Progress toward a global understanding of infective endocarditis. Lessons from the International Collaboration on Endocarditis

NatIonal Danish endocarditis stUdieS - Design and objectives of the NIDUS registry

AIMS

The NatIonal Danish endocarditis stUdieS (NIDUS) registry aims to investigate the mechanisms contributing to the increasing incidence of infective endocarditis (IE) and to discover risk factors associated to the course, treatment and clinical outcomes of the disease.

METHODS

The NIDUS registry was created to investigate a nationwide unselected group of patients hospitalized for IE. The National Danish healthcare registries have been queried for validated IE diagnosis codes (International Classification of Disease, 10th edition [ICD-10]: DI33, DI38, and DI398). Subsequently, a team of 28 healthcare professionals, including experts in endocarditis, will systematically review and evaluate all identified patient records using the modified Duke Criteria and the 2015 European Society of Cardiology modified diagnostic criteria. The registry will contain all cases with definite or possible IE found in primary data sources in Denmark between January 1, 2016, and December 31, 2021. We will gather individual patient data, such as clinical, microbiological, and echocardiographic characteristics, treatment regimens, and clinical outcomes. A digital data collection form will be used to the gathering of data. A sample of approximately 4,300 individual patients will be evaluated using primary data sources.

CONCLUSIONS AND PERSPECTIVES

The NIDUS registry will be the first comprehensive nationwide IE registry, contributing critical knowledge about the course, treatment, and clinical outcomes of the disease. Additionally, it will significantly aid in identifying areas in which future research is needed.

Cardiovascular Diseases and Pharmacomicrobiomics: A Perspective on Possible Treatment Relevance

Cardiovascular diseases (CVDs), the most common cause of mortality in rich countries, include a wide variety of pathologies of the heart muscle and vascular system that compromise the proper functioning of the heart. Most of the risk factors for cardiovascular diseases are well-known: lipid disorders, high serum LDL cholesterol, hypertension, smoking, obesity, diabetes, male sex and physical inactivity. Currently, much evidence shows that: (i) the human microbiota plays a crucial role in maintaining the organism’s healthy status; and (ii) a link exists between microbiota and cardiovascular function that, if dysregulated, could potentially correlate with CVDs. This scenario led the scientific community to carefully analyze the role of the microbiota in response to drugs, considering this the right path to improve the effectiveness of disease treatment. In this review, we examine heart diseases and highlight how the microbiota actually plays a preponderant role in their development. Finally, we investigate pharmacomicrobiomics—a new interesting field—and the microbiota’s role in modulating the response to drugs, to improve their effectiveness by making their action targeted, focusing particular attention on cardiovascular diseases and on innovative potential treatments.

Gender differences in clinical features and complications of infective endocarditis: 11-year experience of a single institute in Egypt

BACKGROUND

No data exists about the gender differences among patients with infective endocarditis (IE) in Egypt. The objective was to study possible gender differences in clinical profiles and outcomes of patients in the IE registry of a tertiary care center over 11 years.

RESULTS

The IE registry included 398 patients with a median age of 30 years (interquartile range, 15 years); 61.1% were males. Males were significantly older than females. Malignancy and recent culprit procedures were more common in females while chronic liver disease and intravenous drug abuse (IVDU) were more in males. IE on top of structurally normal hearts was significantly more in males (25.6% vs 13.6%, p = 0.005) while rheumatic valvular disease was more common in females (46.3% vs 29.9%, p = 0.001). There was no difference in the duration of illness before presentation to our institution. The overall complication rate was high but significantly higher in females. However, there were no significant differences in the major complications: mortality, fulminant sepsis, renal failure requiring dialysis, heart failure class III-IV, or major cerebrovascular emboli.

CONCLUSION

In this registry, IE occurred predominantly in males. Females were significantly younger at presentation. History of recent culprit procedures was more common in females while IVDU was more common in males who had a higher incidence of IE on structurally normal hearts. The overall complication rate was higher in women. IE management and its outcomes were similar in both genders.

Heart transplantation for infective endocarditis: Viable option for a limited few?

Active infection in the recipient is considered a relative contraindication for solid organ transplantation. However, heart transplantation (HT) can be curative in patients with ventricular assist device infections. For patients with infective endocarditis (IE), valve replacement is part of the management strategy based on emergent, acute, or elective indications. HT has been utilized as an uncommon and sporadic treatment option for carefully selected patients with refractory or recurrent IE after all other surgical treatment options have been exhausted or are not feasible. Herein, we review 19 published cases of IE in whom HT was undertaken in the setting of ongoing active infection with reported good outcomes. We attempt to propose general criteria for HT in the setting of IE and discuss challenges and hurdles that clinicians might encounter when considering HT for active IE in the absence of robust data or clearly defined criteria.

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

Current Epidemiology and Outcome of Infective Endocarditis: A Multicenter, Prospective, Cohort Study

The aim of the study was to describe the epidemiologic and clinical characteristics and identify the risk factors of short-term and 1-year mortality in a recent cohort of patients with infective endocarditis (IE).From January 2008, multidisciplinary teams have prospectively collected all consecutive cases of IE, diagnosed according to the Duke criteria, in 25 Spanish hospitals.Overall, 1804 patients were diagnosed. The median age was 69 years (interquartile range, 55-77), 68.0% were men, and 37.1% of the cases were nosocomial or health care-related IE. Gram-positive microorganisms accounted for 79.3% of the episodes, followed by Gram-negative (5.2%), fungi (2.4%), anaerobes (0.9%), polymicrobial infections (1.9%), and unknown etiology (9.1%). Heart surgery was performed in 44.2%, and in-hospital mortality was 28.8%. Risk factors for in-hospital mortality were age, previous heart surgery, cerebrovascular disease, atrial fibrillation, Staphylococcus or Candida etiology, intracardiac complications, heart failure, and septic shock. The 1-year independent risk factors for mortality were age (odds ratio [OR], 1.02), neoplasia (OR, 2.46), renal insufficiency (OR, 1.59), and heart failure (OR, 4.42). Surgery was an independent protective factor for 1-year mortality (OR, 0.44).IE remains a severe disease with a high rate of in-hospital (28.9%) and 1-year mortality (11.2%). Surgery was the only intervention that significantly reduced 1-year mortality.

Clinical epidemiology in Italian Registry of Infective Endocarditis (RIEI): Focus on age, intravascular devices and enterococci

INTRODUCTION

The epidemiology of infective endocarditis (IE) is changing due to a number of factors, including aging and health related comorbidities and medical procedures. The aim of this study is to describe the main clinical, epidemiologic and etiologic changes of IE from a large database in Italy.

METHODS

We prospectively collected episodes of IE in 17 Italian centers from July 2007 to December 2010.

RESULTS

We enrolled 677 patients with definite IE, of which 24% health-care associated. Patients were male (73%) with a median age of 62 years (IQR: 49-74) and 61% had several comorbidities. One hundred and twenty-eight (19%) patients had prosthetic left side IE, 391 (58%) native left side IE, 94 (14%) device-related IE and 54 (8%) right side IE. A predisposing cardiopathy was present in 50%, while odontoiatric and non odontoiatric procedures were reported in 5% and 21% of patients respectively. Symptoms were usually atypical and precocious. The prevalent etiology was represented by Staphylococcus aureus (27%) followed by coagulase-negative staphylococci (CNS, 21%), Streptococcus viridans (15%) and enterococci (14%). CNS and enterococci were relatively more frequent in patients with intravascular devices and prosthesis and S. viridans in left native valve. Diagnosis was made by transthoracic and transesophageal echocardiography in 62% and 94% of cases, respectively. The in-hospital mortality was 14% and 1-year mortality was 21%.

CONCLUSION

The epidemiology is changing in Italy, where IE more often affects older patients with comorbidities and intravascular devices, with an acute onset and including a high frequency of enterococci. There were few preceding odontoiatric procedures.

Association Between Surgical Indications, Operative Risk, and Clinical Outcome in Infective Endocarditis

Background—

Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined.

Methods and Results—

The International Collaboration on Endocarditis–PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non–cardiac device–related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE.

Conclusions—

Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.

Infective Endocarditis

Infective endocarditis (IE) is a noncontagious infection of the endocardium and heart valves. The epidemiology of IE has shifted recently with an increase in health care-associated IE. Infective endocarditis requiring intensive care unit stay is increasing, and nosocomial IE is frequently responsible. Diagnosis of IE requires multiple clinical data points encompassing history and physical examination, microbiology, and cardiac imaging as no one test is sufficiently sensitive or specific. The modified Duke criteria algorithm is the standard of care in the clinical diagnosis of IE. Complications from IE are common, particularly so in the critical care setting, and include congestive heart failure, embolism, septic shock, invasive infection, prosthetic valve dehiscence, heart block, and mycotic aneurysm. A multidisciplinary care team of infectious disease, cardiology, and cardiac surgery physicians is recommended to reduce complications. Intravenous antibiotics are first-line therapy with cardiac surgery being reserved for certain complications of IE and/or for clinical situations in which there is a high risk of complications. Timing of surgery for IE remains controversial and depends on a variety of clinical factors.

Giant vegetation in the right ventricle caused by Staphylococcus aureus and Candida mycoderma

INTRODUCTION

Infective endocarditis (IE) is considered a multifactorial disease. Providing an early diagnosis and invasive treatment together with effective antibiotic treatment remain critical tasks for the cardiologist and the surgeon. Right ventricular endocarditis is a rare type of endocarditis usually caused by Staphylococcus aureus and Candida mycoderma.

CASE PRESENTATION

We present a 25-year-old male patient who presented with persistent malaise, fever, cough, and anorexia after 55 days of antibiotic treatment. Lung computed tomographic scanning excluded severe lung infection. Transthoracic and transesophageal echocardiography revealed a giant vegetation in the right ventricle. Blood culture was positive for S. aureus and C. mycoderma, and antibiotic therapy was immediately applied. Considering the large burden of infected tissue, an early surgical intervention was planned. The cultures of the vegetation specimen were negative. Intraoperative and histological findings confirmed the echocardiographic diagnosis of IE.

CONCLUSIONS

Giant vegetations in the right ventricle caused by S. aureus and C. mycoderma are rare. In addition to medical treatment, more attention should be paid to early surgical consultation.

Association between valvular surgery and mortality among patients with infective endocarditis complicated by heart failure

CONTEXT

Heart failure (HF) is the most common complication of infective endocarditis. However, clinical characteristics of HF in patients with infective endocarditis, use of surgical therapy, and their associations with patient outcome are not well described.

OBJECTIVES

To determine the clinical, echocardiographic, and microbiological variables associated with HF in patients with definite infective endocarditis and to examine variables independently associated with in-hospital and 1-year mortality for patients with infective endocarditis and HF, including the use and association of surgery with outcome.

DESIGN, SETTING, AND PATIENTS

The International Collaboration on Endocarditis-Prospective Cohort Study, a prospective, multicenter study enrolling 4166 patients with definite native- or prosthetic-valve infective endocarditis from 61 centers in 28 countries between June 2000 and December 2006.

MAIN OUTCOME MEASURES

In-hospital and 1-year mortality.

RESULTS

Of 4075 patients with infective endocarditis and known HF status enrolled, 1359 (33.4% [95% CI, 31.9%-34.8%]) had HF, and 906 (66.7% [95% CI, 64.2%-69.2%]) were classified as having New York Heart Association class III or IV symptom status. Within the subset with HF, 839 (61.7% [95% CI, 59.2%-64.3%]) underwent valvular surgery during the index hospitalization. In-hospital mortality was 29.7% (95% CI, 27.2%-32.1%) for the entire HF cohort, with lower mortality observed in patients undergoing valvular surgery compared with medical therapy alone (20.6% [95% CI, 17.9%-23.4%] vs 44.8% [95% CI, 40.4%-49.0%], respectively; P < .001). One-year mortality was 29.1% (95% CI, 26.0%-32.2%) in patients undergoing valvular surgery vs 58.4% (95% CI, 54.1%-62.6%) in those not undergoing surgery (P < .001). Cox proportional hazards modeling with propensity score adjustment for surgery showed that advanced age, diabetes mellitus, health care-associated infection, causative microorganism (Staphylococcus aureus or fungi), severe HF (New York Heart Association class III or IV), stroke, and paravalvular complications were independently associated with 1-year mortality, whereas valvular surgery during the initial hospitalization was associated with lower mortality.

CONCLUSION

In this cohort of patients with infective endocarditis complicated by HF, severity of HF was strongly associated with surgical therapy and subsequent mortality, whereas valvular surgery was associated with lower in-hospital and 1-year mortality.

Role of echocardiogram in decision making for surgery in endocarditis

Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.

The upside-down stentless aortic bioprosthesis to tricuspid valve replacement

Between March 2008 and January 2009, a stentless tricuspid valve replacement (STVR) was performed in three patients with tricuspid valve endocarditis who were resistant to medical therapy. Intraoperative and follow-up echocardiograms revealed good prosthetic function without stenosis or regurgitation. This technique could be considered an additional surgical option to stented biological valves or homograft implantations in very high risk populations.

Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias

BACKGROUND

The impact of early surgery on mortality in patients with native valve endocarditis (NVE) is unresolved. This study sought to evaluate valve surgery compared with medical therapy for NVE and to identify characteristics of patients who are most likely to benefit from early surgery.

METHODS AND RESULTS

Using a prospective, multinational cohort of patients with definite NVE, the effect of early surgery on in-hospital mortality was assessed by propensity-based matching adjustment for survivor bias and by instrumental variable analysis. Patients were stratified by propensity quintile, paravalvular complications, valve perforation, systemic embolization, stroke, Staphylococcus aureus infection, and congestive heart failure. Of the 1552 patients with NVE, 720 (46%) underwent early surgery and 832 (54%) were treated with medical therapy. Compared with medical therapy, early surgery was associated with a significant reduction in mortality in the overall cohort (12.1% [87/720] versus 20.7% [172/832]) and after propensity-based matching and adjustment for survivor bias (absolute risk reduction [ARR] -5.9%, P<0.001). With a combined instrument, the instrumental-variable-adjusted ARR in mortality associated with early surgery was -11.2% (P<0.001). In subgroup analysis, surgery was found to confer a survival benefit compared with medical therapy among patients with a higher propensity for surgery (ARR -10.9% for quintiles 4 and 5, P=0.002) and those with paravalvular complications (ARR -17.3%, P<0.001), systemic embolization (ARR -12.9%, P=0.002), S aureus NVE (ARR -20.1%, P<0.001), and stroke (ARR -13%, P=0.02) but not those with valve perforation or congestive heart failure.

CONCLUSIONS

Early surgery for NVE is associated with an in-hospital mortality benefit compared with medical therapy alone.

Relation of troponin elevation to outcome in patients with infective endocarditis

Elevated troponin is increasingly recognized as a marker of cardiac injury and poor outcomes in diverse disease states. It was hypothesized that patients with infective endocarditis (IE) and elevated cardiac troponin would have more extensive IE and worse clinical outcomes. Patients were enrolled as part of the International Collaboration on Endocarditis (ICE) prospective cohort study; analysis of these patients was done retrospectively. Data from 83 consecutively enrolled patients from a single center were evaluated. Cardiac troponin I (cTnI) was drawn for clinical indications and before any cardiac surgery in 51 of the 83 patients. Outcomes evaluated were hospital mortality, annular or myocardial abscess on the basis of echocardiography or surgery, and central nervous system events. Of 51 patients with cTnI drawn, 33 (65%) had elevated cTnI > or =0.1 mg/dl. There were no differences in age, gender, prosthetic valve IE, Staphylococcus aureus IE, or history of coronary artery disease, congestive heart failure, or diabetes mellitus between patients with and without cTnI elevations. Patients with elevated cTnI were less likely to have isolated right-sided IE and more likely to have left ventricular systolic dysfunction or renal dysfunction (p <0.05 for each). In conclusion, elevated cTnI was associated with the composite of death, abscess, and central nervous system events (p <0.001).

A dangerous dilemma: management of infectious intracranial aneurysms complicating endocarditis

A 41-year-old right-handed man with bicuspid aortic valve and a 3-month history of chronic fever and weight loss presented with sudden onset of severe headache. Computerised tomography of the head revealed a right basal ganglia haemorrhage. Further investigation documented Streptococcus mitis bacteraemia, a fusiform right middle cerebral artery aneurysm, and an abscess at the base of the anterior leaflet of the mitral valve. The patient subsequently died when repeat aneurysmal haemorrhage resulted in cerebral herniation and brain death while on antibiotic therapy. Infectious intracranial aneurysms (IIAs) are uncommon but severe complications of bacterial endocarditis. Several case series have been published evaluating the management of IIAs, but no randomised controlled trials exist to guide treatment decisions. Improved diagnostic techniques, microvascular neurosurgical approaches, and endovascular therapies hold the promise of improved outcomes in the future. This difficult case is used to show an approach towards the management of IIAs complicating bacterial endocarditis based on a review of the published work.

The changing face of infective endocarditis

Infective endocarditis is a disease that continues to evolve in response to changing host conditions and other factors.

Infective endocarditis: diagnosis and management

Despite advances in antimicrobial therapy, diagnostic imaging and cardiac surgery, infective endocarditis (IE) remains challenging clinically and is associated with high morbidity and mortality. Diagnosis relies on several factors: initial clinical suspicion, microbiological data and echocardiographic findings. The use of an integrated diagnostic schema, such as the modified Duke criteria, is useful. Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases. Although the choice of investigation might be influenced by availability, the approach to imaging should be tailored to the individual's clinical situation. Promptly administered intravenous antimicrobial therapy is essential, while the use of antiplatelet or antithrombin therapy to prevent embolic complications is not supported by clinical data. Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult. The principal indications are the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection. The timing of surgery following central nervous system embolization is problematic because of the risk of hemorrhagic transformation. Prophylactic surgery to prevent embolization is currently advocated only for the management of large, mobile vegetations, when undertaken at centers performing high volumes of heart valve surgery. In this review, we describe diagnostic approaches for IE, particularly echocardiography, and provide recommendations for treatment, paying particular attention to surgery in the acute setting.

Surgical Treatment of Mitral Valve Endocarditis in North America

BACKGROUND

Several single-institution series have suggested the feasibility and effectiveness of mitral valve repair for infective endocarditis (IE).

METHODS

We examined 6627 patients with IE undergoing mitral valve surgery at 661 Society of Thoracic Surgeons-participating centers in 1994 to 2003.

RESULTS

The diagnosis of IE was assigned to 5.8% (6,627 of 114,934) of patients having mitral valve surgery. The overall frequency of mitral valve repair for IE was 29.7% (1,965 of 6,627). Mitral valve repair was less frequently used for patients with active IE (423 of 2,654; 15.9%) than those with treated IE (1,459 of 3,570; 40.9%). Operative mortality was 3.7% (72 of 1,965) for mitral valve repair and 10.8% (502 of 4,662) for mitral valve replacement. Mortality rates were lower for patients with treated IE compared with active IE. After adjusting for multiple preoperative risk factors, mitral valve repair (odds ratio, 0.67; 95% confidence interval, 0.51 to 0.88) was associated with a significantly lower risk of death. Active (versus treated) IE (odds ratio, 2.12; 95% confidence interval, 1.68 to 2.68) and recent cerebrovascular accident (odds ratio, 1.71; 95% confidence interval, 1.28 to 2.31) were independent predictors of mortality.

CONCLUSIONS

Mitral valve repair is less commonly applied for IE compared with other indications for mitral valve surgery. Patients with active IE were less likely to receive repair than those with treated IE. Mitral valve repair was associated with a lower risk of mortality. These results provide support for performing mitral valve repair when technically feasible in the setting of IE.

Use of surgery in patients with native valve infective endocarditis: results from the International Collaboration on Endocarditis Merged Database

BACKGROUND

Early surgery has been shown to be beneficial for patients with infective endocarditis (IE), yet surgery is not used in most patients. Evidence of the uncertainty around the use of surgery can be found in the wide variations in the use of cardiac surgery in IE with few precise indications for cardiac surgery yet defined. The aim of the study was to characterize patients with native valve IE relative to surgery and to determine if patients who benefit from an early surgical intervention can be identified.

METHODS

The International Collaboration on Endocarditis Merged Database was used to quantify the differences between patients with IE receiving medical and surgical intervention in 1516 patients with definite native valve IE. Propensity models were built to identify a group of patients that benefit from early surgery.

RESULTS

Patients in the early surgical group were more likely to be male, younger, and with less comorbidities compared with the early medical group (P < .001 for all) and were less likely to have infection with Staphylococcus aureus or viridans group streptococci (P < .05 for all). Intracardiac abscess and heart failure were much more common in the surgical group (P < .001 for all). In an unadjusted comparison, there was no statistically significant survival advantage in the surgical group. However, in the propensity analysis, in the subgroup of patients with the most indications for surgery, there was a significant decrease in mortality associated with early surgery (11.2% vs 38.0%, P < .001).

CONCLUSIONS

The benefits of surgery are not seen uniformly in all patients with native valve IE, but are most realized in a targeted population. This observation requires confirmation in other populations of patients with definite IE.

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

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.

The changing face of infective endocarditis

Infective endocarditis (IE) is an evolving disease with a persistently high mortality and morbidity, even in the modern era of advanced diagnostic imaging, improved antimicrobial chemotherapy, and potentially curative surgery. Despite these improvements in health care, the incidence of the disease has remained unchanged over the past two decades and may even be increasing. Chronic rheumatic heart disease is now an uncommon antecedent, whereas degenerative valve disease of the elderly, mitral valve prolapse, intravenous drug misuse, preceding valve replacement, and vascular instrumentation have become increasingly common, coinciding with an increase in staphylococcal infections and those caused by fastidious organisms. The current understanding of this difficult condition is reviewed and recent developments in medical and surgical management are updated.