Left-sided Native Valve Infective Endocarditis Research Articles

Trends of Infective Endocarditis at Two Teaching Hospitals: A 12-Year Retrospective Cohort Study in Rio de Janeiro, Brazil.

Despite advances in diagnosis and treatment, the incidence and mortality of infective endocarditis (IE) have increased in recent decades. Studies on the risk factors for mortality in endocarditis in Latin America are scarce. This retrospective cohort study included 240 patients diagnosed with IE according to the modified Duke criteria who were admitted to two university hospitals in Rio de Janeiro, Brazil from January 2009 to June 2021. Poisson regression analysis was performed for trend tests. The multivariate Cox proportional hazards model was used to estimate the hazard ratio (HR) of predictors of in-hospital mortality. The median age was 55 years (IQR: 39-66 years), 57% were male, and 41% had a Charlson comorbidity index (CCI) score > 3. Healthcare-associated infective endocarditis (54%), left-sided native valve IE (77.5%), and staphylococcal IE (26%) predominated. Overall, in-hospital mortality was 45.8%, and mortality was significantly higher in the following patients: aged ≥ 60 years (53%), CCI score ≥ 3 (60%), healthcare-associated infective endocarditis (HAIE) (53%), left-sided IE (51%), and enterococcal IE (67%). Poisson regression analysis showed no trend in in-hospital mortality per year. The adjusted multivariate model determined that age ≥ 60 years was an independent risk factor for in-hospital mortality (HR = 1.9; 95% CI 1.2-3.1; p = 0.008). In this 12-year retrospective cohort, there was no evidence of an improvement in survival in patients with IE. Since older age is a risk factor for mortality, consensus is needed for the management of IE in this group of patients.

Left-sided native valve infective endocarditis concomitant with severe valvular regurgitation: Prevalence, characteristics and prognostic factors

Abstract Background The characteristics of patients with left-sided native valve infective endocarditis and severe valvular regurgitation has never been studied. Purpose To analyze the prevalence of severe valvular regurgitation in patients with left-sided infective endocarditis, to describe in detail their characteristics and to determine the prognostic factors of these patients. Patients and methods We included in an ongoing multipurpose database, all patients with definite left-sided infective endocarditis admitted in three Spanish tertiary hospitals from 2005 to 2022. We describe the clinical, epidemiological, microbiological, echocardiographic characteristics of patients with severe valvular regurgitation and compared it with those without it. We also analyzed the independent factors of in-hospital mortality of these patients. Results Of a total of 874 patients with left-sided native valve infective endocarditis of our series, 564 had severe valvular regurgitation (65%). Comparison between patients with and without severe valvular regurgitation is shown in figure 1. Age (HR 1.035 95% CI 1.02-1.05), S. aureus (HR 2.26; 95% CI 1.26-4.1), vegetations (HR 3.7; 95% CI 1.2-11.4), heart failure (HR 2.76; 95% IC 1.5-5.1), renal failure (HR 3.1; 95% CI 1.9-4.9) and septic shock (HR 4.3; 95% CI 2.29-8) were the independent factors of in hospital mortality. On the contrary, cardiac surgery is an independent protector factor of mortality (HR 0.35; 95% CI 0.21-0.59). Conclusions A very high proportion of patients with definite left-sided infective endocarditis have severe valvular regurgitation in our series. Despite important epidemiological, clinical and echocardiographic differences with patients without it, the short-term prognosis is similar Surgery is an independent protective factor in these patients.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism.

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

Single-Centre Retrospective Evaluation of Intraoperative Hemoadsorption in Left-Sided Acute Infective Endocarditis.

Background: Cardiac surgery in patients with infective endocarditis (IE) is still associated with high mortality and morbidity; an already present inflammation might further be aggravated due to a cardiopulmonary bypass-induced dysregulated immune response. Intraoperative hemoadsorption therapy may attenuate this septic response. Our objective was therefore to assess the efficacy of intraoperative hemoadsorption in active left-sided native- and prosthetic infective endocarditis. Methods: Consecutive high-risk patients with active left-sided infective endocarditis were enrolled between January 2015 and April 2021. Patients with intraoperative hemoadsorption (Cytosorbents, Princeton, NJ, USA) were compared to patients without hemoadsorption (control). Endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Predictors for sepsis-associated mortality and in-hospital mortality were analysed by multivariable logistic regression. Results: A total of 202 patients were included, 135 with active left-sided native and 67 with prosthetic valve infective endocarditis. Ninety-nine patients received intraoperative hemoadsorption and 103 patients did not. Ninety-nine propensity-matched pairs were selected for final analyses. Postoperative sepsis and sepsis-related mortality was reduced in the hemoadsorption group (22.2% vs. 39.4%, p = 0.014 and 8.1% vs. 22.2%, p = 0.01, respectively). In-hospital mortality tended to be lower in the hemoadsorption group (14.1% vs. 26.3%, p = 0.052). Key predictors for sepsis-associated mortality and in-hospital mortality were preoperative inotropic support, lactate-levels 24 h after surgery, C-reactive protein levels on postoperative day 1, chest tube output, cumulative inotropes and white blood cell counts on postoperative day 2, and new onset of dialysis. Multivariate regression analysis revealed intraoperative hemoadsorption to be associated with lower sepsis-associated (OR 0.09, 95% CI 0.013–0.62, p = 0.014) as well as in-hospital mortality (OR 0.069, 95% CI 0.006–0.795, p = 0.032). Conclusions: Intraoperative hemoadsorption holds promise to reduce sepsis and sepsis-associated mortality after cardiac surgery for active left-sided native and prosthetic valve infective endocarditis.

Impact of early surgery in non-complicated left-sided native-valve infective endocarditis with large vegetations

The impact of early surgery for patients with left-sided native-valve infective endocarditis (LS-NV-IE) with a large vegetation (between 10 and 30 mm), free of embolic events and of other complication, has not yet been established. We aimed to describe the characteristics of these patients and to assess the impact of early surgery (≤ 7 days) in terms of 6-month outcomes. Among 1340 patients diagnosed with LS-NV-IE, 174 patients with a vegetation between 10 and 30 mm and without class I or IIa indication for surgery (according to European guidelines) were included. The primary endpoint combined death and endocarditis complications (recurrence of endocarditis, heart failure requiring hospitalization, or clinical embolic event) at 6-months. Patients( n = 42) who underwent early surgery were younger ( P = 0.019) and more likely to have a vegetation length > 15 mm (66.7%vs.47.7%) and highly mobile vegetations (59.5%vs.39.4%), than patients managed conservatively. The 6-month event-free survival was 98 ± 2% in the early surgery group and 86 ± 3% in the conservative group ( P = 0.037), even after propensity matching ( P = 0.003). On multivariable analysis, early surgery was associated with better outcome [Adjusted HR(95%CI) = 0.16(0.04–0.97); P = 0.046] ( Fig. 1 ). Early surgery for patients with LS-NV-IE and vegetation between 10 and 30 mm, free of embolic events and of other IE complication, is associated with a lower rate of events at 6 months.

Impact of early surgery in non-complicated left-sided native-valve infective endocarditis with large vegetations

The impact of early surgery for patients with left-sided native-valve infective endocarditis (LS-NV-IE) with a large vegetation (between 10 and 30 mm), free of embolic events and of other complication, has not yet been established. We aimed to describe the characteristics of these patients and to assess the impact of early surgery (≤ 7 days) in terms of 6-month outcomes. Among 1340 patients diagnosed with LS-NV-IE, 174 patients with a vegetation between 10 and 30 mm and without class I or IIa indication for surgery (according to European guidelines) were included. The primary endpoint combined death and endocarditis complications (recurrence of endocarditis, heart failure requiring hospitalization, or clinical embolic event) at 6-months Patients ( n = 42) who underwent early surgery were younger ( P = 0.019) and more likely to have a vegetation length > 15 mm (66.7%vs.47.7%) and highly mobile vegetations (59.5%vs.39.4%), than patients managed conservatively. The 6-month event-free survival was 98 ± 2% in the early surgery group and 86 ± 3% in the conservative group ( P = 0.037), even after propensity matching ( P = 0.003). On multivariable analysis, early surgery was associated with better outcome [Adjusted HR(95%CI) = 0.16(0.04–0.97); P = 0.046] ( Fig. 1 ). Early surgery for patients with LS-NV-IE and vegetation between 10 and 30 mm, free of embolic events and of other IE complication, is associated with a lower rate of events at 6 months.

Prosthesis choice for surgical treatment of left-sided native valve infective endocarditis: Determinants and impact on outcomes

Surgical treatment is required in approximately half of the patients with infective endocarditis (IE) because of severe complications. To date there is no recommendation favoring a specific valve substitute for IE treatment and accordingly there is a wide variation in routine surgical management of these patients. The purpose of this study is to describe surgical practices in our center and to investigate the impact on clinical outcomes. All patients with native valve left-sided IE, who underwent valve replacement surgery with a mechanical or biological prosthesis in our institution between 1 January 2006 and 31 December 2018 were enrolled in this retrospective study. A total of 303 patients were included (mean age = 58 years, 80% men). Patients in whom a biological valve was chosen (64%, n = 194) were older and had more comorbid conditions compared to patients who received a mechanical valve (36%, n = 109). In hospital mortality was respectively 19% ( n = 36) in the bioprosthesis group avec 3% ( n = 3) in the mechanical valve group ( P < 0.0001). The mortality rates at 1 and 3 years were 35% and 41% in the biological valve group, these rates were 8% and 15% in the mechanical valve group. Factors associated to in hospital and mid term mortality were age, comorbid conditions, hemodynamic failure, a double valve replacement or associated bypass surgery. The type of the implanted valve substitute was not independently associated with mortality. For surgical management of IE, a biological valve is the most used valve substitute in our institution. Mechanical valves seem to be implanted in a very selected and low-risk patient subgroup. The valve substitute does not appear to be related to in hospital nor to midterm mortality rates.

Characteristics and Prognosis of Patients With Left-Sided Native Bivalvular Infective Endocarditis

BackgroundMost cases of left-sided native valve infective endocarditis (IE) involve a single valve and little is known concerning IE that simultaneously affects the aortic and mitral valves. MethodsWe aimed to determine the characteristics, identify the prognostic factors, and define the effect of early surgery for patients with left-sided native bivalvular IE. This analysis included 1340 consecutive patients who presented with definite acute left-sided native valve IE in a 2-centre cohort study. ResultsA bivalvular involvement was present in 257 patients (19%). Patients with bivalvular IE had more embolic events (P = 0.044), congestive heart failure (P = 0.016), vegetations, and perivalvular complications (both P < 0.001) than those with monovalvular IE. Early surgery was more frequent for patients with bivalvular IE (P < 0.001). Thirty-day mortality was higher for patients with bivalvular IE than for those with monovalvular IE (24.5% vs 17.6%; P = 0.008), even after adjustment (odds ratio, 1.86 [95% confidence interval, 1.26-2.73]; P < 0.001). Estimated 10-year survival was 70% ± 1% for monovalvular IE and 59% ± 3% for bivalvular IE (P = 0.002). Bivalvular IE was still associated with mortality in multivariable Cox analysis, after adjustment for covariates including age, neurological events, congestive heart failure, Staphylococcus spp infection, perivalvular complications, and early surgery (hazard ratio, 1.70 [95% confidence interval, 1.31-2.11]; P < 0.001). Early surgery was associated with increased survival for patients with bivalvular IE (79% ± 4% vs 35% ± 6%; P < 0.001). ConclusionsBivalvular involvement is frequent in left-sided native valve IE, is associated with more embolic events and congestive heart failure than monovalvular IE, and patients are at a high risk of death. Early surgery is associated with improved survival and should be systematically discussed in the absence of contraindication.

Elderly versus non-elderly patients undergoing surgery for left-sided native valve infective endocarditis: A 10-year institutional experience

This retrospective study aimed to clarify the short- and mid-term outcomes of elderly patients who underwent surgery to treat left-sided native valve infective endocarditis (LSNIE). Between July 2005 and September 2015, 179 patients underwent surgical treatment for active LSNIE at a single institution. Patients were classified into two groups: ≥65 years (elderly group) and <65 years (non-elderly group). Clinical features, surgical information, postoperative complications, and three-year survival rates were compared. The average ages were 74.2 ± 6.4 and 45.2 ± 12.6 years in the elderly and non-elderly groups, respectively. The elderly group had a higher predicted mortality rate and a lower incidence of preoperative septic emboli-related complications. Echocardiographic assessments of infected valves were generally homogenous between the groups. The elderly patients had a higher in-hospital mortality rate than the non-elderly patients (26.3% vs. 5.7%, P = 0.001). For patients who survived to discharge, the three-year cumulative survival rates were 75.0% ± 8.2% and 81.2% ± 3.4% in the elderly and non-elderly groups, respectively (P = 0.484). In conclusion, elderly patients are at a higher risk of in-hospital mortality after surgery for LSNIE. However, once elderly patients are stabilized by surgical treatment and survive to discharge, the mid-term outcomes are promising.

Early transthoracic echocardiography has useful prognostic value in left-sided native valve endocarditis despite limited diagnostic performance.

To investigate the prognostic implications of findings on early transthoracic echocardiography (TTE) in patients with definite left-sided native valveinfective endocarditis (LNVIE). We reviewed a 10-year retrospective cohort of consecutive patients with definite LNVIE treated at a tertiary cardiothoracic centre. TTEstudies performed within the first sevendays of the index blood culture (for culture-positive cases) or hospital admission (for culture-negative cases) were reviewed for the presence of valvular vegetations, perivalvular abscesses, aortic or mitral regurgitation of moderate or greater severity or a bicuspid aortic valve. Six-week outcomes included all-cause mortality, cardiac surgery for endocarditis or new embolic cerebral infarction. Early TTE was performed in 118 of 151 episodes of definite LNVIE at a median of twodays after the index blood culture or hospital admission. Findings on these studies included valvular vegetations or abscesses in 74 patients, moderate or severe aortic or mitral regurgitation in 67 patients and a bicuspid aortic valve in 19 patients. The presence of any of these findings conferred a relative risk of any adverse six-week outcome of 4.80 (95% confidence interval 1.6-17, p = 0.001). The presence of a bicuspid aortic valve appeared particularly predictive of the need for cardiac surgery, including for clinically occult paravalvular abscesses. Early TTE can be used to stratify patients with LNVIE by the risk of major endocarditis-related adverse outcomes occurring within the first sixweeks of treatment.

Native aortic versus mitral valve infective endocarditis: a nationwide registry study

BackgroundNative aortic and mitral valve infective endocarditis (AVE and MVE, respectively) are usually grouped together as left-sided native valve infective endocarditis (LNVE), while the differences between AVE and MVE have...

Outpatient parenteral antimicrobial therapy in Enterococcus faecalis infective endocarditis.

Enterococcus faecalis is the third most common causal agent of infective endocarditis. Currently, the treatment recommended is a combination of ampicillin (2g/4h) plus ceftriaxone (2g/12h), so patients must remain hospitalized for almost 6weeks to receive the treatment. They are not generally included in outpatient parenteral antimicrobial therapy programs because 2 different electronic pumps are required to administer these 2 antibiotics. To enable the treatment of patients with E.faecalis IE at home, we designed a continuation combination regimen of ceftriaxone 4g once daily in a short infusion plus ampicillin 2g/4h using a programmable pump. We analyzed a cohort of patients attended in an outpatient parenteral antimicrobial therapy program that has been working since 2012 in 2 tertiary hospitals. We selected patients attended in this program for E.faecalis IE treated with a continuation regimen of ampicillin 12g daily (2g/4h) and ceftriaxone 4g every 24hours between July 2012 and March 2017. Of the 720 patients included in the outpatient parenteral antimicrobial therapy program, 42 had infective endocarditis, and 4 (9.52%) were treated using the combination regimen described above. All patients were men, and all had left-sided native-valve infective endocarditis. All 4 patients received ampicillin 2g every 4hours and ceftriaxone 2g every 12hours in hospital, for a median duration of 25days (IQR 15-32). Thereafter, in the program, they received the following regimen: a 30-minute infusion of ceftriaxone 4g in 250mL of saline solution, followed by ampicillin 12g daily in 500mL of saline solution delivered by a pump programmed to administer 2g every 4hours. Patients received this treatment at home for a median of 22.5days (IQR 13-32). All patients achieved clinical and microbiological cure with no recurrences or complications after a lengthy follow-up period (median 365days, IQR 221-406). No drug-related adverse events or problems with the pump system were reported. Use of ceftriaxone 4g in a single dose yields a mean plasma concentration of 30μg/mL. Ceftriaxone also has a high plasma protein binding capability, and once this binding is saturated, there is no reason to administer higher doses. Therefore, it seems reasonable to use a dose of 4g of ceftriaxone once daily to have a synergist effect with ampicillin within the vegetation, and enable the treatment of patients with E.faecalis infective endocarditis at home. In conclusion, the administration of ampicillin (2g/4h) plus ceftriaxone (4g/24h) as a continuation regimen in an outpatient parenteral antimicrobial therapy program may be as effective and safe as the usual lengthy in-hospital regimen (ampicillin 2g/4h and ceftriaxone 2g/12h) in patients with E.faecalis infective endocarditis.

Left-sided native valve infective endocarditis: Influence of age and the presence of underlying heart disease

Introduction and objectivesLeft-sided native valve infective endocarditis (LNVIE) epidemiology has been modified as a result of the increase in average age. The aim of our study is to analyse the influence of age and the presence of predisposing heart disease in the prognosis of these patients. MethodsWe analysed a series of 257 cases of LNVIE depending on their age (greater than or equal to 70 years old), both in the overall series and in the subgroup of patients without predisposing heart disease. ResultsMean age was 54.6 (18.6) years. There was an increase in the percentage of cases of older patients between 1987–2000 and 2001–2014 (9.8 vs. 34.8%, p<0.001). These patients present higher prevalence of degenerative valves (50 vs. 22.8%) or not predisposing heart disease (50 vs. 39.9%), p<0.001, health-care associated episodes (41.8 vs. 23.6%, p=0.016), lower rate of surgery (43.7 vs. 63.8%, p=0.005) and higher in-hospital mortality (39.1 vs. 20.7%, p=0.003), with no differences in comorbidities. Older patients who did not have predisposing heart disease also suffered higher in-hospital mortality (47 vs. 22%, p=0.01). Age greater than or equal to 70 years old is an independent predictor of mortality in patients with LNVIE (OR 2.53, 95% CI 1.24–5.15, p=0.011), as in those without previous heart disease (OR 3.98, 95% CI 1.49–10.62, p=0.006). ConclusionsPatients of age greater than or equal to 70 years old and who suffer an LNVIE are becoming more frequent and have a worse prognosis with a lower rate of surgery and higher rates of in-hospital mortality.

Abstract 12649: Long-Term Results of Early Surgery Versus Conventional Treatment for Infective Endocarditis Trial

Introduction: Although event-free survival in patients with infective endocarditis (IE) and large vegetations has been shown to be significantly higher at 6 months in those receiving early surgery vs. conventional treatment, long-term data are lacking. Hypothesis: We tried to compare the long-term outcomes of early surgery with those of a conventional treatment strategy. Methods: The Early Surgery versus Conventional Treatment in Infective Endocarditis (EASE) trial randomly enrolled 76 patients (51 men, 47±16 years) from 2006 through 2011 with left-sided native valve IE accompanied by severe valve disease and a diameter of vegetation &gt; 10 mm. The end points were all-cause death and the composite of death, embolic events and recurrence of IE that occurred within 4 years after enrollment. Results: All patients in the early surgery group (n=37) underwent valve surgery within 48 hours, and 30 (77%) patients in the conventional treatment group (n=39) underwent surgery during the initial hospitalization. During median follow-up of 5.8 years (IQR, 4.8 to 7.1), 4 deaths occurred in the early surgery group and 5 deaths, 10 embolic events and 1 recurrence of IE in the conventional treatment group. There were no significant differences between the early surgery and the conventional treatment group in all-cause mortality (8.1% and 7.7% at 4 years, respectively; HR 1.04; 95% CI, 0.21 to 5.15; P=0.96). At 4 years, the rate of the composite of death from any cause, embolic events or recurrence of IE was 3.7% in the early surgery group as compared with 30.8% in the conventional treatment group (HR, 0.22; 95% CI, 0.06-0.79; P=0.02). The estimated actuarial rate of end points was significantly lower in the early surgery group than in the conventional treatment group (Figure). Conclusions: In the EASE trial, the beneficial effect of early surgery in IE patients with large vegetations persisted during long-term follow-up, and late clinical outcome after surgery was excellent in survivors of IE.

0521: Infective endocarditis complicated by heart failure: characteristics and prognosis

Despite progress in the field of antibiotic prophylaxis, infective endocarditis (IE) remains a common and serious disease. Heart failure (HF) represents the most common cause of death in this pathology. We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by HF and to evaluate the impact of early surgery on 1 year outcome. It is about a single-center observational study that included 241 patients admitted for definite left-sided native valve IE according to the Duke criteria. We are interested in the subgroup of 85 patients with heart failure. The average age of our patients was 42±18 years. When compared with patients without CHF (n = 156), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in HF patients. Aortic valve IE, elderly patients were more frequent in HF patients. Congestive HF was independently predictive of in-hospital mortality [OR=3.1, IC 95% (1.9-8.2); p = 0.007]. Early surgery was performed in 51% of HF patients with a peri-operative mortality of 19%. In the HF group, anemia [OR=4, IC 95% (0.9-17); p = 0.05), uncontrolled infection [OR=4, IC 95% (0.9-16.2);p= 0.05), and major neurological events (OR=9, IC 95% (1.4-21.6); p= 0.019) were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR=0.41 (0.17-0.73); p = 0.02]. Native valve IE complicated by HF is more frequent in aortic IE and is associated with severe regurgitation. Congestive HF is an independent predictor of in-hospital and 1 year mortality. In HF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

Outcome in patients with left-sided native-valve infective endocarditis and isolated large vegetations.

In patients with left-sided native-valve infective endocarditis (IE), the risk of embolism is increased with a vegetation size ≥10 mm. For this reason-according to guidelines-surgery may be considered in patients with isolated large vegetations (without any other indication for surgery). However, the value of surgery in this patient subset has never been systematically studied. We hypothesized that surgery may be superior to medical therapy in terms of clinical outcome in the aforementioned patients. All patients who presented at our institution between January 2000 and July 2012 with isolated left-sided native-valve IE and large vegetations (≥10 mm) were examined. Patients with conventional indications for surgical treatment were excluded. Follow-up for clinical events was performed according to predefined definitions. A total of 71 patients with left-sided native-valve IE and isolated large vegetations qualified for inclusion into the study cohort. Mean vegetation length was 17 ± 5 mm. A total of 59 patients underwent surgery after a mean of 5 ± 6 days following the initiation of antibiotic treatment. Mean follow-up duration was 6.0 ± 2.9 years. Surgical compared to purely medical treatment was associated with a significant increase in long-term all-cause mortality (P = 0.03 by log-rank test, unadjusted analysis). Upon multivariable Cox regression analysis, surgical treatment, affection of mitral valve, blood cultures positive for Staphylococcus aureus, and increasing age showed trends as independent predictors of long-term mortality. Surgical treatment in patients with left-sided native-valve IE and isolated large vegetations without any other indication for surgery seems to be associated with excess mortality. A randomized controlled trial of surgery vs conservative treatment in this subset of patients is justified.

079: Heart failure in native valve infective endocarditis: characteristics, prognosis, and results of surgical treatment

Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. We aimed to analyse the characteristics and prognosis of patients with left-sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome. Two hundred and twenty consecutive patients with definite left-sided native valve IE according to the Duke criteria were included in this analysis. When compared with patients without CHF (n=144), new heart murmur, high comorbidity index, aortic valve IE, and severe valve regurgitation were more frequently observed in CHF patients (n=76, 34.5%). Aortic valve IE, elderly patients were more frequent in CHF patients. Congestive heart failure was independently predictive of in-hospital [OR 3.8 (1.7-9.0); P=0.0013] and 1 year mortality [HR 1.8 (1.1-3.0); P=0.007]. Early surgery was performed in 63% of CHF patients with a peri-operative mortality of 15%. In the CHF group, comorbidity index, anemia, uncontrolled infection, and major neurological events were multivariate predictors of 1 year mortality. Early surgery was independently associated with improved 1 year survival [HR 0.45 (0.22-0.93); P=0.03]. Native valve IE complicated by CHF is more frequent in aortic IE and is associated with severe regurgitation. Congestive heart failure is an independent predictor of in-hospital and 1 year mortality. In CHF patients, early surgery is independently associated with reduced mortality and should be widely considered to improve outcome.

An atypical presentation of infective endocarditis

Infective endocarditis is a well-known clinical entity. However, despite improved diagnostic techniques and advances in treatment options, left-sided native valve infective endocarditis remains a serious disease with high morbidity and mortality, especially in cases caused by Staphylococcus aureus. The clinical heterogeneity of infective endocarditis sometimes prevents rapid recognition, correct diagnosis and timely treatment, which are essential to reduce the morbidity and mortality associated with this disease.We report the case of a 62-year-old man, admitted for atrial fibrillation with complete atrioventricular block, which was found to be the result of methicillin-resistant S. aureus mitral valve endocarditis, complicated by local extension of the infection, heart failure, systemic embolism and multiple organ failure.

An atypical presentation of infective endocarditis

Infective endocarditis is a well-known clinical entity. However, despite improved diagnostic techniques and advances in treatment options, left-sided native valve infective endocarditis remains a serious disease with high morbidity and mortality, especially in cases caused by Staphylococcus aureus. The clinical heterogeneity of infective endocarditis sometimes prevents rapid recognition, correct diagnosis and timely treatment, which are essential to reduce the morbidity and mortality associated with this disease.We report the case of a 62-year-old man, admitted for atrial fibrillation with complete atrioventricular block, which was found to be the result of methicillin-resistant S. aureus mitral valve endocarditis, complicated by local extension of the infection, heart failure, systemic embolism and multiple organ failure.

Impact of early surgery in the active phase on long-term outcomes in left-sided native valve infective endocarditis

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. 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. 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 = .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% ± 5% vs 82% ± 5%, P = .011, major adverse cardiac events: 88% ± 5% vs 69% ± 7%, P = .006, respectively). 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.