Josip Vincelj

Influence of the Timing of Cardiac Surgery on the Outcome of Patients With Infective Endocarditis and Stroke

BACKGROUNDnThe timing of cardiac surgery after stroke in infective endocarditis (IE) remains controversial. We examined the relationship between the timing of surgery after stroke and the incidence of in-hospital and 1-year mortalities.nnnMETHODSnData were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers from June 2000 through December 2006. Multivariate logistic regression and Cox regression analyses were performed to estimate the impact of early surgery on hospital and 1-year mortality after adjustments for other significant covariates.nnnRESULTSnOf the 857 patients with IE complicated by ischemic stroke syndromes, 198 who underwent valve replacement surgery poststroke were available for analysis. Overall, 58 (29.3%) patients underwent early surgical treatment vs 140 (70.7%) patients who underwent late surgical treatment. After adjustment for other risk factors, early surgery was not significantly associated with increased in-hospital mortality rates (odds ratio, 2.308; 95% confidence interval [CI], .942-5.652). Overall, probability of death after 1-year follow-up did not differ between 2 treatment groups (27.1% in early surgery and 19.2% in late surgery group, P = .328; adjusted hazard ratio, 1.138; 95% CI, .802-1.650).nnnCONCLUSIONSnThere is no apparent survival benefit in delaying surgery when indicated in IE patients after ischemic stroke. Further observational analyses that include detailed pre- and postoperative clinical neurologic findings and advanced imaging data (eg, ischemic stroke size), may allow for more refined recommendations on the optimal timing of valvular surgery in patients with IE and recent stroke syndromes.

Moraxella lacunata: A rare cause of infective endocarditis

We describe the first case of Moraxella lacunata definite native valve endocarditis in a patient with previously normal mitral valves. The disease was complicated with embolizations of the brain and spleen. After 6 weeks of antimicrobial treatment, valvular replacement was performed. The clinical course and diagnostic findings suggest that Moraxella lacunata possesses high aggressiveness leading to progressive valvular destruction and embolizations.

P24 ASSOCIATION BETWEEN VALVULAR SURGERY AND MORTALITY AMONG PATIENTS WITH INFECTIVE ENDOCARDITIS COMPLICATED BY SEVERE SEPSIS AND SEPTIC SHOCK

Severe sepsis and septic shock are common complications of infective endocarditis (IE). A prospective, single-center observational study in patients with definite native or prosthetic valve IE admitted between January 1, 2000 and December 31, 2011. The main objective of the study was estimate the safety of valve replacement in patients with severe sepsis and/or septic shock and its impact on patients outcome. We compared clinical characteristics and outcome (in-hospital mortality)in surgically and only medically treated patients stratified on the severity of sepsis. The cohort included 294 patients with definite IE known septic status enrolled. Patients were stratified into two groups. There were 95 (32.3%) patients with severe sepsis and/or septic shock (SSS) and 199 (67.7%) with sepsis (S). Valve replacement was performed in 37(38.9%) patients in the SSS group, and 71 (35.7%) in the S group, p=0.587. APACHE II score was significantly higher among medically treated patients. The mortality in SSS group was significantly higher in medically treated patients, 39/58 (67.2%) vs. 5/37 (13.4%), p<0.001. After adjusting for APACHE II score, SOFA score, age, and congestive heart failure, the beneficial impact of cardiac surgery remained significant. Cardiac surgery decreased the risk of in-hospital death about five times in SSS group, OR=0.096, 95%CI 0.027-0.335. Even in the most severe septic patients with IE, cardiac surgery improves patients outcome. SOFA score is a better predictor of patients outcome than APACHE II score, and should be included in the evaluation of IE patients.

P83 Treatment of ARDS during staphylococcal endocarditis with extracorporeal membranous oxygenation (ECMO)

ECMO is not common in the treatment of endocarditis complications. A case is presented of complete recovery after staphylococcal endocarditis complicated with ARDS and septic meningitis in a 65-year-old female with no co-morbidities except arterial hypertension. The patient was admitted to the hospital on the third day of fever, malaise and cough. On 5th day of hospitalization she developed respiratory failure and was admitted into ICU. The first echocardiography showed mitral valve endocarditis with moderate mitral regurgitation. Septic meningitis was also found. The next day after the admission into ICU mechanical ventilation started because of the progressing hypoxemia. On the same day, because of the further deterioration, we started ECMO procedure and continued it for the next 48 hours. There were no complications of the ECMO treatment. After the weaning, cardiac surgery was performed because of the progression in the size of vegetation and abscess formation of the mitral annulus. The patient was medically treated with cloxacillin for next 28 days. Sixteen months after admission the patient was completely well, Karnofsky score 100%. This case reports a rapid progression of the staphylococcal sepsis in the patient with no apparent risk factors and shows that initial complex critical care, including ECMO, might significantly improve patients perspectives for full recovery.

P76 THE IMPACT OF VALVE SURGERY ON MORTALITY IN INFECTIVE ENDOCARDITIS COMPLICATED WITH EMBOLIC STROKE: A PROPENSITY SCORE ANALYSIS

Data were obtained from the International Collaboration on Endocarditis-Prospective Cohort Study of 4794 patients with definite IE who were admitted to 64 centers in 28 countries from June 2000 through December 2006. The treatment group included patients with embolic in whom valve replacement was performed after stroke (225 patients). The control group included medically treated patients (263 patients). Propensity score, which was the estimated probability that a patient would undergo surgery, was calculated for each patient. After propensity score matching, 119 patients were included in each group. In-hospital mortality was significantly higher in the medically treated group than in the surgery group. Overall, in the medically treated group 36 patients (30.3%) died, in the surgery group 16 (15.1%), p=0.005. The odds of hospital death were almost three times higher in the medically treated group, OR=2.806, 95%CI 1.900-4.227. The probability of one-year survival was also significantly higher in surgery group (0.788 vs. 0.567, p<0.001, log-rank test).