Short- and long-term outcomes of infective endocarditis admission in adults: A population-based registry study in Finland.

Infective endocarditis (IE) is associated with high mortality. However, data on factors associated with length of stay (LOS) in hospital due to IE are scarce. In addition, long-term mortality of more than 1 year is inadequately known. In this large population-based study we investigated age and sex differences, temporal trends, and factors affecting the LOS in patients with IE and in-hospital, 1-year, 5-year and 10-year mortality of IE. Data on patients (≥18 years of age) admitted to hospital due to IE in Finland during 2005-2014 were collected retrospectively from nationwide obligatory registries. We included 2166 patients in our study. Of the patients 67.8% were men. Women were older than men (mean age 63.3 vs. 59.5, p<0.001). The median LOS was 20.0 days in men and 18.0 in women, p = 0.015. In the youngest patients (18-39 years) the median LOS was significantly longer than in the oldest patients (≥80 years) (24.0 vs. 16.0 days, p = 0.014). In-hospital mortality was 10% with no difference between men and women. Mortality was 22.7% at 1 year whereas 5- and 10-year mortality was 37.5% and 48.5%, respectively. The 5-year and 10-year mortality was higher in women (HR 1.18, p = 0.034; HR 1.18, p = 0.021). Both in-hospital and long-term mortality increased significantly with aging and comorbidity burden. Both mortality and LOS remained stable over the study period. In conclusion, men had longer hospital stays due to IE compared to women. The 5- and 10-year mortality was higher in women. The mortality of IE or LOS did not change over time.

Surgical aortic valve replacement and infective endocarditis.

BACKGROUND: We wanted to investigate the influence of native-valve infective endocarditis (IE) on long-term outcomes of surgical aortic valve replacement (SAVR). METHODS: Native-valve patients with IE (n = 191) were compared to propensity score-matched patients without IE (n = 191), all treated with SAVR, in a multicentre, population-based cohort register study in Finland. The median follow-up was 6.2 years. RESULTS: Infective endocarditis as the indication for SAVR was associated with an increased hazard of 10-year mortality (37.1% vs 24.2%; HR 1.83; CI 1.03-3.26; P = .039). Ischaemic stroke was also more frequent in IE patients during 10-year follow-up (15.8% vs 7.5%; HR 3.80; CI 1.42-10.18; P = .008). Major bleeding within first year after SAVR was more frequent in patients with IE (7.0% vs 2.9%; P = .038). Ten-year major bleeding rate was 32.4% in IE vs 24.5% in non-IE groups (P = .174). Aortic valve re-operation rate was 4.3% in IE vs 8.4% in non-IE groups (P = .975). Admission duration after SAVR was longer in IE (median 29 vs 9 days; P < .0001). There was no difference in 30-day mortality after SAVR. CONCLUSIONS: Patients with native-valve IE have a higher risk of death, ischaemic stroke, and early major bleeding after SAVR than matched patients without IE. Results confirm the high risk for complications of IE patients after SAVR and highlight the importance of vigorous prevention of both stroke and bleeding after SAVR in these patients.

Mechanical Versus Biologic Prostheses for Surgical Aortic Valve Replacement in Patients Aged 50 to 70.

BACKGROUND: The use of biologic prosthesis is increasing in surgical aortic valve replacement (SAVR). Recent US guidelines recommend either biologic or mechanical prosthesis for SAVR in patients aged 50 to 70 years. We set out to study long-term outcomes of mechanical versus biologic prosthetic valves in this patient group. METHODS: All patients (excluding infective endocarditis and concomitant surgery other than coronary artery bypass grafting) aged 50 to 70 with first-time SAVR in Finland between 2004 and 2014 were retrospectively studied (N = 2928). Propensity score matching (1:1) was used to identify patients with comparable baseline features (n = 1152). Outcomes were 10-year all-cause mortality, aortic valve reoperation, major bleeding, ischemic stroke, and infective endocarditis. Mean follow-up was 6.7 years. RESULTS: Ten-year all-cause mortality was 18.6% with mechanical valves and 27.6% with biologic valves (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.54-0.97; P = .028). Prosthetic valve reoperation was performed in 1.4% with mechanical valves and in 8.5% with bioprosthetic valves (HR, 0.30; 95% CI, 0.12-0.74; P = .009). Major bleeding occurred in 21.5% with mechanical valves and in 16.9% with biologic prostheses (HR, 1.19; P = .402). Rates of intracranial bleeding were also comparable. Ischemic stroke rates within 10 years were 12.7% with mechanical valves and 9.3% with biologic valves (HR, 1.29; P = .316). Infective endocarditis occurred in 3.7% of mechanical valves and in 7.3% of biologic valves (HR, 0.46; 95% CI, 0.24-0.88; P = .018). CONCLUSIONS: Mechanical valve prostheses were associated with lower mortality, lower rates of reoperation, and lower occurrence of infective endocarditis compared with bioprostheses within 10 years after SAVR in matched patients aged 50 to 70 years. Our results do not support the routine use of biologic valve prostheses in this patient group.

Occurrence of fatal infective endocarditis: a population-based study in Finland.

BACKGROUND: Infective endocarditis (IE) is a serious mainly bacterial infection associated with high mortality. Epidemiology of fatal IE is however largely unknown. We studied occurrence and trends of fatal IE in a population-based setting. METHODS: All adults (≥18 years of age) who deceased due to IE in Finland during 2004-2016 were studied. Data was collected from the nationwide, obligatory Cause of Death Registry. Background population consisted of 28,657,870 person-years and 651,556 deaths. RESULTS: Infective endocarditis contributed to death in 754 cases and was the underlying cause of death in 352 cases. The standardized incidence rate of deaths associated with IE was 1.42 (95% confidence interval (CI): 1.32-1.52) per 100,000 person-years. Incidence rate increased progressively with aging from 50 years of age. Men had a two-fold risk of acquiring fatal infective endocarditis compared to women (risk ratio (RR) 1.95; 95% CI: 1.71-2.22; P < 0.0001). On average, IE contributed to 1.16 (95% CI: 1.08-1.24) out of 1000 deaths in general adult population. The proportionate amount of deaths with IE was highest in population aged < 40 years followed by gradual decrease with aging. Incidence rate and proportion of deaths caused by IE remained stable during the study period. CONCLUSIONS: Our study describes for the first time the population-based epidemiology of fatal IE in adults. Men had a two-fold risk of acquiring fatal IE compared to women. Although occurrence of fatal IE increased with aging, the proportion of deaths to which IE contributed was highest in young adult population.

Mechanical versus biological valve prosthesis for surgical aortic valve replacement in patients with infective endocarditis.

OBJECTIVES: The optimal choice of valve prosthesis in surgical aortic valve replacement for infective endocarditis (IE) is controversial. We studied outcomes after mechanical versus biological prosthetic valve surgical aortic valve replacement in IE patients. METHODS: All patients with native-valve IE aged 16-70 years undergoing mechanical or biological surgical aortic valve replacement in Finland, between 2004 and 2014, were retrospectively studied (n = 213). Outcomes were all-cause mortality, ischaemic stroke, major bleeding and aortic valve reoperation at 1 year and 5 years. Results were adjusted for baseline features (age, sex, comorbidity burden, atrial fibrillation, valvular stenosis, concomitant coronary artery bypass grafting, extension, urgency, year and centre of operation). Median follow-up was 5 years. RESULTS: The 5-year mortality rate was 19.0% with mechanical prostheses and 34.8% with biological prostheses [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.23-0.92; P = 0.03]. Ischaemic stroke rates were 8.3% with mechanical prostheses and 16.8% with biological prostheses at 5 years (HR 0.21, CI 0.06-0.79; P = 0.01). Results were comparable in patients aged 16-59 and 60-70 years (interaction P = 0.84). Major bleeding within 5 years was similar between mechanical (11.3%) and biological valve (13.4%) groups (P = 0.95) with comparable rates of both gastrointestinal and intracranial bleeds. Reoperation rates at 5 years were 5.0% for mechanical prostheses and 9.2% for biological prostheses (P = 0.14). The 1-year ischaemic stroke rate was lower with mechanical prostheses (3.6% vs 11.6%, P =0.03), whereas mortality, major bleeding and reoperation rates were similar between groups. CONCLUSIONS: The use of mechanical aortic valve is associated with lower mid-term mortality compared to biological prosthesis in patients with native-valve IE aged ≤70 years. Our results do not support the routine choice of a biological aortic valve prosthesis in this patient group.

Trends in occurrence and 30-day mortality of infective endocarditis in adults: population-based registry study in Finland.

OBJECTIVES: Infective endocarditis (IE) is a life-threatening disease associated with significant mortality. We studied recent temporal trends and age and sex differences in the occurrence and short-term mortality of IE. DESIGN: Population based retrospective cohort study. SETTING: Data of IE hospital admissions in patients aged ≥18 years in Finland during 2005-2014 and 30-day all-cause mortality data were retrospectively collected from mandatory nationwide registries from 38 hospitals. OUTCOMES: Trends and age and sex differences in occurrence. Thirty-day mortality. RESULTS: There were 2611 cases of IE during the study period (68.2% men, mean age 60 years). Female patients were significantly older than males (62.0 vs 59.0 years, p=0.0004). Total standardised annual incidence rate of IE admission was 6.33/100 000 person-years. Men had significantly higher risk of IE compared with women (9.5 vs 3.7/100 000; incidence rate ratios [IRR] 2.49; p<0.0001) and difference was most prominent at age 40-59 years (IRR 4.49; p<0.0001). Incidence rate varied from 5.7/100 000 in 2005 to 7.1/100 000 in 2012 with estimated average 2.1% increase per year (p=0.036) and similar trends in both sexes. Significant increasing trend was observed in patients aged 18-29 years and 30-39 years (estimated annual increase 7.6% and 7.2%, p=0.002) and borderline in patients aged 40-49 years (annual increase 3.8%, p=0.08). In older population, IE incidence rate remained stable. The overall 30-day mortality after IE admission was 11.3%. Mortality was similar between sexes, increased with ageing, and remained similar during the study period. CONCLUSIONS: Occurrence of IE is increasing in young adults in Finland. Men, especially middle-aged, are at higher risk for IE compared with women. Thirty-day mortality has remained stable at 11%, increased with ageing, and was similar between sexes.