Changes in Clinical Profile, Epidemiology and Prognosis of Left-sided Native-valve Infective Endocarditis Without Predisposing Heart Conditions (original) (raw)
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The Impact of Valve Surgery on 6-Month Mortality in Left-Sided Infective Endocarditis
Circulation, 2007
Background-The role of valve surgery in left-sided infective endocarditis has not been evaluated in randomized controlled trials. We examined the association between valve surgery and all-cause 6-month mortality among patients with left-sided infective endocarditis. Methods and Results-A total of 546 consecutive patients with left-sided infective endocarditis were included. To minimize selection bias, propensity score to undergo valve surgery was used to match patients in the surgical and nonsurgical groups. To adjust for survivor bias, we matched the follow-up time so that each patient in the nonsurgical group survived at least as long as the time to surgery in the respective surgically-treated patient. We also used valve surgery as a time-dependent covariate in different Cox models. A total of 129 (23.6%) patients underwent surgery within 30 days of diagnosis. Death occurred in 99 of the 417 patients (23.7%) in the nonsurgical group versus 35 deaths among the 129 patients (27.1%) in the surgical group. Eighteen of 35 (51%) patients in the surgical group died within 7 days of valve surgery. In the subset of 186 cases (93 pairs of surgical versus nonsurgical cases) matched on the logit of their propensity score, diagnosis decade, and follow-up time, no significant association existed between surgery and mortality (adjusted hazard ratio, 1.3; 95% confidence interval, 0.5 to 3.1). With a Cox model that incorporated surgery as a time-dependent covariate, valve surgery was associated with an increase in the 6-month mortality with an adjusted hazard ratio of 1.9 (95% confidence interval, 1.1 to 3.2). Because the proportionality hazard assumption was violated in the time-dependent analysis, we performed a partitioning analysis. After adjustment for early (operative) mortality, surgery was not associated with a survival benefit (adjusted hazard ratio, 0.92; 95% confidence interval, 0.48 to 1.76). Conclusions-The results of our study suggest that valve surgery in left-sided infective endocarditis is not associated with a survival benefit and could be associated with increased 6-month mortality, even after adjustment for selection and survivor biases as well as confounders. Given the disparity between the results of our study and those of other observational studies, well-designed prospective studies are needed to further evaluate the role of valve surgery in endocarditis management. (Circulation. 2007;115:1721-1728.)
The Journal of Thoracic and Cardiovascular Surgery, 2011
Objective: We sought to evaluate the impact of early surgery in the active phase on long-term outcomes in patients with left-sided native valve infective endocarditis. Methods: Clinical data were retrospectively reviewed in 212 consecutive patients with left-sided native valve infective endocarditis from 1990 to 2009. Early surgery in the active phase (within 2 weeks after the initial diagnosis) was performed in 73 patients, and the conventional treatment strategy was applied in 139 patients. In the conventional treatment group, 99 patients underwent late surgical intervention. To minimize selection bias, propensity score was used to match patients in the early operation and conventional treatment groups. Major adverse cardiac event was defined as a composite of infective endocarditis-related death, repeat surgery, and recurrence of infective endocarditis during follow-up. Results: The mean follow-up period was 5.5 years. In-hospital mortality was lower in the early operation group than in the conventional treatment group (5% vs 13%, P ¼ .08). For 57 propensity score-matched pairs, the estimated actuarial 7-year survivals free from infective endocarditis-related death and major adverse cardiac events were significantly higher in the early operation group than in the conventional treatment group (infective endocarditis-related death: 94% AE 5% vs 82% AE 5%, P ¼ .011, major adverse cardiac events: 88% AE 5% vs 69% AE 7%, P ¼ .006, respectively). Conclusions: Compared with conventional treatment, early surgery in the active phase was associated with better long-term outcomes in patients with left-sided native valve infective endocarditis. Further prospective randomized studies with large study populations are necessary to evaluate more precisely the optimal timing of surgery in patients with native valve infective endocarditis.
2014
Background: We report the preliminary data from a regional registry on ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty in Apulia, Italy; the region is covered by a single public health-care service, a single public emergency medical service (EMS), and a single tele-medicine service provider. Methods: Two hundred and ninety-seven consecutive patients with STEMI transferred by regional free public EMS 1-1-8 for primary-PCI were enrolled in the study; 123 underwent pre-hospital electrocardiograms (ECGs) triage by telecardiology support and directly referred for primary-PCI, those remaining were just transferred by 1-1-8 ambulances for primary percutaneous coronary intervention (PCI) (diagnosis not based on tele-medicine ECG; already hospitalised patients, emergency-room without tele-medicine support). Time from first ECG diagnostic for STEMI to balloon was recorded; a time-to-balloon <1 h was considered as optimal and patients as timely treated. Results: Mean time-to-balloon with pre-hospital triage and tele-cardiology ECG was significantly shorter (0:41±0:17 vs 1:34±1:11 h, p<0.001,-0:53 h,-56%) and rates of patients timely treated higher (85% vs 35%, p<0.001, +141%), both in patients from the 'inner' zone closer to PCI catheterisation laboratories (0:34±0:13 vs 0:54±0:30 h, p<0.001; 96% vs 77%, p<0.01, +30%) and in the 'outer' zone (0:52±0:17 vs 1:41±1:14 h, p<0.001; 69% vs 29%, p<0.001, +138%). Results remained significant even after multivariable analysis (odds ratio for time-to-balloon 0.71, 95% confidence interval (CI) 0.63-0.80, p<0.001; 1.39, 95% CI 1.25-1.55, p<0.001, for timely primary-PCI).
Infective endocarditis: a continuous challenge. The recent experience of a European tertiary center
The Journal of Heart Valve Disease, 2009
Independent predictors were prosthetic valve IE (p = 0.02), advanced age (p = 0.03) and co-morbidity (p = 0.05); all three of these features increased over the five-year study interval. Conclusion: Although increased regional hospital attention to IE seemed to facilitate admission to the authors' center, this did not improve survival, apparently because of an unchanged admission delay and increasing age, comorbidity, and prosthetic valve IE. Delayed admission and health care-induced IE were susceptible to modification. Future measures should, therefore, be particularly focused on high-risk patients, on educating the general practitioners, and on improving access to primary healthcare facilities for blood culture and echocardiography.
European Heart Journal
Through Danish administrative registries, we identified patients who underwent left-sided heart valve replacement from January 1996 to December 2015. Patients were categorized in mitral and aortic valve replacement (MVR and AVR) and followed until: 12 years after valve surgery, end of study, death, emigration, or hospitalization due to IE, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to investigate which baseline characteristics were associated with IE. A total of 18 041 patients were included. The cumulative IE risk at 10 years follow-up was 5.2% in both MVR and AVR patients. In patients with MVR, male sex [hazard ratio (HR) = 1.68, 95% confidence interval (95% CI) 1.06-2.68], bioprosthetic valve (HR = 1.91, 95% CI 1.08-3.37), and heart failure (HR = 1.69, 95% CI 1.06-2.68) were among factors associated with an increased risk of IE. In AVR patients, male sex (HR = 1.59, 95% CI 1.33-1.89), bioprosthetic valve (HR = 1.70, 95% CI 1.35-2.15), and cardiac implantable electronic device (CIED) (HR = 1.57, 95% CI 1.19-2.06) were among factors associated with an increased risk of IE.
Journal of Clinical Medicine
Background: Infective endocarditis (IE) requires multidisciplinary management. We established an endocarditis team within our hospital in 2011 and a state-wide endocarditis network with referring hospitals in 2015. We aimed to investigate their impact on perioperative outcomes. Methods: We retrospectively analyzed data from patients operated on for IE in our center between 01/2007 and 03/2018. To investigate the impact of the endocarditis network on referral latency and pre-operative complications we divided patients into two eras: before (n = 409) and after (n = 221) 01/2015. To investigate the impact of the endocarditis team on post-operative outcomes we conducted multivariate binary logistic regression analyses for the whole population. Kaplan–Meier estimates of 5-year survival were reported. Results: In the second era, after establishing the endocarditis network, the median time from symptoms to referral was halved (7 days (interquartile range: 2–19) vs. 15 days (interquartile r...
Objective: To evaluate the short term outcome of implementing early valve replacement, versus antimicrobial therapy in community-acquired left-sided native valve infective endocarditis (NVIE). Methods: A retrospective study from two medical centers in Amman–Jordan held between 1996–2011. Charts with the following diagnoses were screened: infective endocarditis, subacute and acute endocarditis, cardiac infection, septic emboli, endovascular infection and heart surgery. NVIE diagnosis was based on modified Duke Criteria. Results: Thirty-four patients were included; 21 (61.8%) patients had medical therapy and 13 (38.2%) had valve replacement, all for heart failure, 2/13 (15.4%) with early mitral valve replacement died. Six (17.6%) patients died early in the course of admission. Four (19%) patients died among medically-treated patients; two had severe heart failure, two with cerebrovascular event and secondary sepsis from E. coli respectively. No significant difference was found between the two groups by χ2 test for age, gender, body mass index, valve involved, duke criteria or NYHA class(P =N.S). Conclusion: Mortality remains high in NVIE; the decision to treat patients with valve replacement or medical therapy did not significantly change the outcome in this group of patients, possibly due to selection bias. Surgery was mostly dictated by heart failure.