Julián Fraile

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome.

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis. Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status. Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications. Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE. The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively). Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18). S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE. Abbreviations: AIDS = acquired immunodeficiency syndrome, CI = confidence interval, CNS = central nervous system, HIV = human immunodeficiency virus, MIC = minimum inhibitory concentration, MRSA = methicillin-resistant Staphylococcus aureus, MSSA = methicillin-susceptible Staphylococcus aureus, NVE = native valve endocarditis, OR = odds ratio, PVE = prosthetic valve endocarditis, TEE = transesophageal echocardiogram, TTE = transthoracic echocardiogram.

Q Fever Endocarditis on Porcine Bioprosthetic Valves: Clinicopathologic Features and Microbiologic Findings in Three Patients Treated with Doxycycline, Cotrimoxazole, and Valve Replacement

Three patients developed Q fever endocarditis on porcine bioprosthetic valves. They had a subacute or chronic course with nonspecific symptoms, enlargement of the liver and spleen, and cardiac failure due to destruction of the cusps, without disruption of the valve ring. High-phase I-specific IgG and IgA antibody titers against Coxiella burnetii were found. C. burnetii was isolated in each patient by inoculating suspensions of valve tissue into a human fetal diploid fibroblast cell line, which was grown as monolayers on slides contained inside rubber-stoppered tube cultures. Patients were treated successfully with doxycycline, cotrimoxazole, and valve replacement and were followed up for periods of 24 to 42 months; no evidence of deterioration was found. The human fetal diploid cell culture may be an expeditious, easy, and safe method to isolate C. burnetii from cardiac valves. Valve replacement seemed necessary to cure prosthetic-valve endocarditis due to C. burnetii infection. Combined therapy with doxycycline and cotrimoxazole may control the disease and prevent reinfection of the homografts replacing the valves.

Reoperations for Left-sided Low-Profile Mechanical Prosthetic Obstructions

A series of 2,474 hospital survivors of primary mitral, aortic, and double mitral-aortic valve replacement were observed for a cumulative period of 11.945 years (mean, 4.2 years; range, 0.6-14 years). The linearized incidences of reoperations for thrombotic obstructions were 0.33 +/- 0.08% for mitral valve replacement, 0.36 +/- 0.1% for aortic valve replacement, and 0.42 +/- 0.1% for double valve replacement (p = not significant). Forty-one patients (16 mitral, 12 aortic, and 13 double valve replacements) underwent a total of 44 reoperations with a mean interval of 36 +/- 29 months (range, 0.25-85 months) between operations. Diagnosis was established invasively only in 13 patients (30%). Hospital mortality at reoperation was 18% (8 patients); 28 patients (63%) required emergency surgery. The choice surgical procedures were thrombectomy for clotted aortic prostheses (18 of 24) and valve replacement for obstructed mitral valves (22 of 25; p less than .001). Rethrombosis occurred in 3 patients (1 aortic and 2 double valve replacements). At hospital admission 17 patients (38%) had prothrombin times outside therapeutic ranges (between 20 to 30% of the normal value). The incidence of reoperations for thrombosis in low-profile mechanical prostheses was unaffected by valvar position and number of prostheses implanted. Rethrombosis occurred only in previously cleaned valves, although its occurrence was not significant. The present results indicate that, as experience is gained in the diagnosis and surgical management of this complication, hospital mortality can be reduced significantly (from 37% to 4%).

Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump

Vascular complications associated with intraaortic balloon pump placement are quite common and predominantly related to femoral or iliac damage. Iatrogenic injury of the thoracic aorta is less usual and often fatal. Surgery for the lesions of the descending thoracic aorta still has a relatively high morbidity and mortality. Endovascular covered stentgraft prostheses have become a less invasive therapeutic approach to lesions of the thoracic aorta, especially in patients with high surgical risk. We describe a case of perforation of the thoracic aorta caused by an intraaortic balloon pump. The injury was confirmed by aortography and successfully repaired by implantation of an endovascular stent-graft via the left common iliac artery.

Surgical treatment of prosthetic valve endocarditis in patients with double prostheses: is single-valve replacement safe?

OBJECTIVE Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected. METHODS Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome. RESULTS Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83-18.72). All were considered cured and relapses were not observed. CONCLUSIONS TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.

Long-term survival of salvage cardiac transplantation for infective endocarditis.

Cardiac transplantation has been rarely performed in patients with infective endocarditis. A 31-year-old man developed aortic endocarditis due to Brucella melitensis. He presented with fever and developed acute myocardial infarct, severe aortic regurgitation, and heart failure. Aortic valve replacement did not improve cardiac function; hence, an emergent cardiac transplantation was carried out. Eighteen years later, he is doing well and living an active and productive life. Only 6 patients have received a cardiac transplant as part of the treatment of active infective endocarditis. This patient shows how cardiac transplantation may be successfully used as salvage therapy for patients with infective endocarditis who are not candidates for valve replacement or have severe and irreversible myocardial damage.

Recambio valvular por insuficiencia aórtica severa tras cirugía conservadora según técnica de David

The aortic valve sparing operation is of great interest in the treatment of severe aortic insufficiency caused by annulus enlargement in aortic annuloectasia. If valve leaflets are normal, and we want to prevent complications derived from valve prosthesis and chronic anticoagulation, techni

Technique and Results of Tricuspid Annuloplasty

Acquired lesions of the tricuspid valve may be either primary or secondary. Primary organic lesions of the valve can cause stenosis and regurgitation while secondary lesions are more frequent and invariably associated with rheumatic valvulitis of the mitral and/or aortic valves. In these cases, tricuspid incompetence is the consequence of an annular dilatation produced by right ventricular strain secondary to an increase in pulmonary vascular resistance. The surgical treatment of acquired lesions of the tricuspid valve includes valve repair techniques and prosthetic replacement in severely damaged valves. The suboptimal results obtained (Table I) with tricuspid valve replacement at our institution’ consisting of a high hospital mortality, poor long-term prognosis, and high incidence of prosthetic failures needing reoperations led us in 1972 to describe2 and perform3s4 a tricuspid annuloplasty technique in more than 600 patients who concomitantly underwent associated isolated mitral or combined mitral-aortic valve replacement.

101 THE PATHOLOGY OF PROSTHETIC VALVE ENDOCARDITIS (PVE): “LOOKING THROUGH THE EYES OF THE SURGEON”

model. Classification function coefficients were stratified in quartiles of risk and based on quartiles of coefficients sums, three groups of patients were identified (first + second quartile = 1st group; third quartile = 2nd group; fourth quartile = 3rd group). According to its prevalence in each group, to each factor was then assigned an arbitrary score. Age, pre-operative renal insufficiency, NYHA class III and IV, preoperative mechanical ventilation for pulmonary oedema, emergency surgery, Gram negative endocarditis; and perivalvular involvement (abscess/fistula) were main model variables. Range score from 0 to 2 points defined inclusion in stage 1 (low-risk); 3 to 8 points in stage 2 (average risk); 9 or higher in stage 3 (high-risk). Results: Hospital mortality (overall 9.1%) was: 1.2% in Stage 1 (168 patients), 7.0% in Stage 2 (129 patients), 24.1% in Stage 3 (108 patients) (p < 0.001). Follow-up was 96% complete. Overall actuarial survival was 82%±0.023 at 5 years, 73%±0.03 at 10 years, 59%±0.04 at 15 years. Ten-year survival was 81%, 70%, 59% in stage 1, 2 and 3 respectively (log-rank test: p = 0.002). Conclusions: The newly developed stratification method, computed on clinical preoperative criteria, clearly discriminated patient groups with significantly different in-hospital and long-term prognosis.

Comparison of Reoperation and Complications in Double Valve (Mitral and Aortic) Implants with Mechanical or Biological Prostheses

A total of 1160 patients received a double valve implant, in the mitral and aortic positions, between January 1970 and December 1986. Either mechanical (984 patients) or biological (176 patients) valves were implanted. Operative mortality was 8%. Patients were followed-up for a total of 4641 patient-years (mean 5.12) in the mechanical valve group and a total of 1106 patient-years (mean 6.86) in the biological valve group. There was a significantly higher incidence of reoperation (p < 0.001) in the biological valve compared to the mechanical group because of a high number of primary tissue failures. An analysis of the actuarial data shows no significant difference in long-term survival. In conclusion, we think that the indications for double (mitral and aortic) biological valve implantation should be analyzed carefully. Given the freedom from reoperation after 12 years of only 28%, only very specific cases should be considered for biological valve implantation.