Surgical management of infective endocarditis: an analysis of early and late outcomes

Late-Term Outcomes of Surgical Treatment of Infective Endocarditis

Background: This study aims to evaluate the long-term outcomes of surgical interventions in patients with infective endocarditis (IE) who underwent surgical treatment and to determine the treatment approach for new patients. Patients and Methods: We retrospectively examined the long-term results of patients who underwent surgical treatment for IE between 2007 and 2017. The evaluation included late-term outcomes of IE surgery, surgical procedures, complications, the postoperative period, and clinical findings. Results: The study included 20 patients (12 male, 8 female) with a mean age of 45.1 ± 17.25. The most common cardiac risk factors for endocarditis development were the presence of prosthetic valves and heart valve disease. In addition, non-cardiac risk factors included chronic renal failure, systemic lupus erythematosus, and pemphigus vulgaris. Preoperative and postoperative laboratory findings were compared with in terms of morbidity and mortality, revealing no significant differences. The most prevalent preoperative laboratory findings were anemia (100%), elevated CRP (100%), and leukocytosis (50%). Anemia persisted as the most common laboratory finding in the postoperative evaluation. Conclusion: Our study identified comorbid chronic medical conditions, neurological complications because of IE, postoperative impaired left ventricular function, and treatment strategies such as monotherapy as poor prognostic factors in patients who underwent surgical treatment for IE. The management of IE is observed to be complex in the presence of comorbidities and complications, adversely affecting both survival and quality of life.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

B-type natriuretic peptide levels at admission predict the prognosis of patients with infective endocarditis undergoing cardiac surgery

Purpose: The objective of this study was to explore the relationship between elevated B-type natriuretic peptide (BNP) levels and the prognosis of patients with infective endocarditis (IE) undergoing cardiac surgery. Methods: In total, 162 IE patients with recorded BNP levels upon admission were included in the present study. The primary end point was all-cause mortality. Results: Multivariate Cox analysis revealed a significant association between log BNP and all-cause mortality. Kaplan-Meier analysis revealed a poorer prognosis for patients with BNP levels ≥ the 75th percentile. Furthermore, the linear trend test indicated a significant link between BNP quartiles and the primary end point within the models. Conclusion: Elevated BNP levels upon admission could predict all-cause mortality in IE patients undergoing cardiac surgery.

Hemostatic disorders in patients with infective endocarditis undergoing urgent surgical valve replacement - Rethinking current beliefs

BACKGROUND

Although infective endocarditis (IE) represents a unique model of thrombo-inflammatory disease, the most frequent early complications of surgical valve replacement (SVR) in IE population are coagulopathy and bleeding. The hemostatic capacity and procedure-related coagulation disorders of IE patients undergoing SVR are unknown. The aims of this study were to test periprocedural hemostasis in IE patients undergoing urgent SVR, and to assess the association between disorders of hemostasis and early bleeding as well as with thromboembolic events.

METHODS

A prospective, two-center, hypothesis generating, observational study was performed between Dec 2017 and Jan 2020. Periprocedural hemostasis of IE patients was assessed using Total Thrombus-formation Analysis System (T-TAS Plus) within 24 h before and 72 h post SVR.

RESULTS

Overall, 25 patients with active IE undergoing urgent SVR were tested. Hemostatic capacity of IE patients was significantly impaired pre-SVR as well as post-SVR compared to normal values, in most aspects of T-TAS assays under high and low shear forces, including prolonged activation of coagulation (T10), final clot formation (OT) and clot strength (AUC30). Post-SVR T-TAS results were significantly associated with early bleeding and with red blood cell, platelet, and fresh frozen plasma administration. No association with thrombo-embolic events was found.

CONCLUSIONS

Patients with active IE undergoing urgent SVR have significantly reduced hemostatic capacity before and after SVR. Hemostatic insufficiency post-SVR is related to bleeding and blood products transfusion. T-TAS may be helpful in assessment of periprocedural hemostasis in patients with IE undergoing SVR.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.

Impact of Vegetation Length on Clinical Complications During Surgical Intervention and Long-Term Survival in Infective Endocarditis

We aimed to investigate the impact of vegetation length on clinical complications during surgical intervention and long-term survival in infective endocarditis. This was a retrospective study of patients with infective endocarditis who underwent cardiac surgery between January 2006 and November 2022 at our hospital. 896 patients were divided into 2 groups: group I (vegetation length <10 mm, n = 448) and group II (vegetation length ≥10 mm, n = 448). There were 48 operative deaths (5.4%). Univariate and multivariate analyses showed that vegetation length is statistically significantly associated with destruction of the annulus (p <0.001), neurological complications before surgery (p <0.001), acute renal injury (p <0.001), prolonged intubation time (intubation time >24 hours) (p <0.001), prolonged intensive care unit (ICU) retention time (ICU retention time >3 days) (p <0.001), and in-hospital mortality (p <0.001), respectively. Our study showed that vegetation length is statistically significantly associated with destruction of the annulus, neurological complications before surgery, acute renal injury, prolonged intubation time, prolonged ICU retention time, in-hospital mortality, and 1-year mortality, respectively.

Vegetation Size, Multiplicity, and Position in Patients With Infective Endocarditis

BACKGROUND

Infective endocarditis is a life-threatening condition and is associated with embolic events. We aimed to evaluate the association of vegetation size, multiplicity, and position with cerebral embolism and late mortality in patients with infective endocarditis.

METHODS

We retrospectively reviewed patients with infective endocarditis who were admitted to a single institution between November 2005 and August 2017. A total of 419 patients with infective endocarditis were included in the study, 273 of whom had undergone surgery. The primary endpoint was all-cause mortality, and the secondary endpoint was cerebral embolism. Multivariate Cox regression and logistic regression analyses were performed to identify independent risk factors for 30-day mortality, late mortality, and cerebral embolism.

RESULTS

Age (hazard ratio [HR] 1.02; 95% confidence interval [CI], 1.00 to 1.04), renal failure (HR 4.21; 95% CI, 2.67 to 6.65), surgery (HR 0.31; 95% CI, 0.21 to 0.46), and Acute Physiology and Chronic Health Evaluation II score (HR 1.08; 95% CI, 1.01 to 1.15) were associated with late mortality. Vegetation size, multiplicity, and position were not significantly associated with late mortality, but a mitral vegetation size of greater than 10 mm (odds ratio 2.25; 95% CI, 1.32 to 3.84) was an independent risk factor for cerebral embolism.

CONCLUSIONS

A vegetation size of greater than 10 mm and the mitral position were found to be significant risk factors for cerebral embolism, and for this group, early surgery might be considered to prevent cerebral embolism.

Single-Centre Retrospective Evaluation of Intraoperative Hemoadsorption in Left-Sided Acute Infective Endocarditis

Background: Cardiac surgery in patients with infective endocarditis (IE) is still associated with high mortality and morbidity; an already present inflammation might further be aggravated due to a cardiopulmonary bypass-induced dysregulated immune response. Intraoperative hemoadsorption therapy may attenuate this septic response. Our objective was therefore to assess the efficacy of intraoperative hemoadsorption in active left-sided native- and prosthetic infective endocarditis. Methods: Consecutive high-risk patients with active left-sided infective endocarditis were enrolled between January 2015 and April 2021. Patients with intraoperative hemoadsorption (Cytosorbents, Princeton, NJ, USA) were compared to patients without hemoadsorption (control). Endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Predictors for sepsis-associated mortality and in-hospital mortality were analysed by multivariable logistic regression. Results: A total of 202 patients were included, 135 with active left-sided native and 67 with prosthetic valve infective endocarditis. Ninety-nine patients received intraoperative hemoadsorption and 103 patients did not. Ninety-nine propensity-matched pairs were selected for final analyses. Postoperative sepsis and sepsis-related mortality was reduced in the hemoadsorption group (22.2% vs. 39.4%, p = 0.014 and 8.1% vs. 22.2%, p = 0.01, respectively). In-hospital mortality tended to be lower in the hemoadsorption group (14.1% vs. 26.3%, p = 0.052). Key predictors for sepsis-associated mortality and in-hospital mortality were preoperative inotropic support, lactate-levels 24 h after surgery, C-reactive protein levels on postoperative day 1, chest tube output, cumulative inotropes and white blood cell counts on postoperative day 2, and new onset of dialysis. Multivariate regression analysis revealed intraoperative hemoadsorption to be associated with lower sepsis-associated (OR 0.09, 95% CI 0.013–0.62, p = 0.014) as well as in-hospital mortality (OR 0.069, 95% CI 0.006–0.795, p = 0.032). Conclusions: Intraoperative hemoadsorption holds promise to reduce sepsis and sepsis-associated mortality after cardiac surgery for active left-sided native and prosthetic valve infective endocarditis.

Endocardite Infecciosa: Ainda mais Desafios que Certezas

Após catorze décadas de evolução médica e tecnológica, a endocardite infeciosa continua a desafiar médicos no seu diagnóstico e manejo diário. O aumento da incidência, alterações demográficas (afetando pacientes mais idosos), microbiologia com taxas de infeção por Staphylococcus mais elevadas, com complicações graves ainda frequentes e uma mortalidade substancial tornam a endocardite uma doença muito complexa. Apesar de tudo, a inovação no seu diagnóstico, nomeadamente na área da microbiologia e imagem, e a melhoria nos cuidados intensivos e na cirurgia cardíaca (quanto às técnicas, materiais usados e momento de intervenção) podem ter um impacto no seu prognóstico. Os desafios persistem, incluindo repensar a profilaxia, melhorar os critérios de diagnóstico incluindo a endocardite com culturas negativas e endocardite de prótese valvar, o timing para a intervenção cirúrgica, e sua realização ou não na presença de acidente vascular cerebral isquêmico e em usuários de drogas intravenosas. Uma estratégia combinada na endocardite infeciosa é fundamental, incluindo decisões e protocolos clínicos avançados, um manejo multidisciplinar, organização e políticas de saúde que culminem em melhores resultados para os nossos pacientes.

Surgical Procedure Time and Mortality in Patients with Infective Endocarditis Caused by Staphylococcus aureus or Streptococcus Species

Staphylococcus aureus (SA) and Streptococcus species (SS) show different clinical manifestations in infective endocarditis (IE), but the impact on the complexity of surgical treatment remains unclear. All patients with surgically treated IE due to SA or SS between July 2013 and December 2016 were extracted from a prospectively collected, single-center registry. Data on patient characteristics, surgical procedures, and postprocedural outcomes were collected. SA-IE was more common with prosthetic valves (26.3% vs. 7.3%, p = 0.04), cardiac devices (14.3% vs. 0%, p = 0.03), previous cardiac surgery (28.6% vs. 9.8%, p = 0.03), intravenous drug abuse (14.3% vs. 0%, p = 0.03), and embolic events (57.1% vs. 26.8%, p = 0.007). Preoperative CRP was significantly higher in SA-IE (median 96.1 mg/L vs. 42.4 mg/L, p = 0.002). Otherwise, SS-IE affected more cusps/leaflets (mean 2.4 vs. 1.8, p = 0.03) and led to more valve dysfunction (83.8% vs. 54.3%, p = 0.007). Surgery times did not differ between the groups, though patients with SA spent more time in the intensive care unit (median 7 vs. 4.5 days, p = 0.04). Hospital mortality did not differ, but patients with SA-IE had unfavorable long-term survival (p = 0.001). Future studies need to be larger and focus on the mechanism behind the reduced long-term survival to mitigate the deleterious effect of SA in surgically treated patients with IE.

Outcomes of surgically treated infective endocarditis in a Western Australian population

Background

Infective endocarditis is a disease that carries high morbidity and mortality. The primary endpoint of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary endpoint of this study is to assess the incidence of post-operative stroke, renal failure, complete heart block and recurrence.

Methods

Between the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital, Western Australia. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record. A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital morbidity and mortality.

Results

A total of 89 patients underwent surgery for infective endocarditis from 2015 to 2019, affecting a total of 101 valves. The mean age of patients was 53.7 ± 16.5. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 h of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass time and cross clamp time. Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 11 patients developed a complete heart block post operatively (12%) and endocarditis recurred in 10 patients (11%).

Conclusion

Prolonged cardiopulmonary bypass times were significantly associated with mortality. This study is novel to report a lower mortality rate than previously quoted in the literature. We also report our findings of organisms, preoperative embolic phenomena and surgery in a Western Australian population. We recommend that all patients with endocarditis are discussed in multidisciplinary forum.

Infective endocarditis and outcomes of mitral valve replacement

BACKGROUND

We investigated the long-term outcomes of mitral valve replacement (MVR) in native mitral valve infective endocarditis (IE).

METHODS

Multicentre, population-based cohort register study consisted of 1233 consecutive adult patients treated with first-time MVR in Finland. Mitral valve IE was diagnosed in 170 of these patients. Propensity score matching resulted in 134 pairs with balanced baseline characteristics. The median follow-up was 6.1 years.

RESULTS

Pre-operative native mitral valve IE was associated with an increased hazard of 10-year mortality (38.8% vs 30.5%; HR 2.13; CI 1.17-3.85; P = .013) after MVR. Occurrence of major bleeding was higher in IE patients (26.0%) vs non-IE patients (23.4%) during the 10-year follow-up (HR 2.80; CI 1.01-7.77; P = .048). Hospital admission duration after MVR was longer in IE patients (median 28 vs 11 days; P < .0001). Cumulative ischaemic stroke rate was similar between patient groups (12.1% in IE vs 15.1% in non-IE; P = .493). Re-sternotomy was performed in 13.4% of IE patients and 9.0% of non-IE patients (P = .261).

CONCLUSIONS

Patients with native mitral valve IE have a higher risk of death and major bleeding after MVR than matched patients without IE. Results highlight the importance of complication prevention in these patients.

Surgical aortic valve replacement and infective endocarditis

BACKGROUND

We wanted to investigate the influence of native-valve infective endocarditis (IE) on long-term outcomes of surgical aortic valve replacement (SAVR).

METHODS

Native-valve patients with IE (n = 191) were compared to propensity score-matched patients without IE (n = 191), all treated with SAVR, in a multicentre, population-based cohort register study in Finland. The median follow-up was 6.2 years.

RESULTS

Infective endocarditis as the indication for SAVR was associated with an increased hazard of 10-year mortality (37.1% vs 24.2%; HR 1.83; CI 1.03-3.26; P = .039). Ischaemic stroke was also more frequent in IE patients during 10-year follow-up (15.8% vs 7.5%; HR 3.80; CI 1.42-10.18; P = .008). Major bleeding within first year after SAVR was more frequent in patients with IE (7.0% vs 2.9%; P = .038). Ten-year major bleeding rate was 32.4% in IE vs 24.5% in non-IE groups (P = .174). Aortic valve re-operation rate was 4.3% in IE vs 8.4% in non-IE groups (P = .975). Admission duration after SAVR was longer in IE (median 29 vs 9 days; P < .0001). There was no difference in 30-day mortality after SAVR.

CONCLUSIONS

Patients with native-valve IE have a higher risk of death, ischaemic stroke, and early major bleeding after SAVR than matched patients without IE. Results confirm the high risk for complications of IE patients after SAVR and highlight the importance of vigorous prevention of both stroke and bleeding after SAVR in these patients.

Clinical outcomes of percutaneous debulking of tricuspid valve endocarditis in intravenous drug users

OBJECTIVES

A retrospective case series of a percutaneous approach to debulk tricuspid valve endocarditis (TVE) using an 8 French mechanical aspiration system in patients with a history of intravenous drug use (IVDU) was reported. IVDU associated TVE is increasing in the United States and is associated with high mortality despite early surgical debridement. Patients with advanced disease, shock, and respiratory failure may not be candidates for surgical debridement or replacement. These patients have recurrent events despite medical therapy METHODS: About 25 patients with IVDU associated TVE with persistent bacteremia confirmed by repeat blood cultures after 72 hr of sensitivity directed antibiotics and presence of pulmonary emboli confirmed by computed tomographic (CT) scan, who had undergone percutaneous aspiration were included. Patients were all deemed high risk for surgical debridement by a CT surgeon and evaluated by an infectious disease consultant. Procedures were performed under moderate sedation with intracardiac echo and a steerable guide with a CAT8 Penumbra aspiration catheter.

RESULTS

There were no intraprocedural deaths or complications. About 36% had septic shock on presentation. Survival of index hospitalization was 88%. Repeat blood cultures showed no growth on all surviving patients. Readmission rate was 4% (n = 1) at 1 month. About 40% (n = 2) patients with septic shock survived at 1 month compared with 100% survival (n = 20) in those without shock. Presence of septic shock was associated with reduced survival at 1 month (p < .01).

CONCLUSION

Percutaneous mechanical aspiration with an 8 Fr system is a feasible, minimally invasive alternative to surgical debulking. Mortality remains high in those presenting with septic shock. Further studies are needed to evaluate long-term outcomes.

Burden of infective endocarditis in an Australian cohort of people who inject drugs

BACKGROUND

Infective endocarditis (IE) results in substantial morbidity and mortality in people who inject drugs (PWID).

AIMS

To describe the burden of IE and its outcomes in PWID.

METHODS

Retrospective cohort study of adults admitted to a tertiary referral centre in Melbourne, Australia, with IE due to injection drug use from 1997 to 2015.

RESULTS

Ninety-seven PWID with 127 episodes of IE were identified with a median acute inpatient stay of 37 days (1-84). Admission to an intensive care unit was required in 67/127 (53%) episodes. Twenty-seven percent (34/127) of episodes occurred in patients with a previous episode of endocarditis. One third (43/127, 34%) of episodes involved left-sided cardiac valves. Antimicrobial treatment was completed in 88 (70%) episodes. Valve surgery was performed in 25/127 (20%) episodes. Predictors of surgery in univariable analysis were left-sided cardiac involvement (risk ratio (RR) 6.0), severe valvular regurgitation (RR 2.6) and cardiac failure (RR 2.2) (all P < 0.005). Twenty (16%) episodes resulted in death. Predictors of mortality on univariable analysis were left-sided cardiac involvement (RR 6.4), and not completing treatment (RR 0.12; both P < 0.001). The average estimated cost per episode was AU$74 168.

CONCLUSIONS

IE causes a considerable burden of disease in PWID, with significant healthcare utilisation and cost. Surgery and death are not infrequent complications. In addition to ensuring completion of antimicrobial therapy, strategies such as opioid maintenance programmes may be useful in improving health outcomes for PWID.

Active Infective Native and Prosthetic Valve Endocarditis: Short- and Long-Term Outcomes of Patients after Surgical Treatment

Background: Active infective endocarditis (IE) is a serious disease associated with high mortality. The current study represents our experience over 18 years with surgical treatment for active infective native and prosthetic valve endocarditis (INVE, IPVE). Method: Analysis of 413 patients (171 with IPVE vs. 242 with INVE) who underwent cardiac surgery due to IE between 2002 and 2020. Results: Patients with IPVE were significantly older (64.9 ± 13.2 years vs. 58.3 ± 15.5 years; p < 0.001) with higher EuroSCORE II (21.2 (12.7; 41.8) vs. 6.9 (3.0; 17.0); p < 0.001)) and coronary heart disease (50.6% vs. 38.0%; p < 0.011). Preoperative embolization was significantly higher within INVE (35.5% vs. 16.4%; p < 0.001) with high incidence of cerebral embolization (18.6% vs. 7.6%; p = 0.001) and underwent emergency curative surgery than the IPVE group (19.6% vs. 10.6%; p < 0.001). However, patients with IPVE were significantly represented with intracardiac abscess (44.4% vs.15.7%; p < 0.001). Intraoperatively, the duration of surgery was expectedly significantly higher in the IPVE group (356 min vs. 244 min.; p = 0.001) as well as transfusion of blood (4 units (0–27) vs. 2 units (0–14); p < 0.001). Post-operatively, the incidence of bleeding was markedly higher within the IPVE group (700 mL (438; 1163) vs. 500 mL (250; 1075); p = 0.005). IPVE required significantly more permanent pacemakers (17.6% vs. 7.5%: p = 0.002). The 30-day mortality was higher in the IPVE group (24.6% vs. 13.2%; p < 0.003). Conclusion: Patients with INVE suffered from a higher incidence of cerebral embolization and neurological deficits than patients with IPVE. Surgical treatment in INVE is performed mostly as an emergency indication. However, patients with IPVE were represented commonly with intracardiac abscess, and had a higher indication of pacemaker implantation. The short- and long-term mortality rate among those patients was still high.

Hemoadsorption during Cardiopulmonary Bypass in Patients with Endocarditis Undergoing Valve Surgery: A Retrospective Single-Center Study

Background: Aim of this study was to evaluate the outcomes of endocarditis patients undergoing valve surgery with the Cytosorb^® hemoadsorption (HA) device during cardiopulmonary bypass. Methods: From 2009 until 2019, 241 patients had undergone valve surgery due to endocarditis at the Department of Cardiac Surgery, University Hospital of Basel. We compared patients who received HA during surgery (n = 41) versus patients without HA (n = 200), after applying inverse probability of treatment weighting. Results: In-hospital mortality, major adverse cardiac and cerebrovascular events and postoperative renal failure were similar in both groups. Demand for norepinephrine (88.4 vs. 52.8%; p = 0.001), milrinone (42.2 vs. 17.2%; p = 0.046), red blood cell concentrates (65.2 vs. 30.6%; p = 0.003), and platelets (HA vs. Control: 36.7 vs. 9.8%; p = 0.013) were higher in the HA group. In addition, a higher incidence of reoperation for bleeding (34.0 vs. 7.7 %; p = 0.011), and a prolonged length of in-hospital stay (15.2 (11.8 to 19.6) vs. 9.0 (7.1 to 11.3) days; p = 0.017) were observed in the HA group. Conclusions: No benefits of HA-therapy were observed in patients with infective endocarditis undergoing valve surgery.

Drug Use and Postoperative Mortality Following Valve Surgery for Infective Endocarditis: A Systematic Review and Meta-analysis

BACKGROUND

Infective endocarditis (IE) often requires surgical intervention. An increasingly common cause of IE is injection drug use (IDU-IE). There is conflicting evidence on whether postoperative mortality differs between people with IDU-IE and people with IE from etiologies other than injection drug use (non-IDU-IE). In this manuscript, we compare short-term postoperative mortality in IDU-IE vs non-IDU-IE through systematic review and meta-analysis.

METHODS

The review was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publication databases were queried for key terms included in articles up to September 2017. Randomized controlled trials, prospective cohorts, or retrospective cohorts that reported on 30-day mortality or in-hospital/operative mortality following valve surgery and that compared outcomes between IDU-IE and non-IDU-IE were included.

RESULTS

Thirteen studies with 1593 patients (n = 341 [21.4%] IDU-IE) were included in the meta-analysis. IDU-IE patients more frequently had tricuspid valve infection, Staphylococcus infection, and heart failure before surgery. Meta-analysis revealed no statistically significant difference in 30-day postsurgical mortality or in-hospital mortality between the 2 groups.

CONCLUSIONS

Despite differing preoperative clinical characteristics, early postoperative mortality does not differ between IDU-IE and non-IDU-IE patients who undergo valve surgery. Future research on long-term outcomes following valve replacement is needed to identify opportunities for improved healthcare delivery with IDU-IE.

Cardiac surgery in infective endocarditis and predictors of in-hospital mortality

INTRODUCTION

Infective endocarditis (IE) is a serious disease with significant in-hospital mortality (15-30%) despite advances in medical and surgical therapy.

AIMS

To perform a clinical characterization of patients undergoing cardiac surgery for IE and to identify factors that predict in-hospital mortality.

METHODS

We retrospectively analyzed 145 patients with IE admitted between January 2006 and October 2017.

RESULTS

The median age was 72 years. IE was acquired mainly in the community (69%), and involved the native aortic valve in 54% of patients, biological prosthetic valves in 22.1% and mechanical valves in 10.3%. Staphylococcus spp. (31.0%) were the most frequent etiological agents. Cardiac surgery was emergent in 29 patients, urgent in 108, and elective in eight. The main indications were heart failure (57.9%), large vegetations (20%), systemic embolism (17.2%) and valve dysfunction (15.2%). Overall, biological valves were implanted in 62.1% of patients and mechanical valves in 37.2%. A total of 19 patients (13.1%) died. Predictors of mortality were preoperative atrial fibrillation and lower left ventricular ejection fraction, postoperative severe valve regurgitation associated with cardiogenic shock, sepsis, septic shock associated with cardiogenic shock, cardiac tamponade, need for renal replacement therapy and, although without statistical significance, emergent surgery.

CONCLUSIONS

There is a need for better indicators to enable early identification of surgical candidates for IE, implementation of a heart team, and better surgical strategies, including more rapid intervention, more specific postoperative care, and optimal antibiotic therapy.

Determinants and consequences of positive valve culture when cardiac surgery is performed during the acute phase of infective endocarditis

The optimal timing of cardiac surgery in infective endocarditis (IE) remains debated: Early surgery decreases the risk of embolism, and heart failure, but is associated with an increased rate of positive valve culture. To determine the determinants, and the consequences, of positive valve culture when cardiac surgery is performed during the acute phase of IE, we performed a retrospective study of adult patients who underwent cardiac surgery for definite left-sided IE (Duke Criteria), in two referral centres. During the study period (2002-2016), 148 patients fulfilled inclusion criteria. Median age was 65 years [interquartile range, 53-73], male-to-female ratio was 2.9 (110/38). Cardiac surgery was performed after 14 days [5-26] of appropriate antibiotics. Valve cultures returned positive in 46 cases (31.1%). Factors independently associated with positive valve culture were vegetation size ≥ 10 mm (OR 2.83 [1.16-6.89], P = 0.022) and < 14 days of appropriate antibacterial treatment before surgery (OR 4.68 [2.04-10.7], P < 0.001). Positive valve culture was associated with increased risk of postoperative acute respiratory distress syndrome (37.0% vs. 15.7%, P = 0.008) but was associated neither with an increased risk of postoperative relapse nor with the need for additional cardiac surgery. Duration of appropriate antibacterial treatment and vegetation size are independently predictive of positive valve culture in patients operated during the acute phase of IE. Positive valve culture is associated with increased risk of postoperative acute respiratory distress syndrome.

Infective endocarditis - An update for dental surgeons

Infective endocarditis (IE) is associated with significant morbidity and mortality. The prevention of infective endocarditis, for many years, has involved the identification of at risk patients undergoing medical or dental procedures and the use of pre-procedural antibiotic prophylaxis. However, evidence regarding the effectiveness of such measures is lacking while evidence is mounting for the adverse effects of inappropriate antibiotic use. International guidelines for antibiotic prophylaxis were amended, radically in some cases to reflect this. Subsequent epidemiological observations of IE have shown mixed results, strengthening calls for well conducted randomised control trials, now that there is genuine clinical equipoise among clinicians about this question.

[Clinical features and prognosis of infective endocarditis patients with acute kidney injury]

OBJECTIVE

To investigate the clinical features and treatment of infective endocarditis (IE) patients with acute kidney injury (AKI), and to compare the adverse complications and outcome with IE patients without AKI.

METHODS

Clinical data of 100 IE cases in Peking University First Hospital from January 2002 to June 2018 were retrospectively reviewed. The patients were divided into AKI group (n=21) and non-AKI group (n=79) based on the AKI network (AKIN) definition. The clinical data and prognosis were compared between the two groups.

RESULTS

The incidence of AKI was 21%. The average age was (43.7±15.7) years, and the ratio of male to female was 3 ∶1. There was no significant difference in age and gender between the two groups. Compared with non-AKI group, the AKI group had more rash and lower limbs edema (P=0.017 and P=0.001), higher urine blood and protein positive rate (both P<0.001). Lower hemoglobin and serum albumin level (both P<0.001), worse clinical cardiac function (NYHA III-IV, P=0.033) were found in AKI group compared with non-AKI group. There was no significant difference in microbiologic positive rate and pathogenic bacteria sorts between the two groups. Nine patients refused surgery, and the other 91 cases underwent cardiac surgery with cardiopulmonary bypass under general anesthesia, including 19 cases of AKI group and 72 cases of non-AKI group. The ventilation time and intensive care unit (ICU) stay time were longer in AKI group than in non-AKI group (P=0.028 and P=0.003). AKI group needed more red blood cell transfusion (P=0.010). Using the last serum creatinine before surgery as basic level, there was more new-onset AKI cases in AKI group than in non-AKI group. During the median follow-up time 42 months, there was no significant difference in perioperative and follow-up mortality between the two groups (P=0.463 and P=0.581).

CONCLUSION

More perioperation complications occurred in IE patients with AKI, but no significant difference in in-hospital and follow-up mortality between the AKI and non-AKI groups was observed.

Outcome of early vs delayed surgery for infective mitral endocarditis

BACKGROUND AND AIM OF THE STUDY

Timing of surgery for infective endocarditis is controversial. The objective of this study was to report the outcomes of early vs delayed surgery (DS) of mitral endocarditis.

METHODS

We retrospectively reviewed all patients treated surgically for mitral endocarditis between 2005 and 2016 in a single center. We analyzed midterm outcomes of early surgery (ES; surgery within 7 days or less of prior directed antibiotic treatment) in comparison to DS (surgery after more than 7 days of prior directed antibiotic treatment).

RESULTS

Survival of all patients was 87% at one and 72% at 5 years. Mean follow-up time was 4.0 ± 3.1 years. Thirty-three (36.3%) patients were in the ES and 58 (63.7%) were in the DS group. Patients with ES were younger (47.4 vs 55.3 years), were in New York Heart Association class III or IV more frequently (97.0 vs 65.5%), and had higher EuroScore2 (15.6 vs 8.6%). The ES group had lower freedom from valve reoperation (98.2 vs 87.2%; P = .035) and the composite endpoint of >2 + regurgitation or reoperation at 5 years (98.2 vs 72.7%; P = .004).

CONCLUSIONS

ES was associated with a higher rate of reoperations and the composite endpoint of recurrent MR or reoperation.

Endocarditis in the setting of IDU: multidisciplinary management

PURPOSE OF REVIEW

The purpose of this article is to provide a brief overview of the medical and surgical management of infective endocarditis secondary to IDU, with a focus on the underlying substance use disorder.

RECENT FINDINGS

Patients with infective endocarditis secondary to IDU are often young with unique comorbidities including mental illness, chronic hepatitis C, HIV infection, which are often compounded by limited social and familial supports. The focus of management has been treatment of endocarditis using IV antibiotics alongside surgery. Surgical outcomes compare favorably with those of infective endocarditis in the general population but long-term outcomes of IDUs are significantly worse. This is primarily due to the high rate of recidivism of drug use and the risk of prosthetic valve infective endocarditis. Contemporary management of addiction utilizes an integrative approach, combining both pharmacologic and nonpharmacologic strategies while remaining patient-centered. Given the complexity of care required, we advocate for a multidisciplinary team-based approach including psychiatry, infectious disease, cardiology, cardiac surgery and social services.

SUMMARY

Infective endocarditis secondary to IDU remains a medical and surgical challenge with dismal outcomes. Here we offer practical suggestions on the multidisciplinary management of this challenging and high-risk patient cohort.

Infective Endocarditis in the Intravenous Drug Use Population at a Tertiary Hospital in Melbourne, Australia

BACKGROUND

Infective endocarditis has been associated with underlying cardiac pathology and streptococci infections. Intravenous drug use (IVDU) is increasingly implicated as a contributing factor, resulting in a shift to a younger patient demographic, tricuspid valve involvement, severe staphylococcal infection, and unique management challenges. The objective of this study was to describe the clinical features, management and outcomes of patients with IVDU-associated infective endocarditis in the Australian context.

METHODS

A retrospective review of all episodes of IVDU-associated infective endocarditis at a tertiary hospital in Melbourne, Australia, from 2008 to 2015, was conducted. Included cases met Duke Criteria for 'definite' or 'possible' infective endocarditis, and had a history of IVDU within 3 months of presentation. Demographic data, substance use history, clinical features, surgical intervention, follow-up, and mortality data was collected. We explored factors associated with surgical intervention, recurrence and mortality.

RESULTS

Fifty-five (55) episodes of IVDU-associated infective endocarditis were identified in 46 patients; the median age was 40 years and 58% were male. The tricuspid valve was most commonly affected (38%), and left heart pathology was documented in 53% of cases. Methicillin-sensitive Staphylococcus aureus was the most common pathogen (67%). Thirty-six (36%) per cent of patients underwent surgical intervention, and all patients received antibiotics as a component of treatment, with a median duration of 42 days (IQR 21, 42 days). Heart failure and a vegetation larger than 1 cm were significantly associated with surgical intervention. Total mortality was 14.5%; surgical mortality was 10%. Opioid replacement therapy and the absence of psychiatric co-morbidities were protective factors for surgical intervention and disease recurrence.

CONCLUSIONS

In contrast to common perception, left-sided endocarditis was more common than tricuspid valve endocarditis. Left heart pathology is typically a more severe clinical entity, however, our study determined mortality rates remained similar when compared to right heart pathology. Further research is required to assess rates of left sided disease in the IVDU population, and elucidate the relationship between IVDU and left heart pathology.

Demonstration of infective endocarditis by cardiac CT and transoesophageal echocardiography: comparison with intra-operative findings

Aims

We aimed to compare imaging findings of infective endocarditis between computed tomography (CT) and transoesophageal echocardiography (TEE) using surgical inspection as a reference standard.

Methods and results

Forty-nine patients (aged 54 ± 17 years, 69% men) who underwent pre-operative CT and TEE for infective endocarditis were included. Twelve of these patients had prosthetic valve endocarditis. Imaging findings of infective endocarditis were classified as vegetation, leaflet perforation, abscess/pseudoaneurysm, and paravalvular leakage. Diagnostic performances of CT and TEE were evaluated using surgical inspection as a reference standard. Interobserver agreements for CT findings were obtained using Cohen's κ test. The detection rates of infective endocarditis per patient with CT and TEE were 93.9% (46/49) and 95.9% (47/49), respectively. In per-imaging analysis, the sensitivities of CT and TEE were not significantly different for both native and prosthetic valve infective endocarditis (sensitivity: vegetation, 100% in TEE and 90.9% in CT; leaflet perforation, 87.5% in TEE and 50.0% in CT; abscess/pseudoaneurysm, 40.0% in TEE and 60.0% in CT; paravalvular leakage, 100% in TEE and 50.0% in CT). Interobserver agreements for CT findings were substantial or excellent (0.79-0.88).

Conclusion

Cardiac CT can accurately demonstrate infective endocarditis in pre-operative patients with a similar diagnostic accuracy to TEE. The interobserver agreements for the CT findings of infective endocarditis were excellent.

Effect of the Initial Strategy for Active Endocarditis Complicated With Acute Heart Failure

BACKGROUND

Early surgery for infective endocarditis (IE) with acute heart failure (AHF) is recommended, despite clinical results being unclear. We investigated the effect of initial treatment in such patients. Methods and Results: Outcomes for 470 patients with active IE who underwent valvular surgery during 2009-2016 were reviewed. Of them, 177 had symptomatic AHF when diagnosed with IE (excluding those with cardiogenic shock or intubated for AHF). They were divided into 2 groups based on initial treatment: Group S (underwent valvular surgery immediately; n=74) and Group M (received initial medical treatment for infection and HF; n=103). The median (interquartile range) waiting period from diagnosis to surgery in Groups S and M was 1 (1-3) and 15 (8-33) days, respectively (P<0.001). The 5-year survival rate was higher in Group S than Group M (80% vs. 64%; P=0.108). Group M was divided into Group P (initial medical treatment was effective and elective surgery was performed; n=62) and Group E (emergency surgery was necessary during medical treatment; n=41); overall 5-year survival was significantly worse in Group E than Group P (42% vs. 79%; P<0.012). In Group M, multivariate analysis indicated that Staphylococcus aureus infection (odds ratio 3.82; 95% confidence interval 1.19-13.3; P=0.024) was a significant risk factor for conversion to emergency surgery.

CONCLUSIONS

Considering poor outcomes of emergency surgery for medically refractory HF, early surgery may be a reasonable option for IE patients, especially those with S. aureus infection.

Right-sided infective endocarditis with coronary sinus vegetation

Background

Infective endocarditis (IE) is a rare disease with high mortality. Right-sided IE accounts for 5–10% of cases of IE. The tricuspid valve is most commonly affected, oppositely in coronary sinus (CS). The diagnoses, treatments and outcomes of CS vegetation has not been summarized yet.

Case presentation

We present a 71-year-old man complained of cough and fever. Transthoracic echocardiography revealed the aneurysmal dilated CS with the band medium-echo mobile structure. A sinus venosus atrial septal defect has been detected. He had a persistent left superior vena cava which drained the right atrium via the aneurysmal dilated CS. Blood cultures were positive for Staphylococcus aureus. After intravenous antibiotic therapy, he had the symptom of dyspnea. The suspicious diagnosis is recurrent septic lung emboli which was confirmed by thoracic contrast enhanced computed tomography. The thoracotomy was performed to repair the atrial septum and remove the CS vegetation. Ten days later, the patient was discharged with only mild cough.

Conclusion

Both positive blood cultures and echocardiography are major criteria in right-sided IE with CS vegetation. Current treatment options of CS vegetation include medical therapy and surgery. The surgical strategy for CS vegetation should be individualized, due to the controversial indications and optimum time of surgery. Most people have a good prognosis after proper treatment.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0845-x) contains supplementary material, which is available to authorized users.

Surgery for prosthetic valve endocarditis: a retrospective study of a national registry

OBJECTIVES

We described clinical-epidemiological features of prosthetic valve endocarditis (PVE) and assessed the determinants of early surgical outcomes in multicentre design.

METHODS

Data regarding 2823 patients undergoing surgery for endocarditis at 19 Italian Centers between 1979 and 2015 were collected in a database. Of them, 582 had PVE: in this group, the determinants of early mortality and complications were assessed, also taking into account the different chronological eras encompassed by the study.

RESULTS

Overall hospital (30-day) mortality was 19.2% (112 patients). Postoperative complications of any type occurred in 256 patients (44%). Across 3 eras (1980-2000, 2001-08 and 2009-14), early mortality did not significantly change (20.4%, 17.1%, 20.5%, respectively, P  = 0.60), whereas complication rate increased (18.5%, 38.2%, 52.8%, P  < 0.001), consistent with increasing mean patient age (56 ± 14, 64 ± 15, 65 ± 14 years, respectively, P  < 0.001) and median logistic EuroSCORE (14%, 21%, 23%, P  = 0.025). Older age, female sex, preoperative serum creatinine >-2 mg/dl, chronic pulmonary disease, low ejection fraction, non-streptococcal aetiology, active endocarditis, preoperative intubation, preoperative shock and triple valve surgery were significantly associated with mortality. In multivariable analysis, age (OR = 1.02; P  = 0.03), renal insufficiency (OR = 2.1; P  = 0.05), triple valve surgery (OR = 6.9; P  = 0.004) and shock (OR = 4.5; P  < 0.001) were independently associated with mortality, while streptococcal aetiology, healed endocarditis and ejection fraction with survival. Adjusting for study era, preoperative shock (OR = 3; P  < 0.001), Enterococcus (OR = 2.3; P  = 0.01) and female sex (OR = 1.5; P  = 0.03) independently predicted complications, whereas ejection fraction was protective.

CONCLUSIONS

PVE surgery remains a high-risk one. The strongest predictors of early outcome of PVE surgery are related to patient's haemodynamic status and microbiological factors.

Surgery for Infective Endocarditis: Outcomes and Predictors of Mortality in 360 Consecutive Patients

BACKGROUND A retrospective analysis was conducted of the early and long-term outcomes after surgery for infective endocarditis (IE). MATERIAL AND METHODS We included 360 patients with IE operated upon between 1993 and 2012. The primary endpoint was overall cumulative postoperative survival at 30 days. Secondary endpoints were early postoperative outcomes and complication rates. Factors associated with 30-day mortality were analyzed. RESULTS Mean age was 58.7±14.7 years and 26.9% (n=97) were female. The mean follow-up was 4.41±4.53 years. Postoperative survival was 81.7% at 30 days, 69.4% at 1 year, 63.3% at 5 years, and 63.3% at 10 years. Non-survivors were significantly older (p=0.014), with higher NYHA Class (p=0.002), had higher rates of preoperative diabetes mellitus (p=0.005), renal failure (p=0.001), and hepatic disease (p=0.002). Furthermore, non-survivors had higher baseline alanine aminotransferase (ALT, p=0.048), aspartate transaminase (AST, p=0.027), bilirubin (p=0.013), white cell count (WCC, p=0.034), and CRP (p=0.049). Factors associated with 30-day mortality were longer duration of surgery, CPB, and aortic cross-clamping times (p<0.001, p<0.001, and p=0.003, respectively), as well as higher RBC, FFP, and platelet transfusion requirements (p<0.001, p=0.005, and p<0.001, respectively). Multivariate logistic regression analysis revealed liver cirrhosis (OR 4.583, 95-CI: 1.096-19.170, p=0.037) and longer CPB time (OR 1.025, 95-CI 1.008-1.042, p=0.004) as independent predictors of 30-day mortality. CONCLUSIONS Surgical treatment of IE shows satisfactory early, midterm, and long-term results. Multivariate logistic regression analysis revealed cirrhosis and longer CPB time as independent predictors of 30-day mortality.

Risk and outcomes of aortic valve endocarditis among patients with bicuspid and tricuspid aortic valves

Objective

Patients with structural abnormalities of cardiac valves, including bicuspid aortic valve (BAV), are said to be at higher risk of infective endocarditis (IE). We sought to determine the risk of IE of the BAV compared with the tricuspid aortic valve (TAV) and to determine the risk of aortic valve replacement and mortality after IE.

Methods

From medical records of two US and one Italian hospitals, patients with their first episode of IE of any native valve were identified. In the US cohort 42 patients with BAV and 393 patients with TAV with IE occurring between 1 January 2000 and 30 June 2014 were identified. In the Italian cohort 48 patients with BAV and 341 patients with TAV with IE underwent valve replacement surgery between 1 January 2000 and1 November 2015. The risk of IE for BAV and TAV and subsequent outcomes were determined after matching to patients without IE.

Results

After adjustment for risk factors, the risk of IE in the US cohort was 23.1 (95% CI 8.1 to 100, p <0.0001) times greater for BAV than TAV. Patients with BAV with IE were more likely to have an aortic root abscess. Within the subsequent 5 years, BAV patients with IE were more likely to undergo valve replacement (85%) than TAV patients with IE (46%). Patients with IE were at increased risk of death. The findings were similar in the Italian cohort.

Conclusions

Patients with BAV are at markedly increased risk of IE and aortic root abscess than patients with TAV. Increased risk of IE in patients with BAV indicates they may be a candidate group for long-term trials of antibiotic prophylaxis of IE.

Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Practical Recommendations for Clinicians

There has been an overall improvement in surgical mortality for patients with infective endocarditis (IE), presumably because of improved diagnosis and management, centered around a more aggressive early surgical approach. Surgery is currently performed in approximately half of all cases of IE. Improved survival in surgery-treated patients is correlated with a reduction in heart failure and the prevention of embolic sequelae. It is reported that between 20% and 40% of patients with IE present with stroke or other neurological conditions. It is for these IE patients that the timing of surgical intervention remains a point of considerable discussion and debate. Despite evidence of improved survival in IE patients with earlier surgical treatment, a significant proportion of patients with IE and preexisting neurological complications either undergo delayed surgery or do not have surgery at all, even when surgery is indicated and guideline endorsed. Physicians and surgeons are caught in a common conundrum where the urgency of the heart operation must be balanced against the real or perceived risks of neurological exacerbation. Recent data suggest that the risk of neurological exacerbation may be lower than previously believed. Current guidelines reflect a shift toward early surgery for such patients, but there continue to be important areas of clinical equipoise. Individualized clinical assessment is of major importance for decision making, and, as such, we emphasize the need for the functioning of an endocarditis team, including cardiac surgeons, cardiologists, infectious diseases specialists, neurologists, neurosurgeons, and interventional neuroradiologists. Here, we present 2 illustrative cases, critically review contemporary data, and offer conceptual and practical suggestions for clinicians to address this important, common, and often fatal cardiac condition.

The role of biofilms in persistent infections and factors involved in ica-independent biofilm development and gene regulation in Staphylococcus aureus

Staphylococcus aureus biofilms represent a unique micro-environment that directly contribute to the bacterial fitness within hospital settings. The accumulation of this structure on implanted medical devices has frequently caused the development of persistent and chronic S. aureus-associated infections, which represent an important social and economic burden worldwide. ica-independent biofilms are composed of an assortment of bacterial products and modulated by a multifaceted and overlapping regulatory network; therefore, biofilm composition can vary among S. aureus strains. In the microniches formed by biofilms-produced by a number of bacterial species and composed by different structural components-drug refractory cell subpopulations with distinct physiological characteristics can emerge and result in therapeutic failures in patients with recalcitrant bacterial infections. In this review, we highlight the importance of biofilms in the development of persistence and chronicity in some S. aureus diseases, the main molecules associated with ica-independent biofilm development and the regulatory mechanisms that modulate ica-independent biofilm production, accumulation, and dispersion.

Effect of perioperative sodium bicarbonate administration on renal function following cardiac surgery for infective endocarditis: a randomized, placebo-controlled trial

Background

Patients with infective endocarditis (IE) have an elevated risk of renal dysfunction because of extensive systemic inflammation and use of nephrotoxic antibiotics. In this randomized, placebo-controlled trial, we investigated whether perioperative sodium bicarbonate administration could attenuate postoperative renal dysfunction in patients with IE undergoing cardiac surgery.

Methods

Seventy patients randomly received sodium chloride (n = 35) or sodium bicarbonate (n = 35). Sodium bicarbonate was administered as a 0.5 mmol/kg loading dose for 1 h commencing with anesthetic induction, followed by a 0.15 mmol/kg/h infusion for 23 h. The primary outcome was peak serum creatinine (SCr) level during the first 48 h postoperatively. The incidence of acute kidney injury, SCr level, estimated glomerular filtration rate, and major morbidity endpoints were assessed postoperatively.

Results

The peak SCr during the first 48 h postoperatively (bicarbonate vs. control: 1.01 (0.74, 1.37) mg/dl vs. 0.88 (0.76, 1.27) mg/dl, P = 0.474) and the incidence of acute kidney injury (bicarbonate vs. control: 29% vs. 23%, P = 0.584) were similar in both groups. The postoperative increase in SCr above baseline was greater in the bicarbonate group than in the control group on postoperative day 2 (0.21 (0.07, 0.33) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.028) and postoperative day 5 (0.23 (0.08, 0.36) mg/dl vs. 0.06 (0.00, 0.23) mg/dl, P = 0.017).

Conclusions

Perioperative sodium bicarbonate administration had no favorable impact on postoperative renal function and outcomes in patients with IE undergoing cardiac surgery. Instead, it was associated with possibly harmful renal effects, illustrated by a greater increase in SCr postoperatively, compared to control.

Trial registration

ClinicalTrials.gov, NCT01920126. Registered on 31 July 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1591-z) contains supplementary material, which is available to authorized users.