Impact of early surgery on 6-month outcome in acute infective endocarditis.

BACKGROUND: The mortality in acute infective endocarditis (IE) remains high. Data on results of early surgery are limited. The aim of our study was to determine whether early surgery is associated with reduced 6-month mortality in a large cohort of acute IE. METHODS AND RESULTS: 310 consecutive patients examined by transthoracic and transoesophageal echocardiography (229 males; mean age: 60+/-15) with definite IE according to Duke criteria were prospectively enrolled. Early surgery was performed in 106 (34%) patients (37 mechanical prosthesis, 32 biological prosthesis, 19 valve repairs, 15 pace maker line extractions, three multiple valve replacements) with an operative mortality of 5,7%. The mean time between admission and early surgery was 12+/-9 days. Early surgery was performed more frequently in patients with heart failure (48% vs 33%, p=0.009), uncontrolled infection (40% vs 23%; p=0.002), abscess (35% vs 18%; p=0.001), neurological event (34% vs 20%; p=0.005), embolic event (50% vs 34%; p=0.006), severe regurgitation (60% vs 29%; p=0.001) and large vegetation (>15 mm) (50% vs 23%; p<0.001). In unadjusted analysis, early surgery was associated with lower 6-month mortality (24% vs 37%; p=0.045). After adjustment of variables associated with mortality and comorbidity index, early surgery was identified as an independent predictor of reduced 6-month mortality (HR=0.52; IC 95%=0.2-0.9; p=0.025). CONCLUSION: Early surgery performed in 34% of patients is independently associated with reduced mortality and should be considered in selected cases to improve outcome in acute IE.

Comparison of clinical and morphological characteristics of Staphylococcus aureus endocarditis with endocarditis caused by other pathogens.

OBJECTIVES: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. DESIGN: Cohort study. METHODS: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n = 61) was compared with the group with IE caused by other pathogens (n = 133). RESULTS: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p = 0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. CONCLUSIONS: S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases.

OBJECTIVES: To identify the prognostic markers of a bad outcome in a large population of 104 patients with prosthetic valve endocarditis (PVE), and to study the influence of medical versus surgical strategy on outcome in PVE and thus to identify patients for whom surgery may be beneficial. DESIGN: Multicentre study. METHODS AND RESULTS: Among 104 patients, 22 (21%) died in hospital. Factors associated with in-hospital death were severe co-morbidity (6% of survivors v 41% of those who died, p = 0.05), renal failure (28% v 45%, p = 0.05), moderate to severe regurgitation (22% v 54%, p = 0.006), staphylococcal infection (16% v 54%, p = 0.001), severe heart failure (22% v 64%, p = 0.001), and occurrence of any complication (60% v 90%, p = 0.05). By multivariate analysis, severe heart failure (odds ratio 5.5) and Staphylococcus aureus infection (odds ratio 6.1) were the only independent predictors of in-hospital death. Among 82 in-hospital survivors, 21 (26%) died during a 32 month follow up. A Cox proportional hazards model identified early PVE, co-morbidity, severe heart failure, staphylococcus infection, and new prosthetic dehiscence as independent predictors of long term mortality. Mortality was not significantly different between surgical and non-surgical patients (17% v 25%, respectively, not significant). However, both in-hospital and long term mortality were reduced by a surgical approach in high risk subgroups of patients with staphylococcal PVE and complicated PVE. CONCLUSIONS: Firstly, PVE not only carries a high in-hospital mortality risk but also is associated with high long term mortality and needs close follow up after the initial episode. Secondly, congestive heart failure, early PVE, staphylococcal infection, and complicated PVE are associated with a bad outcome. Thirdly, subgroups of patients could be identified for whom surgery is associated with a better outcome: patients with staphylococcal and complicated PVE. Early surgery is strongly recommended for these patients.

Superiority of surgical versus medical treatment in patients with Staphylococcus aureus infective endocarditis.

BACKGROUND: We present here the clinical features and outcome of 54 patients affected by a Staphylococcus aureus infective endocarditis at the Amiens hospital between 1990 and 2000. The patients operated-on, group A (20 patients), were compared to the population of patients treated by exclusive antibiotherapy, group B (34 patients). PATIENTS AND METHOD: The male gender predominated with a sex ratio of 2.6. The mean age of the global population was 58.7+/-1.6 years. Time between onset of endocarditis symptoms and treatment (entire group) ranged from 1 to 120 days (mean 14.4 days). The main portal of entry were, respectively, for group A and group B: cutaneous 55% and 44.1%; intravascular material 5% and 8.8%; and rhinopharynx 5% and 8.8%. Seventy-five percent of the Staphylococcus aureus isolated were Methi-S. The main surgical treatment indication were: hemodynamic failure (HF) (30%), unstable infection with collapse (UI) (30%), UI+HF (10%), voluminous vegetation (20%) and embolism event (10%). RESULTS: The hospital mortality rate were respectively for the entire group, group A and group B: 25%, 35% and to 41% (ns). For group A, the operative mortality was lower(21%) after the first week. The actuarial survival rate (Kaplan-Meier) after 24 months was 54./+/-6.9% for the global population and 74+/-10.6% for group A and 43+/-8.5 for group B (p<0.001). The multivariate analysis finds severe sepsis and index of comorbidity as independent factors related to the global late mortality and, respectively, the age and the severe sepsis for group A, and the cardiac insufficiency for group B. CONCLUSION: The surgical treatment seems to be the best way to improve the results after Staphylococcus aureus endocarditis. The severity of the sepsis remains the most severe prognostic element, whatever the treatment adopted may be.

[Current data on atmospheric pollutions]. / Quelques données actuelles concernant les pollutions atmosphériques.

Atmospheric pollutions (AP) are very important for human health and ecological equilibrium. They may be natural or anthropogenic and in this later case they can appear outdoor or indoor. Urban air pollution is the most known form of AP. Its main sources are industries, individual and collective heating and now mainly automobile traffic in most cities. Classical AP indicators are SO2, particles, NOx, CO and Pb measured in networks. Important factors of AP are amounts of pollutants emitted and local climatic and meteorological characteristics. Health effects of AP peaks and of AP background levels are not well known. But generally, mean AP levels of SO2 and particles decreased in the last years in most towns as the consequence of collective actions on the three main sources of AP and on fuels, emission and immission levels; but more is wanted about motor-cars. Progress are necessary for limitation of three major ecological risks: "acid-rain" (SO2 and NOx derivatives, ozone,...) which participates in lake and forest attacks; "green house" effects whose air CO2 concentration increase is the main responsible, and stratospheric ozone depletion mainly due to freons (CFC); the consequences of these two last phenomena are not well known but ecological and health risk exist. Besides, indoor air pollution (IAP) is very important because we live more than 20 h a day indoor. IAP may be occupational (a lot of chemical or biological agents) or not. In the later case air pollutants are very various: CO, NOx and particles from heating or cooking, formaldehyde from wood glue, plywood or urea-formol foams, radon and derivatives in some granitic countries, odd jobs products, cosmetics, aero-allergens of chemical or biological origins, microbes,... Environmental tobacco smoke (ETS) is also an important pollutant complex. Risks of IAP are real or potential: acute risk is obvious for CO, aero-allergens, formaldehyde, NOx,...); irritations are produced by ETS, formaldehyde, solvants,...; long term or potential risks are of concern for asbest, radon,... A complex and bad known pathology is described in a lot of modern buildings as the "Sick Building Syndrom". Indoor air quality is very dependant of the quality of ventilation and possible air treatment. It may be considered in all urban epidemiological studies about air pollution.