Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Prosthetic or Bioprosthetic Heart Valves.

The objectives of this study were to describe and compare the clinical characteristics and outcomes of patients with definite and possible infective endocarditis (IE) involving prosthetic heart valve, and to identify prognostic factors for long-term mortality, using data from an unselected cohort of consecutive patients. We studied data from 133 consecutive patients with IE involving prosthetic heart valve seen in an academic institution between 1990 and 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 47, 35%) and patients with definite IE (n = 86, 65%). Overall, 55 patients died over a mean ± SD follow-up of 3.6 ± 4.1 years (median 1.8, interquartile range 4.4 years). Patients with definite IE had a higher risk of death (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.20 to 4.17 p = 0.01). Independent predictors of long-term mortality were increasing age (HR 1.05, 95% CI 1.02 to 1.08, p = 0.002), Staphylococcus aureus infection (HR 3.40, 95% CI 1.00 to 11.76; p = 0.05), infection with unknown microorganism (HR 12.50, 95% CI 2.97 to 52.63; p = 0.0006), and definite IE (HR 8.70, 95% CI 3.55 to 21.28; p <0.0001), whereas infection on pacemaker or defibrillator (HR 0.30, 95%CI 0.10 to 0.87; p = 0.03) was associated with a better prognosis. Patients with definite IE and those with possible IE who underwent surgery had a nonsignificantly better prognosis than their counterparts with no surgery. In conclusion, patients with definite IE (Duke criteria) on a prosthetic heart valve independently had a worse prognosis than those with possible IE.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Native Heart Valves.

There are very few data on the prognosis of possible versus definite infective endocarditis (IE). We studied data from 365 consecutive patients with IE involving native heart valve seen in an academic institution from 1990 to 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 101, 28%) and those with definite IE (n = 264, 72%). Patients with possible IE were older than those with definite IE (66 ± 15 vs 62 ± 16, p = 0.05). A causative microorganism was identified in 66% of patients with possible IE versus all patients with definite IE (p <0.0001) and only 41% had major echocardiographic criteria (vs 100%; p <0.0001). Overall, 139 patients died over a mean ± SD follow-up of 3.9 ± 4.5 years (median 2.2, interquartile range 5.9 years). Patients with possible and definite IE had a similar risk of death. Independent predictors of long-term mortality were increasing age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01 to 1.04; p = 0.0009), vegetation length >15 mm (HR 1.87, 95% CI 1.14 to 3.06; p = 0.01), and stroke (HR 4.10, 95% CI 1.84 to 9.17; p = 0.0006), whereas infection of mitral valve (HR 0.57, 95% CI 0.34 to 0.94; p = 0.03) and surgery (HR 0.43, 95% CI 0.19 to 0.99; p = 0.05) were associated with a better prognosis. Patients with definite IE and those with possible IE who did not undergo surgery had a worse prognosis than their counterparts with surgery. In conclusion, unselected patients with possible IE (Duke criteria) had a similar prognosis than those with definite IE.

Long-Term Outcome and Valve Surgery for Infective Endocarditis in the Systematic Analysis of a Community Study.

BACKGROUND: Information on the long-term prognosis of patients with infective endocarditis (IE) and valve surgical procedures is scarce, and most analyses are based on registries. This study described outcomes and predictors of mortality in a cohort of consecutive patients with IE with a long-term follow-up. METHODS: A total of 616 of patients with IE seen in an academic institution between 1990 and 2012 were identified and followed. The mean follow-up period was 4.8 ± 5.7 years (median, 2.6 years). RESULTS: Cardiac surgical procedures were performed in 47% of the patients, among whom 77% had surgical procedures in the first 6 months. Six-month and long-term (≥6 month) mortality rates were 15% and 40%, respectively. Older age, male sex, infection in a mechanical valve, Staphylococcus aureus infection, presence of vegetation, stroke, and atrioventricular block were independent predictors of mortality, whereas Streptococcus infection was independently associated with a better prognosis. Valve surgical procedures were independently associated with a decrease in mortality: hazard ratio (HR): 0.38; 95% confidence interval (CI): 0.26 to 0.56 for surgical treatment within 45 days; HR 0.36; 95% CI: 0.22 to 0.61 for surgical treatment between 45 and 180 days; and HR: 0.42; 95% CI: 0.25 to 0.73 for surgical treatment beyond 6 months. Decrease in mortality with valve surgical procedures was found in the two subgroups of patients with definite IE (adjusted HR: 0.36; 95% CI: 0.24 to 0.54; p < 0.0001) and in those with possible IE (HR: 0.40; 95% CI: 0.24 to 0.67; p = 0.0005). CONCLUSIONS: In unselected patients with IE, prognostic factors for long-term mortality were consistent with those identified in previous studies for short-term mortality. These results confirm the apparent benefit associated with valve surgical procedures on long-term prognosis.

Stroke and major bleeding risk in elderly patients aged ≥75 years with atrial fibrillation: the Loire Valley atrial fibrillation project.

BACKGROUND AND PURPOSE: Atrial fibrillation (AF) is increasingly prevalent in the elderly, but such patients tend to be under-represented in clinical trials. Increasing age confers a higher risk of stroke and bleeding when antithrombotic therapy is used. We examined risk factors for stroke and bleeding among elderly (age, >75 years) patients within a real world hospitalized cohort from the Loire Valley AF project. METHODS: We identified elderly (age, >75 years) patients with AF, assessed their risk factors, and followed up for stroke, thromboembolism, death, or major bleeding. The effect of vitamin K antagonist (VKA) use on these end points was assessed. RESULTS: We studied 8962 patients with AF, and we identified 4130 elderly (age, ≥75 years) patients. Using Kaplan-Meier analyses, event rates of death, stroke/thromboembolism, the composite of stroke/thromboembolism/death, and major bleeding increased with increasing age. For mortality, VKA-treated patients did better than non-VKA-treated patients. The risk of death and stroke/thromboembolism/death increased with increasing age. The risk of major bleeding did not increase with increasing age strata. VKA treatment was associated with lower mortality in those aged <75 years (adjusted hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.45-0.72), and the effect size was maintained with increasing age strata (Pint=0.67). For stroke/thromboembolism/death, VKA also has a significant benefit in those aged <75 years (adjusted HR, 0.69; [0.57-0.83]), and the effect size was maintained with increasing age strata (Pint=0.58). For major bleeding, there was no statistically significant difference between age strata (Pint=0.67). In elderly patients, age and previous stroke emerged as the main predictors of stroke and thromboembolism. Renal impairment and VKA use were predictors of major bleeding. CONCLUSIONS: Elderly patients with AF have a higher risk of stroke and bleeding, but the benefits of VKA therapy for stroke/thromboembolism or mortality were present regardless of increasing age.

Prognosis in patients hospitalized with permanent and nonpermanent atrial fibrillation in heart failure.

Atrial fibrillation (AF) and heart failure (HF) frequently coexist and are associated with an increased mortality. This study evaluated the prognosis of permanent and nonpermanent AF in patients with both AF and HF. All AF patients seen in our institution were identified and followed up. We included 1,906 patients suffering from AF and HF: 839 patients (44%) had preserved left ventricular ejection fraction (LVEF) and 1,067 patients (56%) had decreased LVEF; 1,056 patients (55%) had nonpermanent AF and 850 patients (45%) had permanent AF. During a median follow-up of 1.9 years (interquartile range 0.3 to 5.0), 377 patients died, 462 were readmitted for HF, and 200 had stroke or thromboembolic events. In patients with decreased LVEF, the rate of death was similar in patients with permanent or nonpermanent AF. In patients with preserved LVEF, permanent AF was associated with a higher risk of death and a higher risk of HF hospitalization. Stroke risk did not differ with permanent AF whatever the LVEF. NYHA functional class was an independent predictor of death (risk ratio [RR]=1.33, 95% confidence interval [CI] 1.12 to 1.59, p=0.001), as was permanent AF (RR=1.79, 95%CI 1.32 to 2.42, p=0.0002). Permanent AF (RR=1.52, 95% CI 1.20 to 1.93, p=0.0006) was also an independent predictor of readmission for HF. In conclusion, in patients with AF and HF, the risk of admission for HF and risk of death were higher when AF was permanent, particularly in patients with preserved LVEF. Stroke risk did not differ according to the pattern of AF, whatever the LVEF.