VGS (n=5), coagulase-negative staphylococci (n=3), enterococcus (n=3), other streptococci (n=8), Enterobacter cloacae (n=1) and Stenotrophomonas maltophilia (n=1), while three cases were culture negative. Two deaths were due to S aureus IE. Review of the literature identified an increasing number of case series in which S aureus was the predominant etiological agent, but VGS still predominated in some recent series.

CONCLUSION

Congenital heart disease remains the primary risk factor for pediatric IE. Prospective population-based studies are required to determine whether S aureus has become the predominant pathogen.

Infective endocarditis complicated by fatal cerebral hemorrhage revealing an unrepaired univentricular heart in a 19-year-old woman

Univentricular heart is a complex and rare cyanotic congenital heart disease. When not operated, affected patients exceptionally reach adulthood. We report the unprecedented case of a 19 year-old young woman, admitted to the hospital for a severe deterioration of general status and ultimately diagnosed to have an infective endocarditis with multiple vegetations in a previously undiagnosed univentricular heart of left ventricular morphology, subsequently rapidly complicated by fatal cerebral hemorrhage.

The changing epidemiology of pediatric endocarditis at a children's hospital over seven decades

This study sought to determine whether improvements in the care of children with congenital heart disease (CHD) have changed the epidemiology of infective endocarditis (IE). A retrospective study of patients 18 years of age and younger treated for IE from 1992 to 2004 (era 3) was conducted at the authors' children's hospital in New York City. This study was compared with two previous studies conducted at the same hospital from 1930 to 1959 (era 1) and from 1977 to 1992 (era 2). During the three eras, IE was diagnosed for 205 children with a median age of 8 years during eras 1 and 2, which decreased to 1.5 years during era 3, partly because of IE after cardiac surgery for young infants. In era 3, nonstreptococcal and nonstaphylococcal pathogens associated with hospital-acquired IE increased. Complications from IE declined during era 3, but after the widespread availability of antibiotics in 1944, crude mortality rates were similar in eras 1 (32%), 2 (21%), and 3 (24%). However, in era 3, mortality occurred only among subjects with hospital-acquired IE. The epidemiology of pediatric IE has changed in the modern era. Currently, IE is most likely to occur among young children with complex congenital heart disease. Pediatric IE remains associated with high crude mortality rates when it is acquired in the hospital.

Pancarditis in a five-year-old boy affecting tricuspid valve and ventricular septum

A five-year-old boy with a structurally normal heart and recent history of adenotomy and gastroenteritis presented with Staphylococcus aureus pancarditis including endocarditis of the tricuspid valve and abscess of the ventricular septum. Surgical treatment consisted of debridement of the valvar vegetations and of the septal abscess. A seven-day continuous mediastinal irrigation with iodine solution was conducted to eliminate local infection sites as well as to prevent from constrictive pericarditis. The patient recovered uneventfully and is in excellent clinical condition with no residues one year after surgery.

Interventions using foreign material to treat congenital heart disease in children increase the risk for infective endocarditis

BACKGROUND

Congenital heart disease (CHD) is a risk factor for infective endocarditis (IE). We aimed to assess the impact of cardiac interventions on the frequency and microbial profile of IE in children with CHD.

METHODS

Episodes of IE were analyzed in children aged < or =18 years with CHD between 1995 and 2005 with respect to cardiac surgery or catheter interventions with or without implantation of foreign material.

RESULTS

Diagnosis of IE was made in 14 (0.36%) of 3826 children with CHD including native IE in 6 and postinterventional IE in 8 patients. During the period 3029 cardiac interventions (1944 surgeries; 1085 catheters) were performed; foreign material was implanted in 1360 interventions (1139 surgeries; 221 catheters) including all 8 patients with postinterventional IE. Cardiac intervention by itself did not change the risk for IE compared with no intervention. The risk of IE after implantation of foreign material was higher than following intervention without implantation (odds ratio, 21.0; 95% confidence interval, 1.2-365; P < 0.05). Pacemaker implantation was associated with the highest risk for IE (odds ratio, 11.0; 95% confidence interval, 2.6-46.5; P < 0.001). Staphylococci were the most frequently isolated organisms in foreign material-associated IE.

CONCLUSIONS

Cardiac intervention in children with CHD does not increase the risk for IE. Postinterventional IE in children with CHD is strongly linked to implantation of foreign material, especially of pacemaker.

Current patterns of infective endocarditis in congenital heart disease

OBJECTIVE

To assess the changing profile of infective endocarditis in patients with congenital heart disease.

METHODS

All cases diagnosed from 1966 to 2001 (revised Duke criteria) were retrospectively reviewed and categorised in periods I (< 1990) and II (>or= 1990).

RESULTS

153 episodes occurred, 81 in period I and 72 in period II. Mean age of affected patients was higher in period II. Non-operated ventricular septal defect, Rastelli correction and palliated cyanotic heart disease increased. Infective endocarditis in corrective surgery changed to patients with prosthetic material. Post-surgical cases decreased. Dental problems were the leading cause (period I 20% v II 33% of cases) with a large variety of pathological organisms (multiple species of Streptococcus). Cutaneous causative infections increased (5% to 17%) with different species of Staphylococcus. Negative blood cultures lessened (20% to 7%, p = 0.03). Streptococci were the most common causative organisms in both periods. Severe heart failure and cardiac complications lessened (20% to 4% and 31% to 18% during periods I and II, respectively). Early surgery was more frequent in period II (32% v 18.5%, p = 0.02). One- and 10-year survival was 91% v 97% in period I and 89% v 97% in period II, respectively (NS).

CONCLUSION

Current targets include complex cyanotic disease, congenital heart disease corrected with prosthetic material and small ventricular septal defect. Postoperative cases lessened; dental and cutaneous causes increased. Survival was unchanged. Prophylactic measures targeted at dental and cutaneous sources should be emphasised.

Results of surgical treatment for infective endocarditis in children

OBJECTIVE

Infective endocarditis is uncommon condition, with a high degree of morbidity and mortality. It is less common in children, albeit tending to be associated with congenital cardiac malformations. We describe our experience of the need for surgical treatment in children with infective endocarditis.

PATIENTS AND METHODS

We analyzed retrospectively the records of 9 children aged below 16 years seen between May 2003 and March 2005 with infective endocarditis, reviewing the demographic details, clinical presentation, microbiological and echocardiographic data, operative findings, and outcome.

RESULTS

Apart from pre-existing renal insufficiency in 1 patient, congenital cardiac malformations were the predisposing factors. Blood cultures were positive in 3, but remained negative in the other 6 patients. The indications for surgical treatment included uncontrolled sepsis, congestive heart failure, recurrent endocarditis, patch or graft dehiscence, and pseudoaneursymal formation. Death due to uncontrolled sepsis resulting in multiorgan failure occurred in 1 patient, who had tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries. Another patient died late postoperatively due to cardiac failure after relapse of the endocarditis in the setting of negative blood cultures.

CONCLUSION

Despite advances in antimicrobial therapy, diagnosis, and measures of treatment for infective endocarditis, complications continue to be responsible for substantial morbidity and mortality. Since blood cultures are frequently negative, clinical and echocardiographic findings should be the major determinants of strategies used for treatment. We believe that our small series of patients seen over the past two years in which surgical treatment was performed will be helpful in guiding the clinical perspectives for children with infective endocarditis.

A 28-year trend of infective endocarditis associated with congenital heart diseases: a single institute experience

BACKGROUND

Infective endocarditis (IE) is still one of the major complications of congenital heart disease and, therefore, prevention has always been an important issue. But there has been no large scale investigation of IE in Japan.

METHODS

Clinical and microbiological features in 183 patients with congenital heart diseases complicated with infective endocarditis (IE), which were treated in our institute in the last 28 years, were reviewed.

RESULT

During the period, the age distribution of the patients shifted to an older age; 80% were older than 15 years in the latest 7 year period. In the underlying diseases more complex conditions increased, such as the post Rastelli operation. Dental or oral diseases were the major preceding events and Streptococcus was the major pathogen throughout the study periods in the data.

CONCLUSION

The result indicates the importance of continuing education for the prevention of IE and oral hygiene especially in adult patients with a risk for IE.

Infective endocarditis in congenital heart disease: Japanese national collaboration study

OBJECTIVE

To provide pure cohorts of paediatric and adult patients with congenital heart disease (CHD) and infective endocarditis (IE) for making future guidelines.

DESIGN

Japanese nationwide survey.

SETTING

66 Japanese institutions.

PATIENTS

170 children, mean (SD) age 7.4 (5.7) years (range 14 days to 17 years), and 69 adults, age 32.5 (14.1) years (range 18-69) who developed IE between 1997 and 2001 (one in 240 admissions with CHD).

MAIN OUTCOME MEASURES

Clinical presentation of IE.

RESULTS

119 patients including 88 with cyanotic CHD had previous cardiac surgery. Procedures preceding IE were dental (12%) followed by cardiovascular surgery (8%). Sites of infection were left sided in 46% and right sided in 51%. Vegetation with diameter of 11 mm was documented in 151 (63%). Frequent complications were embolic events (stroke 11%, other emboli 20%) and cardiac failure (23%). The most common microorganisms were streptococci (50%) and staphylococci (37%) with methicillin resistant Staphylococcus aureus in 7.5%. Empirical treatments were penicillins (alone or with other antibiotics 57%) followed by cephems (22%) and vancomycin (11%). Surgery during active IE was common (26%), with vegetation (45%) and heart failure (29%) as the most frequent indications. Mortality was 8.8%: 8.0% among patients who received medical treatment alone and 11.1% among those with active IE who underwent surgery. The causes of death (n = 21) were surgery (7), infection (7), cardiac failure (6), and renal failure (1).

CONCLUSIONS

Because of a recent increase in the incidence of IE and high mortality and complication rate, it is mandatory to establish well formulated recommendations for management of IE in paediatric and adult patients with CHD based on a large cohort. Results of this nationwide multicentre database should be helpful in establishing guidelines.

Clinical course and complications of infective endocarditis in patients growing up with congenital heart disease

BACKGROUND

Although a high number of patients with congenital heart disease (CHD) undergo surgical palliation or definite correction up to adolescence, adult congenital heart disease (ACHD) may remain a potential lifelong risk factor for infective endocarditis (IE) in patients growing up with congenital heart disease (GUCH).

METHODS

In a retrospective case study of a tertiary care center long-term clinical course and complications of patients with IE and GUCH were analysed.

RESULTS

Data of 52 patients with CHD, who fulfilled the Saiman criteria for infective endocarditis and were treated between April 1986 and March 2001, were identified: Risk factors for infective endocarditis were previous cardiovascular operation (51.9%), use of foreign material (38.5%), dental or other surgical procedures without recommended antibiotic prophylaxis (25.0%), or cardiac catheterization (5.8%). Staphylococcal (38.9%) or streptococcal species (35.2%) were cultivated in most cases as causative microorganisms. Complications were: recurrence of IE (7.7%), septic embolisms (30.8%) leading to central nervous complications (7.7%), embolism of pulmonary arteries (7.7%), renal arteries (1.9%), arteries of the extremities (9.6%), or infarction of spleen (1.9%). Other cardiac (23.1%) or extracardiac (13.5%) complications were frequent. The need of re-operations during or after IE was high (67.3%). The hospital mortality was 1.9%, late mortality was 7.7%.

CONCLUSIONS

Patients with IE and CHD show a broad clinical spectrum of cardiac and extracardiac complications. They may lead to a complicative short- and long-term course with the potential risk of death and a high number of re-operation. Efforts have to be made to improve long-term outcome of patients with ACHD by an interdisciplinary cooperation.

Characteristics of infective endocarditis in a developing country-clinical profile and outcome in 192 Indian patients, 1992–2001

Total 198 episodes of Duke "definite" infective endocarditis (IE) in 192 patients observed over last 10 years were studied [141 males and 51 females, mean age 27.6+/-12.7 years (range 4-68 years)]. Majorities of patients (76.5%) were below 40 years of age. Rheumatic heart disease (RHD) was the commonest underlying heart disease (present in 46.9% patients). Probable source of infection could be identified in only 16.6% episodes. None of our patient was intravenous drug abuser. Fever (90.0%), anemia (81.0%), clubbing (58.1%), splenomegaly (60.6%), changing/new murmur (22.7%) were the common clinical findings. Vegetations were present in 89.9% episodes. Blood cultures were positive in 134 (67.7%) episodes (streptococci in 23.2%, staphylococci in 19.7%, gram negative in 13.6%, enterococci in 8.1%, polymicrobial and fungal in 1.5% episodes each). Complications were cardiovascular [congestive heart failure (CHF) in 41.9%, atrioventricular block in 1.5%, cardiac temponade and acute myocardial infarction in 0.5% each), neurological in 16.6%, renal in 13.1% and embolisms in total 21.7% episodes. Total 182 (91.9%) episodes in 176 patients were managed completely [(medical in 140 (76.9%) and surgical in 42 (23.1%) episodes] while patients in remaining 16 (8.1%) episodes left against medical advises before completion of therapy. Total 21% patients (37 out of 176 completely treated patients) died during therapy (cause of deaths; CHF in 11, septicemia in 10, cerebral embolism in 7, post cardiac surgery in 5, ruptured cerebral mycotic aneurysm in 2, ventricular tachycardia in 2 patients). On stepwise logistic regression analysis; cardiac abscess and CHF were independent predictors of cardiac surgery. Similarly, CHF, renal failure and prosthetic valve dysfunction were independent predictors of mortality. To conclude, spectrum of IE in our country is different from the west, but quite similar as reported from developed countries about 40 years ago. IE in our country occurs in relatively younger population with RHD as the commonest underlying heart disease. Streptococci are still the commonest responsible microorganisms. Morbidity and mortality are still high. Early cardiac surgery, whenever indicated, helps in improving outcome of these patients.

Causative Organism Influences Clinical Profile and Outcome of Infective Endocarditis in Pediatric Patients and Adults With Congenital Heart Disease

BACKGROUND

Studies on microorganisms in a large cohort of patients with congenital heart disease (CHD) and infective endocarditis (IE) are rare. Using a nationwide survey, the relationship between causative microorganisms and clinical profiles in patients with CHD and IE was investigated.

METHODS AND RESULTS

Data from 188 patients with CHD (pediatric patients (n=113), mean age, 6.2+/-4.9 years; adult patients (n=75), mean age 28.4+/-13.4 years) and IE from 60 institutions were analyzed. Causative microorganisms were Streptococcus species (94:50.0%), Staphylococcus species (68:36.2%), Haemophilus species (9:4.8%), Candida (5:2.7%), Pseudomonas species (4:2.1%) and other unclassified microorganisms (8:4.3%). Staphylococcal IE was observed significantly higher in perioperative IE (11/16), in cyanotic patients (32/73) and patients younger than 1 year old (11/16). Streptococcal IE was observed significantly higher in acyanotic patients (64/109) and patients aged 16 years or older (48/75). Total mortality was 20/188 (10.6%) and was high for candidial (2/5; 40%) and pseudomonal IE (2/4; 50%). Mortality was highly associated with younger age, especially infants (5/16), and methicillin-resistant staphylococcal IE (6/15).

CONCLUSIONS

The causative microorganisms are significantly related to the clinical profile and outcome in patients with IE and CHD. These results form the basis for selecting appropriate antibiotics for prevention and management.

Echocardiographic evaluation of asymptomatic parental and sibling cardiovascular anomalies associated with congenital left ventricular outflow tract lesions

OBJECTIVE

Left ventricular outflow tract obstructive (LVOTO) malformations are a leading cause of infant mortality from birth defects. Genetic mechanisms are likely, and there may be a higher rate of asymptomatic LVOTO anomalies in relatives of affected children. This study sought to define the incidence of cardiac anomalies in first-degree relatives of children with congenital aortic valve stenosis (AVS), coarctation of the aorta (CoA), and hypoplastic left heart syndrome (HLHS).

METHODS

A total of 113 probands with a nonsyndromic LVOTO malformation of AVS (n = 25), BAV (n = 3), CoA (n = 52), HLHS (n = 30), and aortic hypoplasia with mitral valve atresia (n = 2) were ascertained through chart review or enrolled at the time of diagnosis. Echocardiography was performed on 282 asymptomatic first-degree relatives.

RESULTS

Four studies had poor acoustic windows, leaving 278 studies for analysis. BAV were found in 13 (4.68%) first-degree relatives. The relative risk of BAV in the relatives was 5.05 (95% confidence interval: 2.2-11.7), and the broad sense heritability was 0.49, based on a general population frequency of 0.9%. BAV was more common in multiplex families compared with sporadic cases. An additional 32 relatives had anomalies of the aorta, aortic valve, left ventricle, or mitral valve.

CONCLUSIONS

The presence of an LVOTO lesion greatly increases the risk of identifying BAV in a parent or sibling, providing additional support for a complex genetic cause. The parents and siblings of affected patients should be screened by echocardiography as the presence of an asymptomatic BAV may carry a significant long-term health risk.

Infective endocarditis: a five-year experience at a tertiary care hospital in Pakistan

OBJECTIVES

Infective endocarditis is common and data regarding its pattern and outcome from developing countries is sparse. We therefore examined the spectrum, demographics and clinical features of infective endocarditis and sought to determine the factors affecting its clinical outcome.

PATIENTS AND METHODS

Over a five-year period at our university hospital in Karachi, Pakistan, we identified 66 patients with infective endocarditis and compared their clinicoepidemiologic features and outcomes to subjects in the West.

RESULTS

The male:female ratio was 2:1; overall median age was 24 years (35.5 years for men and 13.5 years for women) (p < 0.001). Median duration of symptoms before presentation was 20.5 days. Major predisposing cardiac abnormalities included congenital (50%) and rheumatic (23%) lesions, and a history of heart surgery (17%). Causative organisms and valvular sites of infection were similar to those seen in developed countries. Blood culture-negative infective endocarditis was found in 48% of cases. Renal failure was more frequent among culture-positive patients (p = 0.055). Risk factors for mortality included neurologic (p = 0.003) and embolic (p = 0.02) complications, renal (p = 0.03) and left ventricular failure (p = 0.002), and a history of cardiac surgery (p = 0.026). Overall mortality was 27%.

CONCLUSIONS

Patients with infective endocarditis in Pakistan exhibit significant differences compared to their counterparts in the West, including younger age at presentation, incidence of predisposing cardiac conditions, and gender differences reflecting sociocultural bias. Neurologic and embolic complications, renal failure and heart failure predict a worse outcome.

A cost-effectiveness analysis of bacterial endocarditis prophylaxis for febrile children who have cardiac lesions and undergo urinary catheterization in the emergency department

OBJECTIVE

To prevent bacterial endocarditis (BE) in those at risk, the American Heart Association recommends antibiotics for patients who have a known urinary tract infection and are about to undergo urinary catheterization (UC). In young children who have cardiac lesions and undergo UC for fever without a source, the problem with prophylaxis only in the presence of infected urine is that the presence of urinary tract infection is unknown before testing. This study was conducted to determine the cost-effectiveness of BE prophylaxis before UC in febrile children aged 0-24 months with moderate-risk cardiac lesions.

METHODS

We evaluated the cost-effectiveness of BE prophylaxis compared with no prophylaxis from the societal perspective. Clinical outcomes were based on BE incidence and quality-adjusted life years (QALYs). Probabilities were derived from the medical literature. Costs were derived from national and local sources in US dollars for the reference year 2000, using a discount rate of 3%.

RESULTS

On the basis of the analysis, prophylaxis prevents 7 BE cases per 1 million children treated. When antibiotic-associated deaths were included, the no-prophylaxis strategy was more effective and less costly than the prophylaxis strategy. When antibiotic-associated deaths were excluded, amoxicillin cost 10 million dollars per QALY gained and 70 million dollars per case prevented. For vancomycin, it was 13 million dollars per QALY gained and 95 million dollars per case prevented. The results were robust to variations in the prophylactic efficacy of antibiotics, incidence of bacteremia after UC, incidence of BE after bacteremia, and costs associated with BE prophylaxis and treatment.

CONCLUSION

In the emergency department, BE prophylaxis before UC in febrile children who are aged 0 to 24 months and have moderate-risk cardiac lesions is not a cost-effective use of health care resources.

Pulmonary endarteritis and subsequent embolization to the lung as a complication of a patent ductus arteriosus--a case report

The authors describe a case of pulmonary endarteritis and subsequent embolization to the lungs as a complication of a patent ductus arteriosus (PDA). Although 2-dimensional echocardiography has been shown to be of great value in the diagnosis of patients with infective endocarditis, echocardiographic detection of vegetation within the pulmonary artery and subsequent embolization to the lung is extremely rare and, to our knowledge, has been previously reported only in a few cases. In brief, our case not only shows the importance of echocardiography in making this rare diagnosis but also emphasizes the role of echocardiography as an effective means of following up such a case.

Analysis of infective endarteritis in patent ductus arteriosus

This study reports on infective endarteritis in 14 children with patent ductus arteriosus over a period of 6 years. Infective endarteritis mostly involved the small ducts and was previously undiagnosed. These patients were given antibiotic treatment for a variable period of 4 to 10 weeks, and all except 1 underwent subsequent closure.

Análisis clínico y de los factores de riesgo de mortalidad de 86 casos de endocarditis infecciosa en niños y adolescentes en Argentina (1988-2000)

INTRODUCTION

IE is a rare infection in children. Scarce reports with large number of patients are published.

METHODS

Between January 1988 to December 2000 we analyzed all cases of IE cases admitted to our hospital.

RESULTS

86 cases of IE (4.9/10,000 admissions) in 86 children were diagnosed. The median age was 7.6 years. In 77% of patient previous cardiac disease was detected, interventricular defects and Tetralogy of Fallot were the more frequent. Three percent of children had rheumatic heart disease. Thirty-six percent of children had previous heart surgery. Fifty-seven percent have been received previous antibiotics. Eighty-seven percent had positive blood cultures, being the S. aureus and S. viridans the predominantly. Forty-eight percent of children had complications. The metabolic disorders and the nosocomial infections were the most frequent. Twenty-four percent required surgery, 24% of them in the first week of the diagnosis. The mortality in operated children was 19%. In the multivariate analysis we could observe that children with more than 7 years and S. aureus isolation in blood cultures had more incidence of complications and posterior surgery (p < 0.05). Children with S. aureus IE had longer duration of fever, more incidence of complications than patients with S. viridans IE (p < 0.05). Ten percent of children were treated as outpatients. The global mortality was 12,8%. Previous surgery (OR = 6.89; IC 95% 1.54-30.7) and previous antibiotic treatment (OR = 9.98; IC 95% 1.12-88.8) were the factors related with higher mortality in the multivariate analysis. S. aureus was the predominat pathogen and caused more morbidity and mortality than S. viridans IE.

CONCLUSION

Children with IE with previous surgery and previous antibiotic treatment died with more frequency.

Infective endocarditis in Arkansan children from 1990 through 2002

BACKGROUND

Recent medical and surgical advances have increased the potential risk of endocarditis. Epidemiology, pathogens, morbidity and/or mortality may have evolved in the past decade in pediatric patients diagnosed with endocarditis.

METHODS

Retrospective reviews of medical records from Arkansas Children's Hospital were done to identify patients with infective endocarditis from January 1990 through December 2002. Basic demographic and clinical data were gathered and reviewed.

RESULTS

Of 76 patients identified, 57 were included based on diagnostic criteria. Congenital heart disease with (56%) and without (25%) correction were the most common risk factors. Echocardiograms revealed vegetations in 67%. Echocardiograms remain relatively deficient in patients with complex cyanotic heart disease (50% positive) vs. those with normal anatomy (83% positive). Streptococci (30%) and Staphylococcus aureus (21%) were the most common organisms identified overall; however, we observed a predominance of enterococci in infants <2 years of age (41%). Our study revealed a reduced rate of complications, especially of the central nervous system (7% vs. 25 and 33% in prior studies); however, our rate of S. aureus was lower (21% vs. 32 and 39%), and this pathogen continues to be associated with a higher incidence of complications.

CONCLUSIONS

Infective endocarditis continues to present a difficult challenge in pediatrics; its associated pathogens and outcomes have changed little in the past decade.

Survey of prophylaxis and management of infective endocarditis in patients with congenital heart disease: Japanese nationwide survey

Guidelines for the prevention and management of infective endocarditis (IE) in children with congenital heart disease (CHD) have not been established, so the aim of this study was to clarify the incidence, practical prevention and management of IE in patients with CHD in Japan through a nationwide survey. A written questionnaire was sent to members of the Japanese Society of Pediatric Cardiology and Cardiac Surgery and information was obtained from 236 cardiologists in 228 institutions. Four hundred and eight patients with IE were hospitalized during 1997 to 2001 (1/173 admissions with CHD including those hospitalized for cardiac catheterization or surgery). Prevention of IE for CHD was undertaken by 92% of cardiologists, usually oral penicillins (73%) and less frequently cephems (18%) were prescribed. The Duke criteria were used as clinical criteria by 38%. Blood culture was performed once only by 40%. Penicillins and aminoglycosides (38%) were frequently administered for management of culture-negative IE. There were variations in the dose and duration of antibiotics for prevention and management of IE. It appears that the prevalence of IE in CHD is rising and the nationwide survey revealed more variations in practical prevention and management of IE in patients with CHD than expected. The results should be helpful in making future guidelines for management of IE in CHD.

An update on the controversies in bacterial endocarditis of oral origin

OBJECTIVES

The aim of this review was to evaluate the evidence implicating dental procedures in bacterial endocarditis (BE) development and the basis for antimicrobial prophylaxis (AP).

STUDY DESIGN

In this article, the literature is reviewed and meaningful findings about epidemiology, pathogenesis, and AP guidelines for BE of oral origin are highlighted. Available results are used to formulate clinical recommendations for the dental practitioner.

RESULTS

The nature of dental procedures that cause bacteremia, patients at risk for BE, and the effectiveness of AP guidelines, continue to be points of controversy. There appears to be further evidence to support the important role of oral health status in the prevention of BE of dental origin.

CONCLUSIONS

One objective of the dental practitioner in caring for patients at risk for BE should be to promote oral health care. There are no hard data on which to scientifically base the need for AP in patients at risk for BE. However, it would appear prudent, at least from the medicolegal perspective, to provide AP, at least to persons with previous BE or prosthetic heart valves and to those undergoing oral surgery, periodontal treatment, or implant placement.

Antibacterials for the prophylaxis and treatment of bacterial endocarditis in children

Although the overall incidence of infective endocarditis in the paediatric population is considered to be low, over the last 20 years a rising trend in infective endocarditis has been observed among children. This could be due to several reasons including the availability of improved diagnostic techniques, use of continuous central venous catheters and cardiac implants increasing the risk of infection, and the survival of a greater number of infants with congenital heart disease as a result of improved medical management. The predominant causative organisms of paediatric endocarditis include staphylococci and streptococci. There is increased concern surrounding the emergence of endocarditis in children caused by methicillin-resistant Staphylococcus aureus and drug resistant strains of Streptococcus pneumoniae. The treatment approach to paediatric endocarditis is similar to that for adult patients with endocarditis because of similarities in disease pathogenesis and aetiology. The therapeutic goal is to achieve sterilisation of the cardiac vegetations. The choice of antibacterial is dependent upon the susceptibility profile of the causative organism. Vancomycin or gentamicin is recommended for enterococcal endocarditis, according to guidelines from the American Heart Association. For staphylococcal endocarditis in patients with no prosthetic valve, oxacillin or nafcillin with or without gentamicin is the treatment of choice. In the case of endocarditis caused by methicillin-resistant S. aureus, vancomycin is commonly used in patients with no prosthetic valve and a combination of vancomycin, gentamicin and rifampicin (rifampin) for patients with prosthetic material. Cefazolin or ceftriaxone is the treatment of choice for penicillin allergic paediatric patients with endocarditis caused by viridans streptococci. While there have been no major changes in endocarditis therapy for the last decade, the current focus is on the recognition of multiple-drug resistant pathogens and the use of newer agents such as quinupristin/dalfopristin in the treatment of resistant bacterial endocarditis. Prophylactic antibacterial therapy is recommended for procedures thought to be associated with the occurrence of bacteraemia involving organisms commonly associated with endocarditis. These include dental extractions and oral, respiratory tract, genitourinary, gastrointestinal or oesophageal procedures. Prophylactic antibacterials recommended by the American Heart Association during genitourinary and gastrointestinal surgical procedures in high risk patients include ampicillin + gentamicin or vancomycin + gentamicin in high risk patients with penicillin allergy. Ampicillin has been recommended for prophylaxis of bacterial endocarditis in children undergoing oral, respiratory tract or oesophageal procedures. In the case of penicillin allergy in these patients, cephalosporins, clindamycin, azithromycin or clarithromycin have been recommended. The general consensus is that antibacterial prophylaxis during dental procedure is unnecessary, and in fact propagates bacterial resistance.

Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country

BACKGROUND

In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high.

OBJECTIVE

Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome.

SETTING

A tertiary referral center for paediatric and adult cardiology.

PATIENTS AND METHODS

All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases.

RESULTS

Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients).

CONCLUSIONS

The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.

Endocarditis in the Pediatric Population

Endocarditis is a rare, but potentially fatal process in children. Patients with congenital heart disease compose the majority of patients with endocarditis. Neonates and children with central venous catheters are an increasingly frequent group of patients diagnose with this disease. Rheumatic fever predisposing to endocarditis is unusual. Streptococcus viridans and Staphylococcus aureus are the most pervasive organisms associated with endocarditis, though others are becoming more frequent. Blood cultures should be obtained in febrile children with congenital heart disease before the administration of antibiotics. Echocardiography is useful in children with known endocarditis, and in children in whom there is a high level of clinical suspicion for endocarditis. Echocardiography is a poor screening tool for patients without clinical or bacteriologic evidence for endocarditis. Endocarditis prophylaxis for children with congenital heart disease (excluding a secundum atrial septal defect) before appropriate procedures is recommended.

Surgery for infective valve endocarditis in children

OBJECTIVE

Surgery for endocarditis in children is relatively uncommon. Our aim is to assess operative mortality, recurrent infection, re-operation and long-term survival rates following surgery for infective valve endocarditis in children.

PATIENTS

Sixteen consecutive children (ten female, six male, mean age 11.8 years, range 25 days-16 years) undergoing surgery between 1972 and 1999 in Southampton were studied. The aortic valve was affected in five, mitral in four, aortic and mitral in one, tricuspid in five and a pulmonary homograft in one patient. Prosthetic valve endocarditis was present in three. Twelve surgical interventions were emergency and four urgent. Indications for operation included cardiac failure in five, severe valvular dysfunction in nine, vegetations in nine, persistent sepsis in four and embolization in four patients. The offending micro-organism was identified in 13. Valve replacement was performed in 11 and excision of vegetations in two and excision of vegetations and repair in three. Follow-up was complete (mean 11.2 years, range 2 months to 26.3 years, total 179.5 patient years).

RESULTS

There was one operative death (6.2%) in a 25-day-old neonate who presented in a moribund condition. Endocarditis recurred in one patient (6.25%). Freedom from recurrent infection at 10 and 20 years was 100.0 and 87.5%. Seven surgical re-interventions were required in four (25.0%) patients with no operative mortality. Freedom from re-operation at 1, 5, 10 and 20 years, was 84.6, 76.1, 76.1 and 60.9%, respectively. Two patients died 15 and 23 years after their first operation. The cause of the late deaths was non-cardiac in the first and unknown in the other. Actuarial survival, including operative mortality, at 1, 15 and 20 years was 93.7, 93.7 and 78.1%.

CONCLUSIONS

Surgery in children with infective valve endocarditis can be performed with low operative mortality. Although some patients may require re-operation, freedom from recurrent infection and long-term survival are satisfactory.

Pediatric bacterial endocarditis. Treatment and prophylaxis

Endocarditis is a rare but serious complication often related to complex CHD. The incidence, particularly among smaller infants with cyanotic heart disease, seems to be increasing. The pathophysiology is related to a combination of host and bacterial factors that predispose to endothelial colonization and infection. Diagnosis, although occasionally difficult, is life saving, but the treatment is prolonged. Prophylaxis before appropriate procedures may significantly decrease the risk for development in appropriate patients.

[Ductus closure in adults with the Rashkind device: comparative results]

INTRODUCTION

Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demonstrated in children, however a few results have been reported of occlusion in adults.

METHOD

From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Raskind device. Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were studied retrospectively. The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echocardiograms.

RESULTS

The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus. Similar QP/QS (1.61 +/- 0.47 in adults vs 1.49 +/- 0.51) was calculated although pulmonary pressure was superior in children (12.50 +/- 2.97 vs 16.84 +/- 5.88 mmHg; p = 0.003). In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 +/- 1.50 vs 2.41 +/- 0.96 mm; p = 0.009). In adults 17 mm umbrella were used more frequently (91 vs 61%; p = 0.02). Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children. The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77% and 95% vs 83% (p > 0.10). Multivariate analysis identified age as an independent predictor of complete occlusion.

CONCLUSION

Our experience in transcatheter occlusion of persistent ductus arteriosus with Rashkind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.