Gender Based Analysis of a Population Series of Patients Hospitalized with Infective Endocarditis in Portugal - How do Women and Men Compare?

Abstract Background: The impact of gender on the outcome of patients hospitalized with infective endocarditis (IE) is not fully understood. Objective: To verify the association between gender and the clinical profile of patients hospitalized with IE, treatment strategies, and clinical outcomes. Methods: This is a retrospective nationwide study of patients hospitalized with IE, based on hospital admissions between 2010 and 2018 in Portugal. Descriptive statistics were used to present variables. An inferential analysis was performed using multiple logistic regression. A 95% confidence interval and a 5% significance level were considered. Results: In total, 3266 (43.1%) women and 4308 (56.9%) men were hospitalized with IE. The women were older (76 vs 69 years old, p<0.001), more frequently presented arterial hypertension (39.8% vs 35.4%, p<0.001) and atrial fibrillation (29.5% vs 21.2%, p<0.001), and had less cardiovascular comorbidities. Acute heart failure was more common in women (32.9 vs 26.9%, p<0.001) and acute renal failure (13.6% vs 11.7%, p<0.001) and sepsis (12.1% vs 9.1%, p<0.001), in men. Women were less likely to undergo cardiac surgery (OR 0.48 - 95%CI 0.40-0.57, p<0.001) and had a higher postoperative mortality (OR 1.84, 95% CI 1.19-2.84, p=0.006). In-hospital mortality rates were comparable between genders (20.3% vs 19.6%, p=0.45). Conclusions: Women were less likely to undergo cardiac surgery when hospitalized with IE, and the female gender was a predictor factor for postoperative mortality. Overall, in-hospital mortality was not influenced by gender. Further research is necessary to fully clarify the impact of gender on IE management and outcomes.

Association between Insulin use and Infective Endocarditis: An Observational Study

Abstract Background: The association between Diabetes Mellitus (DM) and Infective Endocarditis (IE) is controversial in the literature, since many controversial results have been published. However, when evaluating specifically the evidence on IE and individuals with DM using insulin, we found only two observational studies that considered this variable, with discordant results regarding the prognosis and prevalence of Staphylococcus sp in insulin users compared to non-users. Despite the lack of evidence, in clinical practice the insulin use could be interpreted as minor criteria "injection drug use", using the modified Duke criteria for IE diagnosis. Objectives: To compare the microbiological and valvar profile, as well as the outcome of non-diabetic and diabetic patients with IE who were insulin users or not. Methods: This was an observational, analytical and retrospective study of patients diagnosed with IE between 2003 and 2015 in three tertiary care centers. A total of 211 patients were included, of which 17 were diabetics and 9 were insulin users. Patients were compared using the Shapiro-Wilk normality test and Fisher's exact test, with a significance level of 5%. Results: The mortality from IE in diabetic individuals was higher than that of non-diabetic patients, but with no statistical significance (35.29% vs. 21.1%; p = 0.221), even when the groups were divided into insulin-user diabetic, non-insulin user diabetic and non-diabetic patients (33.3% vs. 37.5% vs. 21.1%, p = 0.229). There was a difference regarding the prevalence of IE caused by S. aureus (57.1% vs. 14.3% vs. 17.4%, p = 0.029) and the involvement of the tricuspid valve (33.3% vs. 0.00% vs. 10.0%, p = 0.034) among insulin users. Conclusion: In our sample, insulin use or the presence of DM did not mean higher in-hospital mortality from IE. It is not possible to generalize the microbiological and valvar findings due to the lack of studies evaluating insulin users in IE; however, particularities have been previously reported and may indicate a different behavior of IE in these patients. New studies considering the insulin use variable are required to elucidate the association between DM and IE.

Sobrevida a 10 años de pacientes egresados luego de cirugía por endocarditis infecciosa en un hospital público / Hospital mortality and long-term survival of 103 patients with infective endocarditis requiring surgery

Background Infective endocarditis (IE) is a serious disease with high mortality, especially among the most severe cases undergoing surgery. Aim To analyze the clinical features, perioperative mortality and long-term survival of patients with infective endocarditis requiring surgery. Material and Methods Review of medical records of patients who underwent heart valve surgery for active infective endocarditis in a public hospital between 1995 and 2008. Demographic characteristics and comorbidities were described. Perioperative and 10 year survival were analyzed retrieving death certificates from the Chilean Identification Service. Results Data from 103 patients aged 46 ± 14 years (74% males) was analyzed. Thirty five percent of patients had an underlying predisposing heart condition such as congenital heart disease in 18.5% and prosthetic valves in 10%. The most common location was the aortic valve and the most common surgical procedure was heart valve replacement with a mechanical prosthetic valve in 87% of the cases. Pathogen identification in blood cultures was achieved in 48% of the cases. The most common causative microorganisms were S. aureus in 12%, coagulase-negative Staphylococcus in 11%, S. viridans in 10% and Enterococcus in 7%. Hospital mortality was 20.4% and ten-year survival was 65%. Conclusions Patients with severe IE requiring surgical treatment still have high perioperative and late mortality.

Experience of treatment of prosthetic valve endocarditis: a retrospective single-center cross-sectional study

ABSTRACT BACKGROUND: The aim of this study was to describe the experience of treatment of early prosthetic valve endocarditis at a heart center. DESIGN AND SETTING: Retrospective single-center study on data collected from electronic medical records covering the period from January 2009 to December 2015. METHODS: Over the study period, 1,557 consecutive valve operations were performed on adult patients. The study population comprised 32 patients (2%) who were diagnosed with prosthetic valve endocarditis within 12 months after the index surgery. Medical records were retrieved from electronic hospital records, retrospectively. Descriptive clinical, echocardiographic, microbiological and treatment-type data were used. Risk factors for early mortality were studied through univariate and multivariate analyses. RESULTS: The main clinical manifestation of infective endocarditis was fever, and this was present in all patients. Most of the prostheses were affected in the aortic position (40.6% of cases). The most commonly cultured microorganisms were Staphylococcus epidermidis and Staphylococcus aureus. Twenty-six patients (81.3%) underwent surgical treatment and six (18.7%) underwent exclusive clinical treatment. The prevalence of postoperative complications was 31.3% and hospital mortality occurred in seven cases (21.9%). The mortality rate was 50% among the patients who underwent medical treatment and 15.4% among those who underwent surgery. There were no independent risk factors for mortality. CONCLUSION: Prosthetic valve endocarditis is an infrequent complication of valve replacement. Surgical treatment has mortality rates compatible with the severity of patients' conditions. Surgical indication should not be delayed when clinical treatment has been ineffective

Endocarditis infecciosa en Hospital de Talca, período 1998 - 2015 / Infective endocarditis at Hospital de Talca, 1998-2015

Resumen: Introducción: La endocarditis infecciosa es una enfermedad con una alta mortalidad que se ha mantenido estable en los últimos años pese a avances en su diagnóstico y tratamiento. Objetivo: Evaluar las características clínicas de los pacientes con Endocarditis Infecciosa tratados en el Hospital de Talca. Materiales y métodos: Estudio retrospectivo en que se revisaron las historias clínicas de los pacientes con endocarditis infecciosa atendidos entre 1998 y 2015 en el Hospital Regional de Talca. Resultados: Se encontraron 62 pacientes con endocarditis infecciosa con un promedio de edad de 49,7 años, 61,2% de ellos de sexo masculino, 21% de ellos con válvula protésica y 13% con antecedentes de enfermedad reumática. Las comorbilidades más frecuentes fueron hipertensión arterial, diabetes mellitus y enfermedad renal crónica. El 72,5% de los pacientes se presentaron con síndrome febril y soplo asociado. Un 87,1% presentaban vegetaciones al ecocardiograma. El 67,1% de los pacientes tenía hemocultivo positivo, de los cuales el microorganismo más frecuente fue el Staphylococcus aureus (22,6%). Un 24,2 % de los pacientes requirieron tratamiento quirúrgico. La mortalidad intrahospitalaria fue de un 19,3%. Conclusiones: Las características clínicas de los pacientes descritos son similares a estudios nacionales e internacionales, con una mortalidad intrahospitalaria elevada.

Abstract: Background: Infective endocarditis is a disease with high mortality that remains stable in recent years despite advances in it's diagnosis and treatment. Aim: Evaluate the clinical characteristics of patients with infective endocarditis treated at Hospital de Talca, Chile. Material and Methods: Retrospective study in which the clinical records of patients with infective endocarditis treated between 1998 and 2015 at Hospital Regional de Talca were reviewed. Results: 62 patients with infective endocarditis were identified. The median age was 49,7 years, 61,2% were males. 21% carried one or more prosthetic heart valve and 13% had previous rheumatic valve disease. The most common comorbidities were hypertension, diabetes, and chronic kidney disease. 72,5% presented with fever and a cardiac murmur, 87,1% had vegetations in echocardiography. In 67% of patients blood cultures were positive and22,6% of them had blood cultures positive for Staphylococcus aureus. 24,2 % of patients required hearth surgery. Hospital mortality was 19,3%. Conclusions: The clinical characteristics of patients included in this series were similar to those found in national and international studies, Hospital mortality was high

Experiencia clínica pediátrica en endocarditis infecciosa por Candida spp / Pediatric clinical experience in infectious endocarditis due to Candida spp

Resumen Introducción: El tratamiento y evolución de endocarditis infecciosa por Candida spp en niños debe basarse en guías de manejo; sin embargo, aún existen controversias al respecto. Objetivo: Describir nuestra experiencia en el tratamiento de EI por Candida spp en pacientes pediátricos. Métodos: Estudio prospectivo, analítico, realizado entre enero de 2006 y diciembre 2017. Análisis paramétrico de variables cuantitativas; razones, proporciones, comparación por medio de χ2 y prueba exacta de Fisher con IC al 95% para variables no paramétricas. Tasa de mortalidad. Resultados: Veinticinco episodios de endocarditis por Candida spp recibieron tratamiento anti fúngico estándar. La mortalidad fue superior en pacientes sometidos a resección de la vegetación endocárdica (66,7%) RR 3,16, χ2 p = 0,029, en niños con síndrome linfo-hemofagocítico SLHF (50%), RR= 1,18 (χ2 NS), en co infección con bacterias multi-resistentes (57,1 %) RR= 2, (χ2 NS) y en EI trombótica (88,9%) RR = 4,74 (χ2 p = 0,004). Conclusiones: Co-infección de EI por Candida sp con bacterias multi-resistentes, SLHF y/o manejo quirúrgico de la vegetación endocárdica, pueden considerarse factores de mal pronóstico.

Background: Treatment and outcome of Candida spp infectious endocarditis in children it most be based on treatment guidelines, however there are some controversies. Aim: To describe our experience on treatment of pediatric candidal infective endocarditis. Methods: Analytic prospective study, from January 2006 to December 2017. Parametric analysis for quantitative variable. Proportions were compared by χ2 and exact Fisher Test CI 95%. Mortality rate. Results: 25 episodes of Candida spp infective endocarditis were treated with standard antifungal drugs. Mortality rate was higher on patients submited to endocardic vegetation resection (66.7%) RR= 3.16, (χ2 p = 0.029), children with lymphohemophagocytic syndrome (LHFS) (50 %) RR= 1.18 (χ2 = N.S.), in multidrug resistant bacterial co infection (57.14%), RR = 2, (χ2 = NS) also thrombotic endocarditis (88.9%) RR= 4.74 (χ2 p = 0.004). Conclusion: Multidrug resistant bacteria co infection with Candida sp IE, LHFS, and/or surgical treatment of endocardic vegetation, might be considered as bad prognostic factors.

Insuficiencia aórtica aguda por endocarditis infecciosa / Acute aortic regurgitation due to infective endocarditis

La insuficiencia aórtica aguda (IAOA) por endocarditis infecciosa (EI) es grave y generalmente requiere tratamiento quirúrgico. Se compararon los pacientes con IAOA grave por EI e insuficiencia cardíaca (IC) en clase funcional I-II NYHA (G1) con los pacientes en clase funcional III-IV (G2) en relación a características clínicas, ecocardiográficas, microbiológicas y evolución hospitalaria y se evaluaron los predictores de mortalidad, en un centro de alta complejidad. Desde 06/92 a 07/16, de 439 pacientes con EI, 86 presentaron IAOA: (G1, 39: 45.4% y G2, 47: 54.7%). El G1 presentó mayor EI protésica (43.6% vs. 17.0%; p < 0.01). Los 47 casos G2 presentaban disnea vs. 12 (30.8%) G1 (p < 0.0001). No hubo diferencias en cuanto a las características clínicas, ecocardiográficas y microbiológicas. El tratamiento quirúrgico fue principalmente por extensión de la infección y/disfunción valvular en el G1 y por IC en el G2. La mortalidad hospitalaria fue del 15.4% vs. 27.7% (G1 y G2 respectivamente, p NS). Fueron predictores en el análisis multivariado: la infección intrahospitalaria (p 0.001), los hemocultivos negativos (p 0.004) y la presencia de IC clase funcional III-IV (p 0.039).Una quinta parte de los pacientes con EI presentaron IAOA. Aquellos con IC grave requirieron tratamiento quirúrgico de emergencia y con IC con clase funcional I-II requirieron cirugía por extensión de la infección y/o disfunción valvular. La mortalidad quirúrgica y hospitalaria continúan siendo elevadas en ambos grupos y fueron predictores de mortalidad hospitalaria: la infección intrahospitalaria, los hemocultivos negativos y la IC avanzada.

Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.

Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact

ABSTRACT Background: Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain. Objectives: To determine the frequency of emboli due to IE and to identify events associated with embolism. Methods: Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0. Results: In the study period, 2006-2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p < 0.01, OR 4.7, 95% CI 2.04-11). Factors associated with embolism to the spleen were positive blood cultures (p = 0.05, OR 8.9, 95% CI 1.45-177) and splenomegaly (p < 0.01, OR 9.28, 95% CI 3.32-29); those associated to the central nervous system were infective endocarditis of the mitral valve (p < 0.05, OR 3.5, 95% CI 1.23-10) and male gender (p < 0.05, OR 3.2, 95% CI 1.04-10). Splenectomy and cardiac surgery did not impact on in-hospital mortality. Conclusions: Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.

Endocarditis infecciosa: ¿afectan su pronóstico las complicaciones neurológicas? / Neurologic complications of infective endocarditis: do they have an impact on prognosis?

De acuerdo a la literatura, en un 20 a 40% de las endocarditis infecciosas se producen complicaciones neurológicas. Nuestro objetivo fue determinar la frecuencia de compromiso neurológico en pacientes con endocarditis infecciosa de válvulas izquierdas, considerando la presentación clínica, tipo de lesión en las imágenes y su influencia en la evolución. Se incluyeron en forma prospectiva 98 pacientes con endocarditis infecciosa de válvulas izquierdas. El 47% (46 casos) presentó compromiso neurológico. En 28 casos (61%) el síntoma fue el déficit focal, en 9 (20%) la alteración de estado de conciencia; el 17% (8) fue asintomático y 2% (1 caso) presentó convulsiones. En las imágenes, la isquemia cerebral (76%) fue la lesión más frecuente. El tamaño de la vegetación mayor a 1 cm se asoció a compromiso neurológico (57% vs. 31%, p = 0.01). Aquellos pacientes con compromiso neurológico tuvieron mayor frecuencia de reemplazo valvular (70% vs. 44%, p = 0.01) y la mortalidad hospitalaria también fue mayor (20% vs. 15%, p = 0.5). El tiempo total de internación fue significativamente más prolongado en sujetos con compromiso neurológico (32 ± 27 vs. 21 ± 15 días, p = 0.01) y la discapacidad fue mayor en los que tenían manifestaciones neurológicas (74% vs. 36% p = 0.0001). En nuestra serie, el síntoma más frecuente fue el déficit focal, y en las imágenes la isquemia cerebral fue el patrón más común. Los casos con lesión neurológica presentaron mayor tiempo de internación y grado de discapacidad al alta, pero no mayor mortalidad hospitalaria.

Neurologic complications of infective endocarditis have been observed in 20-40% of cases. Our aim was to determine the frequency of neurologic involvement, clinical manifestations, lesional patterns and evolution in patients with infective endocarditis. This was a prospective cohort study. We included 98 patients with left-sided infective endocarditis. Forty seven percent presented neurologic involvement at some time of the disease. The frequency of symptoms was: focal deficit 61%, sensory disturbance 17% and seizures 2%, while 20% remain asymptomatic. The most prevailing lesion was cerebral ischemia (76%). Vegetations larger than 1 cm were associated to neurologic involvement (57% vs. 31%, p = 0.01). Valvular replacement was more common among patients with neurologic involvement (70% vs. 44%, p = 0.01). Hospital mortality was 20% in patients with neurologic manifestation versus 15% of those without it (p = 0.5). The length of stay was significantly prolonged in patients with neurologic affection (32 ± 27 vs. 21 ± 15 days, p = 0.01) and a favorable Rankin assessment at the discharge was less likely in patients with neurologic involvement (36% vs. 74%, p = 0.0001). In this cohort, the most frequent clinical manifestation was focal deficit and the most prevalent pattern of lesion was cerebral ischemia. Those with neurologic involvement presented an increased length of stay and more disability at the discharge but not statistical significant difference in hospital mortality.

Morbimortalidad de la endocarditis infecciosa asociada a dispositivos electrónicos implantables permanentes / Morbimortality of infective endocarditis associated with permanent cardiovascular implantable electronic devices

La endocarditis infecciosa (EI) asociada a dispositivos electrónicos implantables permanentes (DEIP) es una complicación de baja frecuencia pero alta mortalidad sin el tratamiento adecuado. El avance sobre el conocimiento de esta patología y el desarrollo de estrategias terapéuticas como el diagnóstico precoz, manejo de antibióticos, técnicas de extracción, entre otras, han mejorado el pronóstico de estos pacientes. Los objetivos de este estudio fueron evaluar la morbimortalidad intrahospitalaria y alejada y analizar algunos factores que justifican las diferencias con los datos de la mortalidad publicada. Se estudiaron en forma retrospectiva pacientes entre marzo/2002 y marzo/2011 con diagnóstico de EI asociada a DEIP. Se analizaron características basales, diagnósticas, terapéuticas, evolución intrahospitalaria y alejada. Se incluyeron 26 casos atendidos en nuestro hospital, 23 de los cuales fueron remitidos desde otros centros para su diagnóstico y tratamiento. La edad promedio fue de 67,5 años. Todos los pacientes recibieron antibióticos durante seis semanas y se les retiró el sistema en forma completa; en el 95% de los pacientes por vía percutánea y en 2 pacientes se requirió estereotomía mediana, atriotomía y colocación de marcapasos epicardíaco. La mortalidad fue del 4% y en el seguimiento fue nula. La morbilidad intrahospitalaria fue del 31%. En el seguimiento alejado no hubo reinfecciones u otra complicación. Como conclusión la EI es un cuadro grave que presenta una morbilidad elevada con estadías hospitalarias prolongadas, pero la mortalidad es baja. La explicación podría estar en las técnicas percutáneas, experiencia, extracción completa, el tiempo del reimplante del nuevo dispositivo y el tratamiento precoz, entre otros factores.

Infective endocarditis (IE) associated with permanent cardiovascular implantable electronic devices (CIEDs) is a complication of low frequency, but high mortality without adequate treatment. Progress on the knowledge of this disease and the development of therapeutic strategies such as early diagnosis, antibiotic management and better extraction techniques, among others, have improved the prognosis of these patients. The objectives of this study were to evaluate the in-hospital and out-of-hospital morbidity, and analyze some factors that explain the differences among the published mortality data. Patients diagnosed with IE associated with CIEDs were studied, retrospectively, between March/2002 and March/2011. We analyzed baseline, diagnostic and therapeutic characteristics, and in-hospital and out-of-hospital courses of the disease. We included 26 cases treated in our hospital, 23 of whom were referred from other centers for diagnosis and treatment. The average age of the patients was 67.5 years. All patients received antibiotics for six weeks and underwent complete removal of the device system, in 95% of patients by percutaneous extraction and 2 patients required a median sternotomy, atriotomy and epicardial pacemaker placement. Mortality was 4% and the follow up mortality was zero. The in-hospital morbidity was 31%. In the follow-ups there were no reinfections or other complications. In conclusion, IE is a serious condition that has a high morbidity with prolonged hospital stays, but with a low mortality. The explanation may lie in the use percutaneous extraction techniques, experience, complete extraction of the device system, the time of reimplantation of the new device and early treatment, among other factors.

Complicaciones posoperatorias y mortalidad en pacientes operados por endocarditis infecciosa / Postoperative complications and mortality observed in patients operated on from infective endocarditis

Objetivo: describir las causas de morbilidad y mortalidad perioperatorias en los pacientes afectos de endocarditis infecciosa activa y significar cómo pueden ser disminuidas. Métodos: se realizó un estudio retrospectivo de las complicaciones posoperatorias y mortalidad en 139 pacientes operados por presentar endocarditis infecciosa en un período de 16 años. Se efectuaron 147 operaciones a los 139 pacientes de las cuales 83 (57,1 por ciento) fueron electivas y 64 (42,9 por ciento) fueron de urgencia. El 24 por ciento de los pacientes fueron remitidos de otros centros en los que habían sido sometidos a tratamiento médico no exitoso por más de 4 semanas. Resultados: las operaciones efectuadas fueron: Sustituciones valvulares aórticas,mitrales y tricuspídeas 75 (41,1 por ciento), extracción de electrodos de marcapasos o desfibriladores automáticos implantables del ventrículo derecho 57 (41 por ciento) , otras operaciones en número de 7 (4,9 por ciento)y 8 reintervenciones. La complicación más frecuente fue la sepsis generalizada (10,07 por ciento p< 0,01), seguidos en orden de frecuencia por el bajo gasto cardíaco y los sangramientos posoperatorios. Las principales causas de los decesos fueron la insuficiencia cardiaca congestiva (13 pacientes, 9,3 por cientop< 0,02) y la sepsis generalizada 5 (3,6 por ciento). La mortalidad en este estudio (16,4 por ciento) se relacionó con varios factores, entre ellos la clase funcional, ya que el 12,2 por ciento de los pacientes se encontraban en clase funcional (III-IV) de la clasificación de la New York Heart Association. La mortalidad fue mayor en los pacientes que tenían más de 4 semanas de tratamiento médico no exitoso (n= 13) 56,5 por ciento. Es notable la baja mortalidad (2,1 por ciento) que ocurrió en los pacientes con endocarditis infecciosa por cables o electrodos de marcapasos o desfibriladores automáticos implantables. Conclusiones: la realización de un diagnóstico temprano, la instauración de un de un tratamiento antibiótico intensivo, de una cirugía precoz unida a una hemostasia rigurosa dará por resultado una paulatina disminución de la mortalidad y morbilidad en las operaciones por endocarditis infecciosa(AU)

Objective: To describe the causes of perioperative morbidity and mortality of patients suffering active infectious endocarditis and to explain how both aspects can be reduced. Methods: A retrospective study of postoperative complications and mortality observed in 139 patients operated on from infectious endocarditis in 16 years. One hundred forty seven surgeries were performed, of which 83 (57.1 percent) were elective and 64 (42.9 percent) were emergency surgeries. In this group, 24 percent had been referred from other medical centers where they had been unsuccessfully treated for 4 weeks. Results: The performed surgeries comprised 15 aortic, mitral and tricuspid valve replacements, 57 (41 percent) removals of pacemaker electrodes or of implanted automatic defibrillators in the right ventricle, seven other types of surgeries and 8 reoperations. The most frequent complication was generalized sepsis ((10.07 percent p< 0.01), followed by the low heart output and postoperative bleeding. The main causes of death were congestive heart failure in 13 patients (9.3 percent, p< 0. 02) and generalized sepsis in 5 patients (3.6 percent). The mortality rates presented in this study (16.4 %) were associated to several factors such as functional class, since 12.2 percent of patients were classified into the functional class III-IV of the New York Heart Association. The mortality rate was higher in those patients who had been unsuccessfully treated for over 4 years (n= 13, 56.5 percent). Low mortality is noticeable (2.1 percent) in patients with infectious endocarditis as a result of pacemaker electrodes or cables, or of implanted automatic defibrillators. Conclusions: Early diagnosis, implementation of an intensive antibiotic treatment, early performance of surgery together with rigorous homeostasis results in a stagger reduction of mortality and morbidity in infectious endocarditis surgeries(AU)

Endocarditis infecciosa: características clínicas, complicaciones y mortalidad en 506 pacientes y factores pronósticos de sobrevida a 10 años (1998-2008). Estudio cooperativo nacional en endocarditis infecciosa en Chile (ECNEI-2) / Clinical characteristics, complications and mortality in 506 patients with infective endocarditis and determinants of survival rate at 10 years

Background: Rates ofmorbidity and mortality in Infective Endocarditis (IE) remain high and prognosis in this disease is still difficult and uncertain. Aim: To study IE in Chile in its active phase during inpatient hospital stay and long term survival rates. Material and Methods: Observational prospective national cohort study of 506 consecutive patients included between June 1,1998 and July 31, 2008, from 37 Chilean hospitals (secondary and tertiary centers) nationwide. Results: The main findings were the presence of Rheumatic valve disease in 22.1 % of patients, a history of intravenous drug abuse (IVDA) only in 0.7%, the presence of Staphylo-coccus aureus in 29.2% of blood cultures, negative blood cultures in 33.2%, heart failure in 51.7% and native valve involvement in 86% ofpatients. Echocardiographic diagnosis was achieved in 94% of patients. Hospital mortality was 26.1% and its prognostics factors were persisting infection (Odds ratio (OR) 6.43, Confidence Interval (CI) 1.45-28.33%), failure of medical treatment and no surgical intervention (OR 48.8; CI 6.67-349.9). Five and 10 years survival rates were 75.6 and 48.6%, respectively. The significant prognostic factors for long term mortality, determined by multivariate analysis were the presence of diabetes, Staphylococcus aureus infection, sepsis, heart failure, renal failure and lack of surgical treatment during the IE episode. Conclusions: The microbiologic diagnosis of IE must be urgently improved in Chile. Mortality rates are still high (26.1%) partly because of a high incidence of negative blood cultures and the need for more surgical valve interventions during in-hospital period. Long term prognostic factors for mortality should be identified early to improve outcome.

Perfil clínico-epidemiológico de pacientes con endocarditis infecciosa, período 2003-2010 en el hospital de Temuco, Chile / Profile of patients with infective endocarditis admitted to a Chilean regional hospital

Background: Mortality due to infective endocarditis (IE) in Chile is close to 30%. Aim: To report the experience with patients admitted with the diagnosis of IE in a regional tertiary hospital. Material and Methods: Retrospective study of 107 patients aged 50 ± 16years (75% males) discharged with a definitive diagnosis of IE according to modified DUKE criteria, between years 2003 and 2010. Demographic variables, severity scores, clinical characteristics, bacteriology and hospital evolution were recorded. Results: Fifty nine percent of patients had concomitant cardiovascular problems. APACHE II and Sequential Organ Failure Assessment (SOFA) scores on admission were 8.4 ± 4.7 and 2.7 ± 2.8 respectively. Native valves were affected in 91% of cases (aortic and mitral valves in 62% and 50% of cases respectively). Prosthetic valves were affected in 9.3% of cases. Rheumatic heart disease was the predominant primary lesion in 10% of patients. Antibiotics were used in 45.1% before blood cultures were performed. In 68% of patients blood cultures were positive. S. viridans (30.8%), S.aureus (18.6%) and coagulase negative Streptocicci (5.6%) were the identified microorganisms. Intensive care unit admission was required in 48% of patients. Renal, heart and neurological deterioration was observed in 53, 34 and 14% of patients, respectively. Twenty percent of patients developed systemic embolism and 37% required heart surgery. Mean hospital stay was 28.3 ± 19.1 days and 27% of patients died. Conclusions: In this series of patients, IE has a high mortality. Most patients studied were admitted in bad conditions.

Endocarditis infecciosa activa: 152 casos / Active infective endocarditis: 152 cases

La endocarditis infecciosa es una enfermedad de baja incidencia que en las últimas décadas mostró modificaciones respecto de su presentación, posibilidad diagnóstica y tratamiento. A pesar de estos avances, la mortalidad hospitalaria sigue siendo muy elevada. Nuestro objetivo fue analizar las características de los pacientes con endocarditis infecciosa activa y su relación con la mortalidad hospitalaria a lo largo de 16 años. Se realizó un registro prospectivo entre 1994 y 2010 de pacientes ingresados con endocarditis. Se analizaron características clínicas, evolución y tratamiento y se registraron los eventos intrahospitalarios. Ingresaron 152 pacientes, 64.5% varones, edad 45 ± 16 años, las causas más frecuentes de cardiopatía de base fueron: congénita 32 (21%) y reumática 20 (13.2%). Los motivos de internación fueron síndrome febril 116 (76.3%) e insuficiencia cardíaca 61 (40.1%). Se identificó el agente infeccioso en 106 (69.7%) de los casos, el más frecuente fue Streptococcus viridans. El ecocardiograma mostró vegetaciones en 123 (80.9%) de los pacientes y 88 (57.8%) presentaron complicaciones durante su internación, siendo la más frecuente la insuficiencia cardíaca. Se indicó tratamiento quirúrgico en 96 (63.1%) de los casos, fundamentalmente por insuficiencia cardíaca en 66. La mortalidad hospitalaria global fue 46 (30.2%). El desarrollo de complicaciones en la internación, la indicación de cirugía y la presencia de insuficiencia cardíaca refractaria al tratamiento fueron predictores independientes de mortalidad hospitalaria, mientras que la presencia de vegetaciones resultó un predictor independiente de mejor supervivencia. La identificación temprana de estos predictores descriptos podría ayudar a mejorar los resultados.

Active infective endocarditis (IE) is a disease of low incidence that has showed changes in presentation, diagnosis and treatment options during the past decades. Despite these advances, mortality remains very high. Our goal was to analyze the characteristics of patients with active IE and their relationship with in-hospital mortality over 16 years. Between 1994 and 2010 we performed a prospective registry of 152 consecutive patients (64.5% male, age 45 ± 16 years) admitted with IE. Clinical characteristics, treatment and inpatient outcomes were analyzed. The most common causes of underlying heart disease were: congenital (21%) and rheumatic fever (13.2%). The reasons for hospitalization were fever (76.3%) and heart failure (40.1%). The infectious agent was identified in 69.7% of cases, and the most frequent was Streptococcus viridans. The echocardiogram showed vegetations in 80.9% of patients and 57.8% of them presented complications (the most frequent was heart failure) during hospitalization. Surgical treatment was indicated in 63.2% of cases, mainly due to heart failure. The overall hospital mortality was 30.2%. The presence of complications, requirement of surgical treatment and refractory heart failure were independent predictors of mortality whereas the single presence of vegetation showed better survival rate. The identification of these predictors could help to improve the outcomes in IE.

Streptococcus bovis endocarditis: Clinical, Echocardiographic and prognostic features.

The aim of this study was to determine clinic and echocardiographic characteristics of Streptococcus bovis endocarditis [El] and its prognosis. We studied the clinic and echocardiographic characteristics of 54 patients with a Streptococcus bovis El among 350 cases of El. We included 44 men and 10 women, 64 +/- 15 years of age, with a native valvular disease in 31.5% of cases and a valvular prosthesis in 13%. 74% had a worsened general state; 48% presented with signs of cardiac insufficiency. 12 patients [22%] were followed for cancer including 7 digestive colic localizations [confirmed by coloscopy and histology]. Vegetation was identified in all patients. It was a left localization in 98.1%. Vegetation diameter was>10 mm in 37 patient s [68.5%] and>20 mm in 9 patients [16%]. During the follow-up, 59.3% developed an embolic accident, 17 cases of CVA and 7 cases of spondylodiscitis [7 out of 11 cases of spondylodiscitis described in the 350 cases of El]. Mortality reached 7%. The statistical analysis showed that Streptococcus Bouis was the major predictive factor for embolic complications, especially for spondylodiscitis. Streptococcus bovis El is more frequent in patients with digestive colic neoplasia. It is characterized by large vegetation which has a high embolic potential worsening the prognosis

Factores asociados a mortalidad en cirugía de la endocarditis infecciosa en el Hospital Regional de Concepción entre 1985 y 2005 / Risk factors associated to mortality in cardiac surgery for infective endocarditis: 1995-2005, Hospital Regional de Concepcion, Chile

Introducción: Se presenta la experiencia en tratamiento quirúrgico de endocarditis infecciosa (EI) y analizan factores asociados a mortalidad. Método: Estudio retrospectivo de pacientes operados por EI en el Hospital Regional de Concepción entre 1985 y 2005 (N=126). Se estudian características clínicas, cirugía efectuada, y morbimortalidad. Se comparó la mortalidad según periodo (1985–1994, 1995–2005), sexo, edad, válvula afectada, duración del tratamiento médico, indicación de cirugía y procedimiento efectuado. Las diferencias se estudiaron con test de probabilidad exacta de Fisher y test de independencia de variables según la distribución Chi–cuadrado. Resultados: Se operaron 52 pacientes entre 1985 y 1994. Edad promedio 43.5 años. 98 pacientes (77.8%) de sexo masculino. Las válvulas afectadas fueron aórtica (66.7%), mitral (10.3%), mitral y aórtica (21.4%). El tratamiento médico fue < 14 días en 47 (37%), entre 15 y 30 días en 50 (40%) y > 31 días en 29 (23%). Las principales indicaciones quirúrgicas fueron la insuficiencia cardiaca (54.7%) y vegetaciones >1cm (31%). Se realizaron 96 reemplazos univalvulares y 21 reemplazos bivalvulares. Presentaron complicaciones 63 pacientes y fallecieron 19 (15.1%). Se observó una mayor mortalidad en cirugía antes de 1995, sexo femenino, edad mayor de 50 años, compromiso bivalvular, periodo de tratamiento médico inferior a 30 días, indicación quirúrgica por insuficienciacardiaca y reemplazo bivalvular. Las diferencias no tuvieron significación estadística.Conclusiones: En nuestra serie, la mayor mortalidad quirúrgica se observó en los pacientes de mayor edad, sexo femenino y con compromiso bivalvular. Las diferencias observadas no tuvieron significación estadística.

Aim: to review the results of cardiac surgery in patients with Infective Endocarditis (IE) and to determine risk factors associated to surgical mortality. Method: A retrospective study of patients with cardiac surgery for IE at the Hospital Regional de Concepcion between 1985 and 2005 (n=126). We tabulated the clinical characteristics, type of surgery, morbidity and mortality. Mortality was compared for the period 1985-1994 vs. the period 1995-2005, according to sex, age, valve involved, duration of medical treatment, indication for surgery and procedure performed at operation. Differences were evaluated by the Fisher exact test or Chi square, as required Results: The mean age was 34.5 years; 98 patients (77.8%) were males. The aortic valve was affected in 66.7%,mitral valve in 10.3%, and both valves in 21.4%. Medical treatment lasted less than 14 days in 37%, 15-30 Days in 40% and >31 days in 23% of patients. Main surgical indications were congestive heart failure (54.7%) and vegetations greater than 1cm (31%). A single valve was replaced in 96 patients and 2 valves in 21. Complications occurred in 63 patients; the mortality rate was 15.1%. Compared to the later period, patients operated on before 1995 had greater mortality rate, proportion of women, age >50 years, bivalvular disease, frequency of medical treatment under 30 days, CHF as an indication for surgery and bivalvular replacements. However, the differences were not statistically significant.Conclusion: Older age, female sex and bivalvular disease were associated, although not significantly, with surgical mortality for IE.