Bernard Iung

Preeminence of Staphylococcus aureus in Infective Endocarditis: A 1-Year Population-Based Survey

BACKGROUND Observational studies showed that the profile of infective endocarditis (IE) significantly changed over the past decades. However, most studies involved referral centers. We conducted a population-based study to control for this referral bias. The objective was to update the description of characteristics of IE in France and to compare the profile of community-acquired versus healthcare-associated IE. METHODS A prospective population-based observational study conducted in all medical facilities from 7 French regions (32% of French individuals aged ≥18 years) identified 497 adults with Duke-Li-definite IE who were first admitted to the hospital in 2008. Main measures included age-standardized and sex-standardized incidence of IE and multivariate Cox regression analysis for risk factors of in-hospital death. RESULTS The age-standardized and sex-standardized annual incidence of IE was 33.8 (95% confidence interval [CI], 30.8-36.9) cases per million inhabitants. The incidence was highest in men aged 75-79 years. A majority of patients had no previously known heart disease. Staphylococci were the most common causal agents, accounting for 36.2% of cases (Staphylococcus aureus, 26.6%; coagulase-negative staphylococci, 9.7%). Healthcare-associated IE represented 26.7% of all cases and exhibited a clinical pattern significantly different from that of community-acquired IE. S. aureus as the causal agent of IE was the most important factor associated with in-hospital death in community-acquired IE (hazard ratio [HR], 2.82 [95% CI, 1.72-4.61]) and the single factor in healthcare-associated IE (HR, 2.54 [95% CI, 1.33-4.85]). CONCLUSIONS S. aureus became both the leading cause and the most important prognostic factor of IE, and healthcare-associated IE appeared as a major subgroup of the disease.

Temporal Trends in Infective Endocarditis in the Context of Prophylaxis Guideline Modifications: Three Successive Population-Based Surveys

OBJECTIVES The goal of this study was to evaluate temporal trends in infective endocarditis (IE) incidence and clinical characteristics after 2002 French IE prophylaxis guideline modifications. BACKGROUND There are limited data on changes in the epidemiology of IE since recent guidelines recommended restricting the indications of antibiotic prophylaxis of IE. METHODS Three 1-year population-based surveys were conducted in 1991, 1999, and 2008 in 3 French regions totaling 11 million inhabitants age ≥20 years. We prospectively collected IE cases from all medical centers and analyzed age- and sex-standardized IE annual incidence trends. RESULTS Overall, 993 expert-validated IE cases were analyzed (323 in 1991; 331 in 1999; and 339 in 2008). IE incidence remained stable over time (95% confidence intervals given in parentheses/brackets): 35 (31 to 39), 33 (30 to 37), and 32 (28 to 35) cases per million in 1991, 1999, and 2008, respectively. Oral streptococci IE incidence did not increase either in the whole patient population (8.1 [6.4 to 10.1], 6.3 [4.8 to 8.1], and 6.3 [4.9 to 8.0] in 1991, 1999, and 2008, respectively) or in patients with pre-existing native valve disease. The increased incidence of Staphylococcus aureus IE (5.2 [3.9 to 6.8], 6.8 [5.3 to 8.6], and 8.2 [6.6 to 10.2]) was not significant in the whole patient population (p = 0.228) but was significant in the subgroup of patients without previously known native valve disease (1.6 [0.9 to 2.7], 3.7 [2.6 to 5.1], and 4.1 [3.0 to 5.6]; p = 0.012). CONCLUSIONS Scaling down antibiotic prophylaxis indications was not associated with an increased incidence of oral streptococcal IE. A focus on avoidance of S. aureus bacteremia in all patients, including those with no previously known valve disease, will be required to improve IE prevention.

Brief Report: Prevalence of Antineutrophil Cytoplasmic Antibodies in Infective Endocarditis

Infective endocarditis (IE) mimics primary systemic vasculitis, and there are sporadic reports of positivity for antineutrophil cytoplasmic antibodies (ANCAs) among patients with IE. Because the frequency of ANCAs in IE is unknown, this study was undertaken to assess the seroprevalence of ANCAs in a large number of patients with IE.

Contemporary criteria for the selection of patients for percutaneous balloon mitral valvuloplasty.

Percutaneous balloon mitral valvuloplasty is now the treatment of choice for many patients with symptomatic mitral stenosis Applications are expanding to include several categories of patients previously considered ineligible for the procedure. Commissural fusion is now recognised as the principal pathology underlying mitral stenosis, and commissural splitting underlies successful interventional treatment. Although the technique of surgical commissurotomy was first described as early as 1948,1 percutaneous commissurotomy became a feasible option with the advent of the Inoue balloon in 1984.2 Percutaneous balloon mitral valvuloplasty (PBMV) is now the treatment of choice for many patients with symptomatic mitral stenosis. Numerous large series have reported excellent short, medium, and long term outcome3–7 with a low incidence of serious complications.8 Furthermore, randomised trials comparing balloon valvuloplasty with the surgical alternatives of open or closed commissurotomy have demonstrated equivalent outcome,9,10 although patients treated using the percutaneous approach enjoy the advantages of reduced procedural morbidity and mortality and a short hospital stay. Specific advantages of the Inoue balloon in comparison with other percutaneous techniques include a lower risk of complications (particularly left ventricular perforation which is more frequent using double balloon techniques), easier manoeuvrability, its slender profile (creating a smaller defect in the interatrial septum), its self positioning characteristics, short inflation–deflation cycle, and capacity to permit gradually increasing successive balloon inflation sizes, which allow the operator to terminate the procedure when commissural splitting is achieved or when there is an increase in the severity of mitral regurgitation. Disadvantages include circumferential application of pressure during balloon inflation, occasionally resulting in paracommissural tears, especially in degenerate, calcified valves. In developing nations, the application of PBMV is frequently limited on account of the high cost of the Inoue balloon. The development of a percutaneous metallic valvulotome, which can be autoclaved after each …

The optimal management of anti-thrombotic therapy after valve replacement: certainties and uncertainties

Anti-thrombotic therapy after valve replacement encompasses a number of different situations. Long-term anticoagulation of mechanical prostheses uses vitamin K antagonists with a target international normalized ratio adapted to the characteristics of the prosthesis and the patient. The association of low-dose aspirin is systematic in the American guidelines and more restrictive in the European guidelines. Early heparin therapy is frequently used early after mechanical valve replacement, although there are no precise recommendations regarding timing, type, and dose of drug. Direct oral anticoagulants are presently contraindicated in patients with mechanical prosthesis. The main advantage of bioprostheses is the absence of long-term anticoagulant therapy. Early anticoagulation is indicated after valve replacement for mitral bioprostheses, whereas aspirin is now favoured early after bioprosthetic valve replacement in the aortic position. Early dual antiplatelet therapy is indicated after transcatheter aortic valve implantation, followed by single antiplatelet therapy. However, this relies on low levels of evidence and optimization of anti-thrombotic therapy is warranted in these high-risk patients. Although guidelines are consistent in most instances, discrepancies and the low-level of evidence of certain recommendations highlight the need for further controlled trials, in particular with regard to the combination of antiplatelet therapy with oral anticoagulant and the early post-operative anti-thrombotic therapy following the procedure.

Cardiac surgery during the acute phase of infective endocarditis: discrepancies between European Society of Cardiology guidelines and practices

AIMS Indications for surgery in acute infective endocarditis (IE) are detailed in guidelines, but their application is not well known. We analysed the agreement between the patients attending physicians and European Society of Cardiology guidelines regarding indications for surgery. We also assessed whether surgery was performed in patients who had an indication. METHODS AND RESULTS From the 2008 prospective population-based French survey on IE, 303 patients with definite left-sided native IE were identified. For each case, we prospectively recorded (i) indication for surgery according to the attending physicians and (ii) indication for surgery according to guidelines. Surgery was indicated in 194 (65%) patients according to attending physicians and in 221 (73%) according to guidelines, while 139 (46%) underwent surgery. Agreement was moderate between attending physicians and guidelines (kappa 0.41-0.59) and between indication according to guidelines and the performance of surgery (kappa 0.38). Of the 90 (30%) patients not operated despite indication, contraindication to surgery was reported by the attending physicians in 42 (47%), and indication was not identified in 48 (53%). One-year survival was 76% in patients with indication and surgery performed (n = 131), 69% in patients without indication and no surgery (n = 74), 56% in patients with identified indication and contraindication to surgery (n = 42), and 60% in patients with no identified indication (n = 48; P = 0.059). CONCLUSION Cardiac surgery during acute IE was recommended in almost three out of four patients, although fewer than half were actually operated. Indication was not acknowledged by the attending physicians in one out of six patients.

Relationship Between Valve Calcification and Long-Term Results of Percutaneous Mitral Commissurotomy for Rheumatic Mitral Stenosis

Background—Indications of percutaneous mitral commissurotomy (PMC) remain debated in calcific mitral stenosis. We analyzed long-term results of PMC for calcific mitral stenosis and the factors associated with late functional results. Methods and Results—We compared the characteristics and outcome of 314 patients undergoing PMC for calcific mitral stenosis with 710 patients with noncalcified valves followed up to 20 years. Calcification was defined by fluoroscopy, and its extent was graded from 1 to 4. Good immediate results (valve area ≥1.5 cm2 with mitral regurgitation ⩽2/4) were obtained in 251 patients (80%) with calcified valves and 661 (93%) with noncalcified valves (P<0.001). The hazard ratio for good functional results (survival without cardiovascular death, without mitral reintervention, and in New York Heart Association class I or II) was 2.5 (95% confidence interval [2.1–2.9]; P<0.0001) in patients with calcified valves (12±3% at 20 years) relative to the noncalcified group (38±2% at 20 years). In the 251 patients with calcified valves who had good immediate results, 15-year rates of good functional results were 35±4% for minor (grade 1) calcification, 24±6% for grade 2, and 10±6% for severe (grades 3–4) calcification. Factors associated with poor late functional results on multivariable analysis were calcification extent, older age, higher New York Heart Association class, atrial fibrillation, and higher mean gradient after PMC. Conclusions—Although late results of PMC are less satisfying in calcific mitral stenosis, long-term functional outcome depends on calcification extent, patient characteristics, and immediate results of PMC. These findings support the use of PMC as first-line treatment in selected patients with calcific mitral stenosis.

Prognostic value of new onset atrial fibrillation after transcatheter aortic valve implantation: A FRANCE 2 registry substudy.

BACKGROUND The development of new onset atrial fibrillation (NOAF) post-transcatheter aortic valve implantation (TAVI) is common and may be associated with an adverse prognosis. This study seeks to identify incidence, predictors, and impact of NOAF post-TAVI. METHODS From the multicenter study of the French national transcatheter aortic valve implantation registry, FRANCE 2, a total of 1959 patients with sinus rhythm prior to TAVI were enrolled into this study. The incidence of post-TAVI NOAF, predictors of development of NOAF and impact on 30-day and 1-year-mortalities were assessed. RESULTS Of the 1959 TAVI patients (mean-age: 82.6 ± 7.5 years, mean-logistic-EuroSCORE: 21.8 ± 14.3), 149 (7.6%) developed NOAF with the remaining 1810 (92.4%) control patients demonstrating no evidence of AF as defined by the Valve Academic Research Consortium (VARC). Advanced age and major and life-threatening bleeding were independent predictors of NOAF (95% CI: 0.93-0.99; p=0.006, 95% CI: 1.58-4.00; p<0.001, 95% CI: 1.09-3.75; p=0.025, respectively). A trend towards a higher incidence of major and life-threatening bleeding was observed in the patients undergoing TAVI via the transapical (TA)-approach compared with the transfemoral (TF)-approach. Both 30-day and cumulative 1-year-mortalities were significantly higher in patients with NOAF compared to patients without NOAF (3.0% vs. 7.4%; p=0.005, 9.1% vs. 20.8%; p<0.001, respectively). In addition, NOAF was an independent predictor of 30-day and 1-year-mortalities (HR: 2.16; 95% CI: 1.06-4.41; p=0.033, HR: 2.12; 95% CI: 1.42-3.15; p<0.001, respectively). CONCLUSION Advanced age and major and life-threatening bleeding were independently associated with increased incidence of NOAF, which itself was an independent predictor of 30-day and 1-year-mortalities. With regards to the various transcatheter approaches, a trend towards a higher incidence of major and life-threatening bleeding was observed only with the TA-approach.

First Reported Human Case of Native Mitral Infective Endocarditis Caused by Streptococcus canis

A 65 year-old woman was admitted for acute heart failure and severe sepsis revealing definite mitral infective endocarditis with severe regurgitation, complicated by multiple embolisms. Three blood cultures yielded a group G Streptococcus canis strain. Urgent surgery was performed with bioprosthetic valve replacement. Polymerase chain reaction analysis of the valve found S canis DNA. Amoxicillin and gentamicin were given for 2 weeks followed by 4 weeks of amoxicillin alone. She reported contact with a dog without bite. S canis has been reported to cause zoonotic septicemia but to our knowledge, this is the first human case of native valve infective endocarditis.

2015 ESC Guidelines on the management of infective endocarditis: a big step forward for an old disease

In 2009, the European Society of Cardiology (ESC) Guidelines on the prevention, diagnosis and treatment of infective endocarditis (IE)1 introduced several innovative concepts, including limitation of antibiotic prophylaxis to the highest-risk patients, a focus on healthcare-associated IE and identification of the optimal timing for surgery. The recently published 2015 ESC Guidelines on the management of IE2 recently reinforced these changes and proposed new important features, including the need for a collaborative approach (the ‘Endocarditis Team’), the emergence of nuclear imaging techniques in the early diagnosis of IE and the refinement of surgical indications. This editorial will focus in the main changes reported in the 2015 ESC Guidelines as compared with previous recommendations. The new 2015 ESC Guidelines were ‘conservative’ on this topic, and can be summarised as follows: Some recent epidemiological studies alerted the scientific community on the risk of increased incidence of IE following the reduction of antibiotic prophylaxis.3 ,4 However, since this trend was not observed in other studies, and because of the known worse prognosis of IE in high-risk patients, in particular those with prosthetic IE, 2015 ESC Guidelines maintained the principle of antibiotic prophylaxis in high-risk patients and focused for the …