Itziar Gómez

Age-Dependent Profile of Left-Sided Infective Endocarditis A 3-Center Experience

Background— The influence of age on the main epidemiological, clinical, echocardiographic, microbiological, and prognostic features of patients with infective endocarditis remains unknown. We present the series with the largest numbers and range of ages of subjects to date that analyzes the influence of age on the main characteristics of patients with isolated left-sided infective endocarditis. Furthermore, this series is the first one in which patients have been distributed according to age quartile. Methods and Results— A total of 600 episodes of left-sided endocarditis consecutively diagnosed in 3 tertiary centers were stratified into age-specific quartiles and 107 variables compared between the different groups. With increasing age, the percentage of women, previous heart disease, predisposing disease (diabetes mellitus and cancer), and infection by enterococci and Streptococcus bovis also increased. Valvular insufficiency and perforation and Staphylococcus aureus infection were more common in younger patients. The therapeutic approach differed depending on patient age because of the growing proportion of older patients who only received medical treatment. Clinical course and hospital prognosis were worse in the older patients because of increased surgical mortality among them. Conclusions— Increasing age is associated with less valvular impairment (insufficiency and perforation), a more favorable microbiological profile, and increased surgical mortality among adults with left-sided infective endocarditis.

Rationale, design, and methods for the early surgery in infective endocarditis study (ENDOVAL 1): A multicenter, prospective, randomized trial comparing the state-of-the-art therapeutic strategy versus early surgery strategy in infective endocarditis

BACKGROUND The prognosis of infective endocarditis is poor and has remained steady over the last 4 decades. Several nonrandomized studies suggest that early surgery could improve prognosis. METHODS ENDOVAL 1 is a multicenter, prospective, randomized study designed to compare the state-of-the-art therapeutic strategy (advised by the international societies in their guidelines) with the early-surgery strategy in high-risk patients with infective endocarditis. Patients with infective endocarditis without indication for surgery will be included if they meet at least one of the following: (1) early-onset prosthetic endocarditis; (2) Staphylococcus aureus endocarditis; (3) periannular complications; (4) new-onset conduction abnormalities; (5) new-onset severe valvular dysfunction. A total of 216 patients will be randomized to either of the 2 strategies. Stratification will be done within 3 days of admission. In the early surgery arm, the surgical procedure will be performed within 48 hours of randomization. The only event to be considered will be death within 30 days. The study will be extended to 1 year. In the follow-up substudy, death and a new episode of endocarditis will be regarded as events. CONCLUSION ENDOVAL 1, the first randomized study on endocarditis, will provide crucial information regarding the putative benefit of early surgery over the state-of-the-art therapeutic approach in high-risk patients with infective endocarditis.

Isolated Right-Sided Valvular Endocarditis in Non-Intravenous Drug Users

INTRODUCTION AND OBJECTIVES Characteristics of isolated right-sided endocarditis in patients without a pacemaker and who are not intravenous drug users (IVDU) are poorly understood. The aim of this study was to investigate the current frequency of this entity and describe its clinical, microbiological, echocardiographic and prognostic profile. METHODS We have prospectively analyzed 17 consecutive cases of isolated right-sided endocarditis in non-IVDU who did not have a pacemaker, out of a total of 583 consecutive episodes of endocarditis (2.9%). RESULTS Mean age was 38+/-15 years; 11 of the 17 patients were men. Almost half of the patients had at least one predisposing disease. An intravascular catheter was the most frequent port of entry (35%). The most common signs and symptoms on admission were fever, dyspnea, septic pulmonary embolisms, pleural effusion and right-sided heart failure. The most frequent microorganism was Staphylococcus aureus (41%). In most cases (82%) the infection was located in the tricuspid valve. Recurrent pulmonary embolisms were the most frequent complication and the main cause for surgery, which was needed in 5 patients (29%). Two patients died during hospitalization (12%), both from septic shock. During follow-up one patient died of unknown causes 1 month after discharge, and other relapsed 3 months after discharge. CONCLUSIONS Isolated right-sided endocarditis should be included in the differential diagnosis of patients with febrile syndrome, respiratory symptoms and predisposing disease, even when they do not have a pacemaker and are not IVDU. The presence of intravascular catheters and Staphylococcus bacteriemia should heighten suspicion of endocarditis.

Variabilidad inter e intraobservador en la valoración ecocardiográfica de la función del ventrículo derecho

Introduccion y objetivos La valoracion ecocardiografica de la funcion sistolica ventricular derecha es actualmente una cuestion pendiente de resolver, dadas las peculiaridades anatomicas del ventriculo derecho. Se han desarrollado diversos metodos para su calculo. El objetivo del presente estudio es determinar la fiabilidad y reproducibilidad de diferentes parametros ecocardiograficos estudiando su variabilidad inter e intraobservador. Metodos Se incluyeron 30 pacientes con valvulopatia mitral aislada candidatos a cirugia cardiaca. Se realizo un ecocardiograma a todos los pacientes por dos investigadores de forma independiente en un periodo de 24 h. El analisis intraobservador se obtuvo a partir del primer mes desde imagenes grabadas. Los parametros utilizados fueron la TAPSE (elevacion sistolica del plano del anillo tricuspideo), la velocidad pico sistolica del anillo tricuspideo por Doppler tisular, la fraccion de acortamiento del tracto de salida ventricular derecho, la fraccion de acortamiento de los diametros del ventriculo derecho y la fraccion de acortamiento de las areas del ventriculo derecho. La variabilidad fue analizada mediante el coeficiente de correlacion intraclase. Resultados La fuerza de concordancia de la TAPSE y la velocidad pico del anillo tricuspideo es buena en el analisis interobservador y excelente en el analisis intraobservador. Sin embargo, la fraccion de acortamiento del tracto de salida, de las areas y de los diametros muestran una pobre concordancia en el analisis inter e intraobservador Conclusiones Las medidas ecocardiograficas mas fiables y reproducibles en la valoracion de la funcion sistolica ventricular derecha en pacientes con valvulopatia mitral aislada son la TAPSE y la velocidad pico del anillo tricuspideo.

Prognostic role of persistent positive blood cultures after initiation of antibiotic therapy in left-sided infective endocarditis.

AIM Persistent infection is not a scientific evidence-based definition. The guidelines of infective endocarditis (IE) establish a cut-off point of 7-10 days, which is arbitrary and probably too long. Our hypothesis is that persistent positive blood cultures after 48-72 h from the initiation of antibiotic therapy are associated with a worse prognosis in patients with left-sided IE. METHODS AND RESULTS We repeated blood cultures after 48-72 h of the initiation of the antibiotic treatment in 407 patients with left-sided IE of a total of 692 episodes consecutively diagnosed from 1996 to 2011. We have compared the profile of patients whose blood cultures became negative and those with persistent positive blood cultures. We performed a multivariate logistic regression model to determine the prognostic implication of persistent positive blood cultures. Of 256 patients with positive blood cultures at admission, 89 (35%) had persistent positive cultures after 48-72 h from the initiation of the antibiotic treatment. Persistent positive blood cultures (OR: 2.1; 95% CI: 1.2-3.6), age (OR: 1.026; 95% CI: 1.007-1.046), Staphylococcus aureus infection (OR: 3.3; 95% CI: 1.6-6.6), heart failure (OR: 2.8; 95% CI: 1.6-4.7), and renal failure (OR: 2.9; 95% CI: 1.8-4.9) were found to be independently associated with higher in-hospital mortality. CONCLUSIONS The presence of persistent positive blood cultures is an independent risk factor for in-hospital mortality which doubles the risk of death of patients with left-sided IE. It should be taken into account in the risk stratification of these patients.

Endocarditis derecha aislada en pacientes no adictos a drogas por vía parenteral

Introduccion y objetivos La endocarditis derecha aislada es una entidad poco conocida cuando afecta a pacientes no portadores de marcapasos y no adictos a drogas por via parenteral (ADVP). Nuestro objetivo es estudiar la frecuencia actual de esta entidad y describir su perfil clinico, microbiologico, ecocardiografico y pronostico. Metodos Hemos analizado 17 casos de endocarditis derecha aislada en pacientes no ADVP y no portadores de marcapasos, de un total de 583 episodios consecutivamente diagnosticados de endocarditis infecciosa (3%). Resultados La media de edad fue 38 ± 15 anos y 11 pacientes eran varones. El 47% de los pacientes presentaban alguna enfermedad predisponente. El cateter intravascular fue la puerta de entrada mas frecuente (35%). Los sintomas y signos mas comunes al ingreso fueron fiebre, disnea, embolia pulmonar septica, derrame pleural e insuficiencia cardiaca derecha. El microorganismo mas frecuente fue Staphylococcus aureus (41%). La mayoria de los casos asentaron en la valvula tricuspide (82%). La embolia pulmonar recurrente fue la complicacion mas frecuente y la principal causa de cirugia, que fue precisa en 5 (29%) casos. Fallecieron 2 (12%) pacientes, ambos por shock septico. En el seguimiento, 1 paciente fallecio al mes del alta por causa desconocida y 1 presento una recaida al tercer mes. Conclusiones La endocarditis derecha aislada debe incluirse en el diagnostico diferencial de pacientes con sindrome febril, sintomas respiratorios y alguna enfermedad predisponente, aunque no sean portadores de marcapasos o ADVP. La presencia de cateteres intravasculares y la bacteriemia por estafilococos refuerzan la sospecha de endocarditis en estos pacientes.

Internal and external validation of a model to predict adverse outcomes in patients with left-sided infective endocarditis

Introduction Early identification of prognostic factors is essential to improve the grim prognosis associated with left-sided infective endocarditis. This group identified three independent risk factors obtained within 72 h of admission, (Staphylococcus aureus, heart failure and periannular complications) for inhospital mortality or urgent surgery in a series of 317 patients diagnosed at five tertiary centres (derivation sample). A stratification score was constructed for the test cohort by a simple arithmetic sum of the number of variables present. The goal was to validate this model internally and externally in a prospective manner with two different cohorts of patients. Methods The appropriateness of the model was tested prospectively on predicting events in two cohorts of patients with left-sided endocarditis: internally with the 263 consecutive patients diagnosed at the same centres where the model was derived (internal validation sample), and externally with 264 patients admitted at another hospital (external validation sample). Results The discriminatory power of the model, expressed as the area under the receiver operating characteristic curve was similar between derivation and both validation samples (internal 0.67 vs 0.68, p=0.79; external 0.67 vs p=0.74, p=0.09). There was a progressive, significant pattern of increasing event rates as the risk stratification score increased in both validation cohorts (p<0.001 by χ2 for trend). Conclusions The early risk stratification model derived, based on variables obtained within 72 h of admission, is applicable to different populations with left-sided endocarditis. A simple bedside assessment tool is provided to clinicians that identifies patients at high risk of having an adverse event.

Inter- and Intra-Observer Variability in the Echocardiographic Evaluation of Right Ventricular Function

INTRODUCTION AND OBJECTIVES Echocardiographic evaluation of right ventricular systolic function remains subject to debate because of the anatomic peculiarities of the right ventricle. Several methods have been developed for quantifying right ventricular systolic function. The aim of this study was to determine the reliability and reproducibility of a number of echocardiographic parameters by evaluating their inter-observer and intra-observer variability. METHODS The study included 30 patients with isolated mitral valvulopathy scheduled for heart surgery. All underwent echocardiography, which was performed independently by two echocardiographers within 24 hours. The intra-observer analysis was carried out using the recorded images at least 1 month after they had been obtained. The parameters studied were the tricuspid annular plane systolic excursion (TAPSE), the tricuspid annular peak systolic velocity on tissue Doppler imaging, right ventricular outflow tract fractional shortening, fractional shortening of right ventricular diameters, and fractional shortening of right ventricular areas. Variability was analyzed using the intraclass correlation coefficient. RESULTS The degree of concordance on TAPSE and tricuspid annular peak systolic velocity measurement was good in the inter-observer analysis and excellent in the intra-observer analysis. However, concordance was poor on measurements of the fractional shortening of the right ventricular outflow tract, areas and diameters on both inter-observer and intra-observer analyses. CONCLUSIONS The most reliable and reproducible echocardiographic parameters for evaluating right ventricular systolic function in patients with isolated mitral valvulopathy were the TAPSE and the tricuspid annular peak systolic velocity.

Clinical classification and prognosis of isolated right-sided infective endocarditis.

AbstractFrom an epidemiologic point of view, right-sided infective endocarditis (RSIE) affects different types of patients: intravenous drug users (IDUs), cardiac device carriers (pacemakers and implantable automatic defibrillators), and the “3 noes” endocarditis group: no left-sided, no IDUs, no cardiac devices. Our objective is to describe and compare the clinical profile and outcome of these groups of patients.Every episode of infective endocarditis (IE) consecutively diagnosed in 3 tertiary centers from 1996 to 2012 was included in an ongoing multipurpose database. We assessed 85 epidemiologic, clinical, echocardiographic, and outcome variables in patients with isolated RSIE. A bivariated comparative analysis between the 3 groups was conducted.Among 866 IE episodes, 121 were classified as isolated RSIE (14%): 36 IDUs (30%), 65 cardiac device carriers (54%), and 20 “3 noes” group (16%). IDUs were mainly young men (36 ± 7 years) without previous heart disease, few comorbidities, and frequent previous endocarditis episodes (28%). Human immunodeficiency virus infection was frequent (69%). Cardiac device carriers were older (66 ± 15 years) and had less comorbidities (34%). Removal of the infected device was performed in 91% of the patients without any death. The “3 noes” endocarditis group was composed mainly by middle-age men (56 ± 18 years), health care related infections (50%), and had many comorbidities (75%). Whereas Staphylococcus aureus were the most frequent cause in IDUs (72% vs 34% in device carriers and 34% in the “3 noes” group, P = 0.001), coagulase negative Staphylococci predominated in the device carriers (58% vs 11% in drug users and 35% in the “3 noes”, P < 0.001). Significant differences in mortality were found (17% in drug users, 3% in device carriers, and 30% in the “3 noes” group; P < 0.001).These results suggest that RSIE should be separated into 3 groups (IDUs, cardiac device carriers, and the “3 noes”) and considered as independent entities as there are relevant epidemiologic, clinical, microbiological, echocardiographic, and prognostic differences among them.

Propensity score matched comparison of transcatheter aortic valve implantation versus conventional surgery in intermediate and low risk aortic stenosis patients: A hint of real-world

BACKGROUND Recently, the use of transcatheter aortic valve implantation (TAVI) in inter-mediate-low risk patients has been evaluated in the PARTNER II randomized trial. However, in the last years, this therapy has been employed in this scenario with underreported results, as compared to surgical aortic valve replacement (SAVR). METHODS We enrolled 362 consecutive patients with severe symptomatic aortic stenosis and intermediate-low surgical risk (logEuroSCORE < 20%), treated in our center with TAVI (103 patients) or single SAVR (259 patients) between 2009 and 2014. Patients were matched according to age, gender, logEuroSCORE, and use of bioprosthesis. RESULTS Mean age of the patients was 73 ± 10.4 years, and 40.3% were women. LogEuroSCORE and Society Thoracic Surgeons score were 7.0 ± 4.4% and 4.2 ± 2.5%, respectively, with mean left ventricular ejection fraction of 52 ± 9%. There were no differences regarding other comorbidities. The length-of-hospitalization was 11 ± 5 days after TAVI vs. 17 ± 9 days after SAVR (p = 0.003). After matched comparison, no differences in terms of in-hospital mortality (5.7% after TAVI vs. 2.9% after SAVR, p = 0.687) and 1-year mortality (11.4% vs. 7.1%, p = 0.381) were found. The combined endpoint of stroke and mortality at 1-year was also similar between both groups (15.7% in TAVI patients vs. 14.4% after SAVR, p = 0.136). Multivariate analysis determined that aortic regurgitation (AR) was an independent predictor of mortality (OR = 3.623, 95% CI: 1.267-10.358, p = 0.016). Although the rate of AR was higher after TAVI, none of the patients treated with the newest generation devices (10.7%) presented more than a mild degree of AR. CONCLUSIONS TAVI is feasible and shows comparable results to surgery in terms of early, 1-year mortality, as well as cerebrovascular events in patients with severe aortic stenosis and intermediate-low operative risk. Better transvalvular gradients, yet higher rates of AR were found, however, newer devices presented comparable rate of AR.