Increased incidence of infective endocarditis in patients with ventricular septal defect

Incidence and predictive factors of mortality of infective endocarditis in adults with congenital heart disease: A systematic review and meta-analysis

INTRODUCTION

Congenital heart diseases (CHD) with abnormal turbulent blood flow are associated with the highest risk of infective endocarditis (IE). Despite advancement in diagnostics and treatment, the mortality rate of IE remains high due the life-threatening complications. Our study aims to assess the incidence and mortality rates of IE and predictive factors for mortality among adults CHD (ACHD).

METHODS

A systematic literature search was conducted on PubMed, SCOPUS, and Ovid SP to retrieve relevant studies. The pooled estimates and predictors of mortality were calculated using the random-effects generic inverse variance method using R programming.

RESULTS

12 studies involving 3738 ACHD patients were included in this meta-analysis. The overall incidence of IE in ACHD was 1.26 per 1000 patient-years (95% CI 0.55-1.96). 60% (95% CI 46-72%) of patients had surgical management for IE. The mortality rate of IE was 9% (95% CI 7-12%). The predictors of mortality were conservative management (OR: 5.07, 95% CI: 4.63-5.57), renal dysfunction (OR: 4.15, 95% CI: 2.92-5.88), cerebral complications (OR: 3.59, 95% CI: 1.78-7.23), abscesses/valve complications (OR: 2.67, 95% CI: 1.71-4.16), Staphylococcus aureus infection (OR: 2.32, 95% CI: 1.33-4.06), emboli (OR: 2.03, 95% CI: 1.47-2.79), body mass index (OR: 1.10, 95% CI: 1.01-1.21), age (OR: 1.02, 95% CI: 1.00-1.04), and previous IE (OR: 1.02, 95% CI: 1.00-1.04).

CONCLUSION

The mortality rate of IE in ACHD is low. However, conservative management is associated with the highest risk of mortality.

A Case of Concurrent Tricuspid Valve, Mitral Valve, and Device Endocarditis

Endocarditis involving multiple valves is a relatively rare phenomenon, and much about its etiology, prognosis, and best practices for treatment remains uncharacterized. Currently, the treatment of multiple-valve endocarditis is similar to that of single-valve endocarditis. However, limited data suggest that patients may potentially benefit from different treatment approaches not yet clearly defined. Here, we present a unique case of a 22-year-old female with a history of aortic coarctation repair and a ventricular septal defect (VSD) patch repair who presented to the emergency department (ED) after acute onset of fever, chills, nausea, vomiting, and diarrhea. The patient was admitted to the ICU with septic shock and was found to have concurrent mitral valve, tricuspid valve, and VSD patch endocarditis. We discussed her hospital course and treatment as well as current treatment approaches to multiple-valve endocarditis.

Ventricular Septal Defect and Right-Sided Infective Endocarditis

Right-sided infective endocarditis (IE), which represents a small but not negligible percentage of IE cases, can be observed in patients with congenital heart diseases. We discuss the case of a young woman with unrepaired perimembranous ventricular septal defect and repeated episodes of right ventricle and tricuspid valve IE with septic embolism.

Infective endocarditis in a cohort of adult CHD patients

BACKGROUND

CHD increases the risk of infective endocarditis due to the substrate of prosthetic materials and residual lesions. However, lesion-specific and mortality risks data are lacking. We sought to analyse clinical course and mortality of infective endocarditis in a cohort of adult CHD.

METHODS

Retrospective analysis of all cases of proven and probable infective endocarditis (Duke's criteria) followed in our adult CHD clinic between 1970 and August, 2021. Epidemiological, clinical and imaging data were analysed. Predictors of surgical treatment and mortality were assessed using regression analysis.

RESULTS

During a mean follow-up of 15.8 ± 10.9 years, 96 patients had 105 infective endocarditis episodes, half with previous cardiac surgery (corrective or palliative). The most frequent diagnoses were: ventricular septal defect, bicuspid aortic valve, Tetralogy of Fallot and pulmonary atresia. The site of infection was identified by echocardiography in 82 episodes (91%), most frequently in aortic (n = 27), tricuspid (n = 15), and mitral (n = 13) valves. Blood cultures were positive in 79% of cases, being streptococci (n = 29) and staphylococci (n = 23) the predominant pathogens. Surgery was necessary in 40% and the in-hospital mortality was 10.5%, associated with heart failure (p < 0.001; OR 13.5) and a non-surgical approach (p = 0.003; OR 5.06).

CONCLUSIONS

In an adult CHD cohort, infective endocarditis was more frequent in patients with ventricular septal defect and bicuspid aortic valves, which contradicts the current guidelines that excludes them from prophylaxis. Surgical treatment is often required and mortality remains substantial. Prevention of this serious complication should be one of the major tasks in the care of adults with CHD.

Tricuspid Valve Endocarditis in Four Patients with Unrepaired Restrictive Perimembranous Ventricular Septal Defects

Congenital heart disease (CHD) is the most common predisposing factor for pediatric infective endocarditis (IE). Although patients with unrepaired ventricular septal defects (VSDs) are at greater risk of IE than those without CHD, the American Heart Association (AHA) considers VSDs to be relatively low risk and therefore does not recommend antibiotic prophylaxis against IE. Even among patients with VSDs who develop IE, current AHA and European Society for Cardiology (ESC) guidelines do not recommend surgical VSD closure, despite the potential for a second IE event. We present a case series of four children with small, restrictive, perimembranous VSDs who developed tricuspid valve (TV) IE. All four experienced delayed diagnosis and secondary complications, including three with septic pulmonary emboli. All four patients ultimately underwent surgical VSD closure. These cases highlight the importance of recognizing IE as a possible cause of prolonged fever in children, even among those with even 'low-risk' CHD. The cases also draw attention to the potential benefits of VSD closure in patients who develop IE.

Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease

Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.

Sub-pulmonic stenosis caused by a right ventricular outflow tract vegetation in a children with restricted ventricular septal defect

Infective endocarditis involving the right heart is rarely observed in the pediatric population. Echocardiography plays an important role in its diagnosis, and surgery is indicated in patients with heart failure and persistent sepsis not responding to medical treatment. Here, we report a rare case of restricted ventricular septal defect complicated by a vegetation developed in the right ventricular outflow tract and causing sub-pulmonic stenosis in a 3-year-old male child.

A Seventeen-Year Descriptive Study of Infective Endocarditis Features at a Tertiary, Teaching Hospital

Introduction

Infective endocarditis (IE) is a microbial infection affecting the endothelial lining of the heart chambers and valves. Despite advances in diagnostic methods and management, IE still carries high levels of morbidity and mortality. There are no comprehensive data describing incidence, risk factors, and outcomes of IE in Saudi Arabia.

Our study aims to describe the epidemiological and clinical characteristics and outcomes of adult patients with IE treated in a tertiary, Teaching Hospital.

Methods

This is a descriptive, retrospective review of charts (between January 2003 and June 2019) conducted at King Abdulaziz University Hospital. We included all patients 16 years and older with a definitive diagnosis of IE based on Duke Criteria. We collected the following information: demographics, risk factors, comorbidities, microbial type, antibiotic choice, complications, laboratory data, echocardiography data, and mortality.

Results

We found a total of 60 adult patients with definitive diagnoses of IE: 55% of them were males, and the mean age was 48.71 ± 18.3 years. Hypertension was the most common comorbidity, affecting 23 patients (38.3%), followed by end-stage renal disease (ESRD) in 20 patients (33.3%) and diabetes in 17 (28.3%). Staphylococcus aureus was the most common organism (25%), and vancomycin was the most prescribed antibiotic. Fifty-eight patients were treated medically (96.5%). Furthermore, 88% of the patients had vegetations, detected by echocardiography, and the majority had single-valve involvement. Sepsis was the most common complication, and the mortality rate was 36.7%.

Conclusion

There was a small number of definitive IE cases over a 17-years span in our institution. Surprisingly, a higher mortality rate was found among our patients and a lower surgical intervention rate in comparison with the literature. Though we acknowledge the limitations of a retrospective, chart review study, we can speculate that the high mortality rate may be in part related to a higher number of virulent organisms, delayed presentation, and lack of prompt surgical intervention.

Outcomes of closure of doubly committed subarterial ventricular septal defects in adults

BACKGROUND

Outcome data of doubly committed subarterial ventricular septal defect closure in adults are limited.

METHODS

A review was made of the inpatients >18 years of age who underwent doubly committed subarterial ventricular septal defect closure between June 2010 and June 2017.

RESULTS

The patients were categorised into two groups: The valve intervention group consisted of 31 patients who underwent aortic valvuloplasty, aortic valve replacement, or repair of sinus Valsalva aneurysm in addition to doubly committed subarterial ventricular septal defect closure; non-valvular intervention group comprised 58 patients who underwent only doubly committed subarterial ventricular septal defect closure. The groups did not differ by sex and age. Patients in the valve intervention group, with a larger ventricular septal defect size, were shorter and tended to be lighter. The valve intervention group had more patients with pneumonia perioperatively. No infective endocarditis and reoperation were noted during the study period. At last follow-up, 91 and 96.6% of the studied patients were free from left ventricle dilation and pulmonary hypertension. In patients without pre-operative aortic regurgitation, 12 developed new mild aortic regurgitation during the follow-up.

CONCLUSIONS

About 34.8% of adult patients with doubly committed subarterial ventricular septal defect required concurrent intervention on aortic valve or sinus Valsalva aneurysm. The midterm results of doubly committed subarterial ventricular septal defect closure in adult patients were favourable. However, the incidence of new mild aortic regurgitation after ventricular septal defect closure was high (27.3%). Long-term follow-up of aortic regurgitation progression is needed.

Perioperative Echocardiography in the Adult With Congenital Heart Disease

Survival of patients with congenital heart disease has significantly improved over the last 2 decades, confronting interventionalists, surgeons, anesthesiologists, cardiologists, and intensivists with often unfamiliar complex pathophysiology in the perioperative setting. Aside from cardiac catheterization, echocardiography has become the main imaging modality in the hospitalized adult with congenital heart disease. The great variety of congenital lesions and their prior surgical management challenges practitioners to generate optimal imaging, reporting, and interpretation of these complex anatomic structures. Standardization of echocardiographic studies can not only provide significant benefits in the surveillance of these patients, but also facilitate understanding of pathophysiologic mechanism and assist clinical management in the perioperative setting. Knowledge in obtaining and interpreting uniform imaging protocols is essential for the perioperative clinician. In this publication, the authors review current international consensus recommendations on echocardiographic imaging of adults with congenital heart disease and describe the fundamental components by specific lesion. The authors will emphasize key aspects pertinent to the clinical management when imaging these patients in the perioperative setting. The goal of this review is to familiarize the perioperative physician on how to structure and standardize echocardiographic image acquisition of congenital heart disease anatomy for optimal clinical management.

Recurrent lung nodules as a presentation of ventricular septal defect-related endocarditis

Infective endocarditis is an uncommon microbial infection of the endocardial surface of the heart. Patients with structural heart disease, such as a ventricular septal defect, are at higher risk for infective endocarditis and clinicians must have a high index of suspicion in such patients presenting with recurrent fevers. We present a patient with a known ventricular septal defect presenting with recurrent fevers associated with migratory lung nodules following a "low-risk" dental procedure without antibiotic prophylaxis. The unusual presentation delayed the diagnosis of the migratory lung lesions as septic pulmonary emboli and consequentially the diagnosis of ventricular septal defect related infective endocarditis. The patient made an uneventful recovery following antibiotic therapy and surgical intervention.