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Abdel-Haq N, Shawaqfeh A, Gupta S, Ang JY, Thomas R, Asmar BI. Infective Endocarditis at a Referral Children's Hospital During 19-Year Period: Trends and Outcomes. Pediatr Cardiol 2024; 45:1741-1749. [PMID: 37610636 DOI: 10.1007/s00246-023-03274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND We noted a recent increase in cases of infective endocarditis (IE) at our institution. The purpose of the study is to examine the incidence, risk factors, microbiology and outcome of IE in our pediatric population. METHODS Retrospective review of IE cases during 2002-2020 at Children's Hospital of Michigan, Detroit. RESULTS 68 patients with IE were identified. There was a 2-fold increase in incidence during the 2012-2020 (late period) compared to the 2002-2011 (early period). The most common predisposing conditions were congenital heart disease (CHD) in 39 (57.4%) and central venous catheter (CVC) in 19 (27.9%). CHD was more frequent in the late period (29/43, 67.4%) compared to early period (10/25, 40.0%) (p = 0.042). In CHD patients, palliative or corrective cardiac surgery was performed prior to IE diagnosis in 4/25 (16%) in early period and 23/43 (53.5%) in the late period (p = 0.004). S. aureus was the most common causative organism (35.3%) followed by streptococci (22.1%). Valve replacement or valvuloplasty was performed in 22.1% of patients. Complications occurred in 20 (29.4%). Mortality occurred in 7 (10.3%): 3 had CHD, 3 had CVC and underlying conditions and 1 had fulminant MRSA infection. CONCLUSION(S) The higher incidence of IE during the late period is likely due to an increase in patients with CHD who had undergone prior cardiac surgery. S. aureus was the predominant pathogen in all patients including those with CHD, followed by streptococci. IE in children continues to be associated with high rates of morbidity and mortality.
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Affiliation(s)
- Nahed Abdel-Haq
- Children's Hospital of Michigan, Detroit, MI, USA.
- Central Michigan University, Mount Pleasant, MI, USA.
- Wayne State University, Detroit, MI, USA.
- Division of Infectious Diseases, Children's Hospital of Michigan, 3901 Beaubien Blvd Detroit, Mount Pleasant, MI, 48201, USA.
| | | | | | - Jocelyn Y Ang
- Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mount Pleasant, MI, USA
- Wayne State University, Detroit, MI, USA
| | - Ronald Thomas
- Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mount Pleasant, MI, USA
| | - Basim I Asmar
- Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mount Pleasant, MI, USA
- Wayne State University, Detroit, MI, USA
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2
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Marín-Cruz I, Pedrero-Tomé R, Toral B, Flores M, Orellana-Miguel MÁ, Boni L, Belda-Hofheinz S, Prieto-Tato LM, Fernández-Cooke E, Epalza C, López-Medrano F, Rojo P, Blázquez-Gamero D. Infective endocarditis in pediatric patients: a decade of insights from a leading Spanish heart surgery reference center. Eur J Pediatr 2024; 183:3905-3913. [PMID: 38913227 PMCID: PMC11322191 DOI: 10.1007/s00431-024-05606-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 06/25/2024]
Abstract
Infective endocarditis (IE) is a rare disease in children and is associated with significant morbidity and mortality. In recent years, significant changes have occurred in pediatric care that could have influenced the microbiology and presentation of IE. The aim of this work was to study epidemiological, microbiological, and clinical features of IE treated at a Pediatric Cardiac Surgery Reference Center located in Madrid (Spain) in a 10-years' period. A descriptive observational retrospective study was performed, including pediatric patients < 16 years old with definite or possible IE admitted to a reference center between January 2012 and December 2021. Thirty-two IE episodes were identified. Twenty-eight (87.5%) had congenital heart disease (CHD), 8 (25.0%) were preterm infants, 1 (3.1%) was immunocompromised and 6 (18.8%) had other chronic conditions; in 11 (34.4%) episodes more than one underlying condition was associated. In 20 (62.5%) episodes there was an indwelling central venous catheter (CVC); children with other comorbidities (preterm, immunocompromised, other chronic conditions) were more likely to have a CVC at diagnosis compared with patients with isolated CHD (p < 0.001). Thirty-six microbiological isolates were obtained in the 32 episodes; 4 (12.5%) episodes had 2 isolated microorganisms. Microbiological isolates were 20 (55.6%) Gram-positive bacteria (GPB), 10 (27.8%) non-HACEK Gram-negative bacteria (GNB), 1 (2.8%) HACEK-group bacterium, 4 (11.1%) fungi and 1 (2.8%) Coxiella burnetii. In 10 (31.3%) episodes, patients were colonized by multidrug-resistant bacteria (MDRB) and the etiology of IE in 3 (30.0%) of those episodes was the colonizing MDRB. MDRB colonization was associated with MDRB IE (p = 0.007). The most common complication was septic embolism: 11 (34.4%) episodes (9 pulmonary and 2 cerebral). In-hospital mortality was 6.3% (n = 2), all of them due to underlying conditions and not to IE or its complications. Clinical features and complications of IE episodes caused by non-HACEK GNB and those caused by GPB were compared, finding no statistically significant differences. Conclusion: Risk factors for developing IE, the proportion of embolic complications, and mortality rate were consistent with previously published findings. Proportion of IE cases attributed to non-HACEK GNB was higher than previously reported, suggesting an evolving epidemiology of IE. One-third of children colonized with MDRB subsequently developed IE caused by the same MDRB strains, so empirical coverage of MDRB organisms must be considered when IE is suspected in MDRB colonized patients. No significant differences in clinical features and complications were observed when comparing IE episodes caused by non-HACEK GNB and those caused by GPB, however larger cohort studies are needed. What is Known: • Infective endocarditis (IE) is a rare disease in children, associated with significant morbidity and mortality. • The main risk factor for developing IE in children is an underlying congenital heart disease. What is New: • With current changing epidemiology in pediatric IE, a higher proportion of IE caused by non-HACEK Gram-negative bacteria should be expected. • A significant percentage of children colonized by multidrug-resistant bacteria can develop an IE due to those bacteria.
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Affiliation(s)
- Inés Marín-Cruz
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | - Belén Toral
- Pediatric Cardiology, Instituto Pediátrico del Corazón, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marta Flores
- Pediatric Cardiology, Instituto Pediátrico del Corazón, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María Ángeles Orellana-Miguel
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
- Microbiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Lorenzo Boni
- Cardiothoracic Surgery, Instituto Pediátrico del Corazón, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sylvia Belda-Hofheinz
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
- Pediatric Intensive Care Unit, Hospital Universitario 12 de Octubre, Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
- Mother-Child Health and Development Network (Red SAMID), Carlos-III Health Institute, Madrid, Spain
| | - Luis M Prieto-Tato
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Elisa Fernández-Cooke
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Cristina Epalza
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Francisco López-Medrano
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
- Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Pablo Rojo
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
- Universidad Complutense de Madrid, Madrid, Spain
| | - Daniel Blázquez-Gamero
- Pediatric Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain.
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.
- Universidad Complutense de Madrid, Madrid, Spain.
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3
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Lupu A, Nedelcu AH, Budescu PD, Jechel E, Starcea IM, Frasinariu OE, Ioniuc I, Badescu MC, Salaru DL, Munteanu D, Russu R, Sascau RA, Statescu C, Lupu VV. Pediatric endocarditis - a stone left after the pandemic cascade. Front Cell Infect Microbiol 2024; 14:1393315. [PMID: 39077433 PMCID: PMC11284175 DOI: 10.3389/fcimb.2024.1393315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 07/01/2024] [Indexed: 07/31/2024] Open
Abstract
Infective endocarditis is a rare disease in children. The etiology is mainly bacterial. However, viral infective endocarditis, possibly related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has also been reported. The pathophysiological principle of the connection between the two entities seems to be attributed to the transient immune deficiency of the body during the infection. Additionally, SARS-CoV-2 is reported in the literature as a direct cardiopathic virus. Therefore, the new coronavirus seems to have the ability to affect both the intact cardiac tissue and the previously damaged one both during the acute episode and at a distance from it. Consequently, we propose to review the main pathophysiological aspects of pediatric cardiac damage caused by SARS-CoV-2. The ultimate goal is to deepen existing knowledge, broaden the horizon of understanding and analysis regarding the systemic damage induced by viral infections, and strengthen an information base from which to start a meta-analysis. Next, we performed a non-systematized screening of the specialized literature with reference to cases of endocarditis in the pediatric population, reported in the period 2020-2023. From the total of articles found, we chose to include in the review a number of 6 case reports, including a number of 7 patients (5 children and 2 adolescents). Analysis of reports suggests that SARS-CoV-2 infection could play a role in the development of endocarditis, either directly through active infection or indirectly through a post-infectious immune response. Also, pre-existing conditions and complex medical history predispose to an increased risk of developing a severe, complicated form of endocarditis. Also, the lack of data on the vaccination history and the failure to categorize the infection depending on the type of antibodies (IgM or IgG) in some studies represent a major bias in the reports. The latter make it difficult to evaluate the influence of vaccination and the impact of acute versus chronic infection on the course of cases.
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Affiliation(s)
| | | | - Paula Diana Budescu
- *Correspondence: Alin Horatiu Nedelcu, ; Paula Diana Budescu, ; Elena Jechel,
| | - Elena Jechel
- *Correspondence: Alin Horatiu Nedelcu, ; Paula Diana Budescu, ; Elena Jechel,
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Essa Y, Said SM. Diagnostic work-up and current management strategies for infective endocarditis in the pediatric population. Indian J Thorac Cardiovasc Surg 2024; 40:29-39. [PMID: 38827553 PMCID: PMC11139826 DOI: 10.1007/s12055-024-01700-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 06/04/2024] Open
Abstract
Infective endocarditis (IE) remains a serious disease that is associated with significant morbidity and mortality, and despite the significant advances that have been made in understanding the disease process in past decades, its incidence appears to be on the rise recently. Endocarditis in children is no longer a rare occurrence. This appeared to be related to a combination of the improved survival of children with congenital heart diseases (CHDs), increase use of intracardiac protheses, and catheter-related interventions. The American Heart Association (AHA) 2007 guidelines reduced the recommendations for use of prophylactic antibiotics in those with CHDs which occurred despite the noticeable increase in endocarditis incidence around that time. In general, the recommendations for managing children with IE are derived from the adults' guidelines, and the evidence-base is lacking in many clinical scenarios. Understanding the epidemiology, clinical presentations, microbiology, and outcomes of different management strategies for endocarditis is needed to have a clear and optimal plan for these children. In the current narrative review, we discuss IE in the pediatric population in terms of etiology, predisposing factors, and different treatment strategies for this unique population.
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Affiliation(s)
- Yasin Essa
- Department of Surgery, Division of Pediatric and Adult Congenital Cardiac Surgery, Maria Fareri Children’s Hospital, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595 USA
| | - Sameh M. Said
- Department of Surgery, Division of Pediatric and Adult Congenital Cardiac Surgery, Maria Fareri Children’s Hospital, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595 USA
- Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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5
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Iyer KS. The infected right ventricular outflow tract in children and adults with congenital heart disease. Indian J Thorac Cardiovasc Surg 2024; 40:110-114. [PMID: 38827552 PMCID: PMC11139819 DOI: 10.1007/s12055-024-01748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/20/2024] [Accepted: 04/28/2024] [Indexed: 06/04/2024] Open
Abstract
Abnormalities of the right ventricular outflow tract are common within the spectrum of congenital heart disease. Reconstruction of this outflow with or without the use of prosthetic material forms an integral part of many surgical procedures. Consequently, this part of the heart constitutes an important locus for infective endocarditis. Focused literature on infective endocarditis of the right ventricular outflow is sparse. This narrative review therefore attempts to collate the currently available data on a subject that is gaining importance because of the increasing numbers of surgical and catheter-based interventions on the right ventricular outflow. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-024-01748-z.
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Affiliation(s)
- Krishna Subramony Iyer
- Pediatric & Congenital Heart Surgery, Fortis Escorts Heart Institute, Okhla Road, New Delhi, 110025 India
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Duval L, Lagrange-Xelot M, Moiton MP, Bourgoin P, Pommier V, Abdelmoumen K, Robin S, Rouquette V, Levin C. A Rare Case of Endocarditis in a Teenager. Pediatr Infect Dis J 2024; 43:e145-e146. [PMID: 38100723 DOI: 10.1097/inf.0000000000004224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Laure Duval
- Department of Pediatrics, CHU Felix Guyon, Reunion Island, France
| | | | | | - Pierre Bourgoin
- Department of Pediatric Intensive Care Unit, CHU Nantes, Nantes, France
| | - Victor Pommier
- Department of Pediatric Cardiology, CHU Felix Guyon, Reunion Island, France
| | - Karim Abdelmoumen
- Department of Infectious Disease, Mayotte Hospital Center, Mayotte Island, France
| | - Stéphanie Robin
- Department of Pediatrics, CHU Felix Guyon, Reunion Island, France
| | - Virginie Rouquette
- Department of Anonymous Screening and Information Center, Mayotte Hospital Center, Mayotte Island, France
| | - Cécile Levin
- Department of Pediatrics, CHU Felix Guyon, Reunion Island, France
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7
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Joye R, Cousin VL, Malaspinas I, Mwizerwa L, Bouhabib M, Nalecz T, Sologashvili T, Beghetti M, L’Huillier AG, Wacker J. Infective Endocarditis Due to Kingella kingae. Microorganisms 2024; 12:164. [PMID: 38257992 PMCID: PMC10819173 DOI: 10.3390/microorganisms12010164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
Infective endocarditis due to Kingella kingae is a rare but serious invasive infection that occurs mostly in children. Recent advances in nucleic acid amplification testing as well as in cardiac imaging have enabled more accurate diagnosis. A good understanding of the epidemiology and virulence factors remains crucial to guide the therapeutic approach. Here, we synthesize the current state of knowledge on epidemiological features, pathophysiological insights, complications, and therapy regarding Kingella kingae endocarditis in children and adults. Finally, throughout this comprehensive review, knowledge gaps and areas for future research are also identified.
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Affiliation(s)
- Raphael Joye
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
| | - Vladimir L. Cousin
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
- Pediatric Intensive Care Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Iliona Malaspinas
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
| | - Leonce Mwizerwa
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
| | - Maya Bouhabib
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
| | - Tomasz Nalecz
- Pediatric Cardiac Surgery Unit, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (T.N.); (T.S.)
| | - Tornike Sologashvili
- Pediatric Cardiac Surgery Unit, Department of Surgery, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (T.N.); (T.S.)
| | - Maurice Beghetti
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
| | - Arnaud G. L’Huillier
- Pediatric Infectious Disease Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Julie Wacker
- Pediatric Cardiology Unit, Department of Woman, Child, and Adolescent Medicine, Faculty of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (V.L.C.); (I.M.); (L.M.); (M.B.); (J.W.)
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Goycochea-Valdivia WA, Aboza-García M, Moreno-Pérez de Tudela R, Carazo-Gallego B, Roldan-Tormo E, Ruiz-Sáez B, Vázquez-Pérez Á, Peromingo-Matute E, Croche-Santander B, Obando-Pacheco P, Obando-Santaella I. Infective endocarditis in paediatric patients from Andalusia (Spain), 2008-2020. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:549-558. [PMID: 36464618 DOI: 10.1016/j.eimce.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Paediatric infective endocarditis (IE) is a serious condition associated with significant mortality. Information in Spain is limited and comes from case series from single centres. The aim was to describe the epidemiology, clinical features, microbiology and outcome of paediatric IE in Andalusia. PATIENTS AND METHODS Multi-centre descriptive observational retrospective study of patients <18 years old with a diagnosis of IE who were admitted to six Andalusian hospitals during 2008-2020. RESULTS 44 episodes of IE (41 patients) with a median age of 103 months (IQR 37-150 months) were identified. Congenital heart disease (CHD) was the main predisposing factor, identified in 34 cases (77%). A total of 21 (48%) episodes of IE occurred in patients with prosthetic material. These had higher rate of CHD (p = 0.002) and increased end organ dysfunction (p = 0.04) compared to those with native valve. Fever was an almost universal symptom, associated in 23% of the episodes with heart failure. Staphylococcus aureus (25%) followed by coagulase-negative staphylococci (18%) and Streptococcus viridans (14%) were the most frequently isolated microorganisms, and three (7%) patients with central venous catheters had a fungal infection. Thromboembolic events were observed in 30% of the episodes, surgical intervention was required in 48% of cases. Mortality rate was 9%. Prosthetic material and CRP > 140 mg/L were independent predictors of complicated IE. CONCLUSIONS Our findings emphasize the high morbidity of paediatric IE. The information provided could be useful for the identification of epidemiological and clinical profiles of children with IE and complicated forms.
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Affiliation(s)
| | - Marta Aboza-García
- Unidad de Infectología e Inmunopatologías Pediátricas, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Begoña Carazo-Gallego
- Sección de Infectología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Elena Roldan-Tormo
- Sección de Infectología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Beatriz Ruiz-Sáez
- Unidad de Infecciosas Pediátricas, Hospital Universitario Reina Sofía, Córdoba, Spain
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 268] [Impact Index Per Article: 268.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Demir F, Varan C, Erdem S, Atmış A, Akbaş T, Subaşı B, Güzel Y, Özbarlas N. Infective endocarditis in childhood: a single-centre experience of 26 years. Cardiol Young 2023; 33:1950-1955. [PMID: 36419327 DOI: 10.1017/s1047951122003419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to present the clinical and microbiological characteristics of patients with infective endocarditis.A retrospective evaluation was made of patients diagnosed with infective endocarditis between 1995 and 2021. The clinical and laboratory characteristics of the patients were recorded together with conditions constituting a risk for the development of endocarditis, treatment, and surgical outcomes.Evaluation was made of 68 patients with a mean age of 7.3 years (3 months-17 years), diagnosed with infective endocarditis. An underlying cause of CHD was determined in 47 (69%) patients and rheumatic valve disease in 3 (4.4%). There was no structural heart disease in 18 (26%) patients of whom 13 of them had other risk factors. A causative organism was found in 41 (60%) cases, and the microorganism most often determined was viridans group streptococcus. No difference was determined between the patients diagnosed before and after 2007 in respect of the frequency of viridans streptococcus (p > 0.05). Septic emboli were seen in 18 (26%) patients, of which 17 required surgical treatments. In 5 of 11 (16.6%) patients with mortality, the agent was S. aureus. Of the total 28 (41%) patients were evaluated as hospital-acquired endocarditis. The most frequently determined agents in this group were staphylococcus epidermidis and S. aureus.Although CHDs continue to be the greatest risk factor for endocarditis, there is an increasing frequency of endocarditis in patients with no structural heart disease. Mortality rates are still high in infective endocarditis, especially in S. aureus endocarditis.
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Affiliation(s)
- Fadli Demir
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Celal Varan
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Sevcan Erdem
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Anıl Atmış
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Tolga Akbaş
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Berivan Subaşı
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Yasin Güzel
- Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - Nazan Özbarlas
- Department of Pediatric Cardiology, Faculty of Medicine, Çukurova University, Adana, Turkey
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Dardari M, Cinteza E, Vasile CM, Padovani P, Vatasescu R. Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies. J Clin Med 2023; 12:4941. [PMID: 37568344 PMCID: PMC10420327 DOI: 10.3390/jcm12154941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.
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Affiliation(s)
- Mohamed Dardari
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.D.); (R.V.)
- Electrophysiology and Cardiac Pacing Lab., Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Eliza Cinteza
- Interventional Cardiology Compartment, Marie Sklodowska Curie Children Emergency Hospital, 041451 Bucharest, Romania
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Corina Maria Vasile
- Pediatric and Adult Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, 33600 Bordeaux, France
| | - Paul Padovani
- Nantes Université, CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, 44000 Nantes, France;
| | - Radu Vatasescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (M.D.); (R.V.)
- Electrophysiology and Cardiac Pacing Lab., Clinical Emergency Hospital, 014461 Bucharest, Romania
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The Epidemiology of Infective Endocarditis in New South Wales, Australia: A Retrospective Cross-Sectional Study From 2001 to 2020. Heart Lung Circ 2023; 32:506-517. [PMID: 36775764 DOI: 10.1016/j.hlc.2022.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/30/2022] [Accepted: 12/07/2022] [Indexed: 02/12/2023]
Abstract
OBJECTIVES This study aimed to investigate the demographic differences amongst patients diagnosed with infective endocarditis (IE), predictors of adverse events, and the association between clinical decision-making and adverse health outcomes amongst patients with IE. DESIGN A retrospective cross-sectional study was conducted using the New South Wales (NSW) Admitted Patient Data Collection (APDC) from the Centre for Health Record Linkage (CHeReL). PARTICIPANTS All patients (N=18,044) from 2001 to 2020 in New South Wales who received a diagnosis of IE using ICD-10-AM diagnostic code 133.0 were included. METHODS Categorical variables were compared using the chi-square test or Fisher's exact test, while the t-test was used for continuous variables. The association between clinical decision-making and adverse health outcomes amongst patients with IE were examined via generalised linear mixed models. RESULTS Sex, age, birthplace and referral impacted clinical decision-making, in-hospital death and severity of the disease. Women experienced a higher risk of death and fewer escalations of care. Admission and mortality increased with age, with those aged 60 and above responsible for 60.8% of hospitalisations. Despite octogenarians making up one-fifth of admissions and having the worst mortality rate (15.1%), they experienced only one in 10 intensive care (ICU) admissions. Overseas-born patients had fewer escalations of care and experienced less severe disease if referred by a medical practitioner. One out of 10 admissions that resulted in a hospital death were given non-emergency status, and one in two ICU patients died in hospital. CONCLUSIONS Sex, age, place of birth, and clinical decision-making were important predictors of severe disease and death in hospital, lending weight that health care clinical decisions may adversely impact health outcomes for populations of interest.
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Swiss Evaluation Registry for Pediatric Infective Endocarditis (SERPIE) - Risk factors for complications in children and adolescents with infective endocarditis. Int J Cardiol 2023; 370:463-471. [PMID: 36334644 DOI: 10.1016/j.ijcard.2022.10.173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Infective endocarditis (IE) in pediatric patients is a severe cardiac disease and its actual epidemiology and clinical outcome in Switzerland is scarcely studied. METHODS Retrospective nationwide multicenter data analysis of pediatric IE in children (<18 years) between 2011 and 2020. RESULTS 69 patients were treated for definite (40/69;58%) or possible IE (29/69;42%). 61% (42/69) were male. Diagnosis was made at median 6.4 years (IQR 0.8-12.6) of age with 19 patients (28%) during the first year of life. 84% (58/69) had congenital heart defects. IE was located on pulmonary (25/69;35%), mitral (10/69;14%), tricuspid (8/69;12%) and aortic valve (6/69;9%), and rarely on ventricular septal defect (VSD;4/69;6%) and atrial septal defect (ASD;1/69;1%). In 22% (16/69) localization was unknown. 70% (48/69) had postoperative IE, with prosthetic material involved in 60% (29/48; right ventricular to pulmonary artery conduit (24), VSD (4), ASD (1)). Causative organisms were mostly Staphylococci spp. (25;36%) including Staphylococcus aureus (19;28%), and Streptococci spp. (13;19%). 51% (35/69) suffered from severe complications including congestive heart failure (16;23%), sepsis (17;25%) and embolism (19;28%). Staphylococcus aureus was found as a predictor of severe complications in univariate and multivariate analysis (p = 0.02 and p = 0.033). In 46% (32/69) cardiac surgery was performed. 7% (5/69) died. CONCLUSIONS IE in childhood remains a severe cardiac disease with relevant mortality. The high morbidity and high rate of complications is associated with Staphylococcus aureus infections. Congenital heart defects act as a risk factor for IE, in particular the high number of cases associated with prosthetic pulmonary valve needs further evaluation and therapeutic alternatives.
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Muacevic A, Adler JR, Kahraman Ö. The Incidence and Clinical Characteristics of Infective Endocarditis in Children: A Five-Year, Single-Centre Retrospective Evaluation. Cureus 2022; 14:e31747. [PMID: 36569694 PMCID: PMC9770546 DOI: 10.7759/cureus.31747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Infective endocarditis (IE) is a rare disease with high mortality and morbidity. In recent years, an increase in the frequency of infective endocarditis has been observed due to the increase in the survival of cases with congenital heart diseases (CHDs) and the use of central catheters. In addition to revealing the incidence of IE in our clinic, this study aimed to evaluate the demographic characteristics, predisposing factors, clinical, laboratory, microbiological, and echocardiographic findings, and the complications of follow-up of our patients diagnosed with IE in light of the literature. MATERIAL AND METHODS Thirteen patients with IE who were hospitalized in Pediatric Cardiology Clinic, Pamukkale University Medical Faculty Hospital between January 2016 and August 2021 were retrospectively reviewed. The patients included in the study were evaluated in terms of demographic characteristics, predisposing factors, clinical, laboratory and microbiological findings, echocardiography data, surgical intervention needs, and complications. The incidence of IE in our clinic was defined as the rate of IE among patients admitted to the hospital and reported as the number of patients with IE per 100,000 hospital admissions. RESULTS The median age of these 13 patients was 11 (7-14) years, and the male/female ratio was 6/7. The five-year IE incidence in Pediatric Cardiology Clinic, Pamukkale University Medical Faculty Hospital, was found to be 2.5 in approximately 100,000 hospital admissions. A predisposing factor was detected in all patients. Six patients (46%) had CHDs, and four patients (31%) had acquired heart disease. The other three (23%) patients were receiving immunosuppressive therapy, and these patients had long-term port catheters. Eight (62%) patients had positive blood cultures. Streptococcus viridans, Streptococcus gordonii, Staphylococcus aureus, coagulase-negativeStaphylococcus, Brucella spp, and Candida albicans were isolated in the blood cultures of these patients. IE-related complications developed in seven (54%) patients. Five (38%) had heart failure, three patients (23%) had thromboembolic events, two (15%) had glomerulonephritis, and one (8%) had thrombophlebitis. Four patients were referred to early surgery. Two patients with recurrent IE attacks were referred to surgery after their treatment was completed. CONCLUSION The incidence of IE has shown an increase recently with increased rates of survival attributable to corrective surgeries performed for congenital heart diseases, increased prosthetic materials used in cardiac surgeries, and increased use of permanent catheters. In our study, the incidence of IE was found to be 2.5 in 100,000 hospital admissions. Our results have shown that rheumatic heart diseases, besides CHDs, are still an important risk factor for Turkey. Due to the low number of cases in IE studies in the pediatric population, there is a need for further studies to be conducted in large series in this field.
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Vicent L, Goenaga MA, Muñoz P, Marín-Arriaza M, Valerio M, Fariñas MC, Cobo-Belaustegui M, de Alarcón A, Rodríguez-Esteban MÁ, Miró JM, Goikoetxea-Agirre AJ, de Castro Campos D, García-Vázquez E, Martínez-Sellés M. Infective endocarditis in children and adolescents: a different profile with clinical implications. Pediatr Res 2022; 92:1400-1406. [PMID: 35149848 DOI: 10.1038/s41390-022-01959-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Our aim was to compare pediatric infective endocarditis (IE) with the clinical profile and outcomes of IE in adults. METHODS Prospective multicenter registry in 31 Spanish hospitals including all patients with a diagnosis of IE from 2008 to 2020. RESULTS A total of 5590 patients were included, 49 were <18 years (0.1%). Congenital heart disease (CHD) was present in 31 children and adolescents (63.2%). Right-sided location was more common in children/adolescents than in adults (46.9% vs. 6.3%, P < 0.001). Pediatric pulmonary IE was more frequent in patients with CHD (48.4%) than in those without (5.6%), P = 0.004. Staphylococcus aureus etiology tended to be more common in pediatric patients (32.7%) than in adults (22.3%), P = 0.082. Heart failure was less common in pediatric patients than in adults, due to the lower rate of heart failure in children/adolescents with CHD (9.6%) with respect to those without CHD (44.4%), P = 0.005. Inhospital mortality was high in both children, and adolescents and adults (16.3% vs. 25.9%; P = 0.126). CONCLUSIONS Most IE cases in children and adolescents are seen in patients with CHD that have a more common right-sided location and a lower prevalence of heart failure than patients without CHD. IE in children and adolescents without CHD has a more similar profile to IE in adults. IMPACT Infective endocarditis (IE) in children and adolescents is often seen in patients with congenital heart disease (CHD). Right-sided location is the most common in patients with CHD and heart failure is less common as a complication compared with patients without CHD. Infective endocarditis (IE) in children/adolescents without CHD has a more similar profile to IE in adults. In children/adolescents without CHD, locations were similar to adults, including a predominance of left-sided IE. Acute heart failure was the most frequent complication, seen mainly in adults, and in children/adolescents without CHD.
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Affiliation(s)
- Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario Doce de Octubre, Instituto de Salud Carlos III, Madrid, Spain
| | - Miguel Angel Goenaga
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donosti, ISS Biodonostia, San Sebastián, Spain
| | - Patricia Muñoz
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid. Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Mercedes Marín-Arriaza
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid. Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Maricela Valerio
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid. Instituto de Investigación Sanitaria Gregorio Marañón, CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - M Carmen Fariñas
- Servicio de Cardiología, Hospital Universitario Doce de Octubre, Instituto de Salud Carlos III, Madrid, Spain.,Infectious Diseases Unit, Hospital Universitario Marqués de Valdecilla, University of Cantabria, Santander, Spain
| | | | - Arístides de Alarcón
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine Infectious Diseases Research Group. Institute of Biomedicine of Seville (IBIS), University of Seville/CSIC/University Virgen del Rocío and Virgen Macarena, Seville, Spain
| | - M Ángeles Rodríguez-Esteban
- Servicio de Cardiología, Hospital Universitario Doce de Octubre, Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J M Miró
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | - Elisa García-Vázquez
- Servicio de Medicina Interna-Infecciosas, IMIB, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Murcia, Spain
| | - Manuel Martínez-Sellés
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donosti, ISS Biodonostia, San Sebastián, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain. .,Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Universidad Europea, Universidad Complutense, Calle Dr. Esquerdo, 46, 28007, Madrid, Spain.
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Endocarditis infecciosa en pacientes pediátricos de Andalucía (España), 2008-2020. Enferm Infecc Microbiol Clin 2022. [DOI: 10.1016/j.eimc.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Maser M, Freisinger E, Bronstein L, Köppe J, Orwat S, Kaleschke G, Baumgartner H, Diller GP, Lammers A. Frequency, Mortality, and Predictors of Adverse Outcomes for Endocarditis in Patients with Congenital Heart Disease: Results of a Nationwide Analysis including 2512 Endocarditis Cases. J Clin Med 2021; 10:jcm10215071. [PMID: 34768591 PMCID: PMC8584301 DOI: 10.3390/jcm10215071] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Infective endocarditis (IE) represents a major complication in patients with congenital heart disease (CHD) and is associated with high morbidity and mortality. The aim of this study was to analyse the frequency and outcome of IE in contemporary CHD patients based on all IE hospital admissions in Germany over a 10-year period. Methods: Based on data of all hospital admissions in Germany from 2009 to 2018, we identified all CHD cases with a diagnosis of IE. The data contained information on patient demographics, diagnoses, surgical procedures, and mortality. The primary endpoint of the study was endocarditis-associated mortality as well as major adverse events (defined as death or myocardial infarction, stroke, pulmonary embolism, sepsis, renal dialysis, resuscitation, or intubation). Results: Overall, 309,245 CHD inpatient cases were included in the analysis (underlying heart defects of simple complexity 55%, moderate complexity 23%, and complex heart defects 22%, respectively). Of those, 2512 (0.8% of all inpatient cases) were treated for IE. The mortality rate of IE inpatient cases was 6% with a major adverse events rate of 46%, and 41.5% of cases required surgical intervention. The overall IE associated mortality was lower in adult CHD cases compared to the 153,242 in adult IE cases without CHD (7.1% vs. 16.1%, p < 0.001). After adjustments using multivariable logistic regression analysis, the presence or complexity of CHD was not associated with the outcomes. Meanwhile, age, male sex, and co-morbidities emerged as significant predictors of adverse outcomes. Conclusions: IE accounts for a minority of CHD related hospitalizations but remains a deadly disease, and major adverse events are common in this setting. Due to different demographic and co-morbidity spectrums, adult CHD patients tend to have better survival prospects when compared to non-CHD IE patients. Acquired co-morbidities emerged as the main predictors of adverse outcomes.
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Affiliation(s)
- Maarja Maser
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
- Correspondence: ; Tel.: +49-251-83-46110; Fax: +49-251-83-46109
| | - Eva Freisinger
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, 48149 Muenster, Germany;
| | - Leo Bronstein
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Muenster, Germany; (L.B.); (J.K.)
| | - Jeanette Köppe
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Muenster, Germany; (L.B.); (J.K.)
| | - Stefan Orwat
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
| | - Gerrit Kaleschke
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
| | - Helmut Baumgartner
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
| | - Gerhard-Paul Diller
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
- National Register for Congenital Heart Defects, Competence Network for Congenital Heart Defects, 13353 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), 13353 Berlin, Germany
| | - Astrid Lammers
- Department of Cardiology III-Adult Congenital and Valvular Heart Disease, University Hospital Muenster, 48149 Muenster, Germany; (S.O.); (G.K.); (H.B.); (G.-P.D.); (A.L.)
- Department of Pediatric Cardiology, University Hospital Muenster, 48149 Muenster, Germany
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