Results of surgical treatment for infective endocarditis in children

Clinical Characteristics of Infective Endocarditis in Children

BACKGROUND

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children.

METHODS

A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed.

RESULTS

Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000-2007 to 20 (74%) cases in 2008-2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%).

CONCLUSIONS

The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.

The utility of cardiac MRI in diagnosis of infective endocarditis: preliminary results

PURPOSE

We aimed to evaluate the utility of cardiac magnetic resonance imaging (MRI) for the diagnosis of infective endocarditis (IE).

METHODS

Sixteen patients with a preliminary diagnosis of IE (10 women and six men; age range, 4-66 years) were referred for cardiac MRI. MRI sequences were as follows: echo-planar cine true fast imaging with steady-state precession (true-FISP), dark-blood fast spin echo T1-weighted imaging, T2-weighted imaging, dark-blood half-Fourier single shot turbo spin echo (HASTE), and early contrast-enhanced first-pass fast low-angle shot (FLASH). Delayed contrast-enhanced images were obtained using three-dimensional inversion recovery FLASH after 15±5 min. The MRI features were evaluated, including valvular pathologies on cine MRI and contrast enhancement on the walls of the cardiac chambers, major thoracic vasculature, and paravalvular tissue, attributable to endothelial extension of inflammation on contrast-enhanced images.

RESULTS

Fourteen valvular vegetations were detected in eleven patients on cardiac MRI. It was not possible to depict valvular vegetations in five patients. Vegetations were detected on the aortic valve (n=7), mitral valve (n=3), tricuspid and pulmonary valves (n=1). Delayed contrast enhancement attributable to extension of inflammation was observed on the aortic wall and aortic root (n=11), paravalvular tissue (n=4), mitral valve (n=2), walls of the cardiac chambers (n=6), interventricular septum (n=3), and wall of the pulmonary artery and superior mesenteric artery (n=1).

CONCLUSION

Valvular vegetation features of IE can be detected by MRI. Moreover, in the absence of vegetations, detection of delayed enhancement representing endothelial inflammation of the cardiovascular structures can contribute to the diagnosis and treatment planning of IE.

[Infective fungal endocarditis in patients with no previous cardiac disease]

Infective endocarditis is a serious and uncommon condition affecting the endocardium. Less than 10% of these cases are of fungal origin. A growing number of individuals are at high risk, due to insertion of central venous catheters, total parenteral nutrition and prolonged exposure to broad-spectrum antibiotics, even without previous heart diseases. We retrospectively analysed the records of six children with Candida endocarditis, reviewing the comorbidities, clinical outcome, and treatment. The antifungal agents used were amphotericin B, 5-fluorocytosine and fluconazole. Patients underwent surgical excision of vegetation, five tricuspid valve repairs and one mitral valve replacement. There were no hospital deaths, and one child needed a new valvuloplasty one year later. The mean follow up was five years, and all have good valvular function without recurrent endocarditis. A combination of synergistic long-term antifungal treatment and early surgical intervention is recommended.

Prophylaxis of infective endocarditis in patients with congenital heart disease in the context of recent modified guidelines

Infective endocarditis (IE) is a life-threatening complication that may impair significantly the long-term prognosis of patients with cardiac disease. The profile of IE has changed over recent decades, with a decreasing prevalence of rheumatic fever and increasing survival of patients with congenital heart disease (CHDs). Given the high rates of morbidity and mortality, and based on previous experimental studies, antibiotic prevention of IE has long been recommended for at-risk groups. Serial revised guidelines for prophylaxis have been published over the years. The most recent recommendations differ dramatically from previous guidelines and provide new insights into the prophylaxis of IE. Emphasis is put on oral activities (particularly brushing teeth) as both buccal and skin hygiene may present the greatest threats for individuals at-risk of IE. Significant limitations in both at-risk patients and procedures result in a potential and substantial change in the practice of clinicians and raise concerns about the safety and reliability of these new recommendations for patients with CHD.

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.

Healthcare-associated versus community-associated infective endocarditis in children

BACKGROUND

Infective endocarditis (IE) in children is continuously changing in regard to underlying conditions, predisposing factors, etiologic agents, clinical manifestations, treatment, and outcome. We describe current characteristics and compare healthcare-associated and community-associated disease.

PATIENTS AND METHODS

All children (<18 years) who were treated at our center between January 1992 through June 2004 and met the Duke criteria for definite or possible IE were included. Demographic, clinical, and laboratory data were collected. Cases were categorized as healthcare- or community-associated.

RESULTS

A total of 50 children with IE were identified (51 events; 0.32/1000 hospitalizations). Twenty children (41%) had an isolated congenital heart disease, 13 (25%) had an underlying chronic disease, 9 (18%) were previously healthy, and 8 (16%) were preterm. Mortality rate was 12% (6/51). Compared with the community-associated cases (21/51, 41%), the healthcare-associated cases (30/51, 59%) showed female preponderance, younger age, 1.7-fold longer hospitalization, 1.6-fold longer time to pathogen eradication, and 3.4-fold higher mortality. The leading causes of healthcare-associated IE were Candida sp (8/30, 27%), coagulase-negative staphylococci (6/30, 20%), and Gram-negative bacilli (5/30, 16%). By contrast, the leading causes of community-associated IE were viridans streptococci (8/21, 38%) and Staphylococcus aureus (4/21, 19%).

CONCLUSIONS

A high proportion of pediatric IE is healthcare-associated that occurs in younger and sicker children. Healthcare-associated IE differs from community-associated IE in the patients' age, causative pathogens, and mortality. These trends and the different etiologies may affect future antibiotic management of this important pediatric infection.