Nana Toyoda

Trends in Infective Endocarditis in California and New York State, 1998-2013

Importance Prophylaxis and treatment guidelines for infective endocarditis have changed substantially over the past decade. In the United States, few population-based studies have explored the contemporary epidemiology and outcomes of endocarditis. Objective To quantify trends in the incidence and etiologies of infective endocarditis in the United States. Design, Setting, and Participants Retrospective population epidemiology study of patients hospitalized with a first episode of endocarditis identified from mandatory state databases in California and New York State between January 1, 1998, and December 31, 2013. Exposure Infective endocarditis. Main Outcomes and Measures Outcomes were crude and standardized incidence of endocarditis and trends in patient characteristics and disease etiology. Trends in acquisition mode, organism, and mortality were analyzed. Results Among 75 829 patients with first episodes of endocarditis (mean [SD] age, 62.3 [18.9] years; 59.1% male), the standardized annual incidence was stable between 7.6 (95% CI, 7.4 to 7.9) and 7.8 (95% CI, 7.6 to 8.0) cases per 100 000 persons (annual percentage change [APC], −0.06%; 95% CI, −0.3% to 0.2%; P = .59). From 1998 through 2013, the proportion of patients with native-valve endocarditis decreased (from 74.5% to 68.4%; APC, −0.7%; 95% CI, −0.9% to −0.5%; P < .001). Prosthetic-valve endocarditis increased (from 12.0% to 13.8%; APC, 1.3%; 95% CI, 0.8% to 1.7%; P < .001), and cardiac device–related endocarditis increased (from 1.3% to 4.1%; APC, 8.8%; 95% CI, 7.8% to 9.9%; P < .001). The proportion of patients with health care–associated nosocomial endocarditis decreased (from 17.7% to 15.3%; APC, −1.0%; 95% CI, −1.4% to −0.7%; P < .001). The proportion of patients with health care–associated nonnosocomial endocarditis increased (from 32.1% to 35.9%; APC, 0.8%; 95% CI, 0.5% to 1.1%; P < .001). The incidence of oral streptococcal endocarditis did not increase (unadjusted: APC, −0.1%; 95% CI, −0.8% to 0.6%; P = .77; adjusted: APC, −1.3%; 95% CI, −1.8% to −0.7%; P < .001). Crude 90-day mortality was unchanged (from 23.9% to 24.2%; APC, −0.3%; 95% CI, −1.0% to 0.4%; P = .44); adjusted risk of 90-day mortality decreased (adjusted hazard ratio per year, 0.982; 95% CI, 0.978 to 0.986; P < .001). Conclusions and Relevance In California and New York State, the overall standardized incidence of infective endocarditis was stable from 1998 through 2013, with changes in patient characteristics and etiology over this time.

Real-world outcomes of surgery for native mitral valve endocarditis

Background: Consensus guidelines recommend repair over replacement for the surgical treatment of active native mitral valve infective endocarditis. However, contemporary practice and long‐term outcome data are limited. Methods: Multivariable Cox regression was used to compare outcomes of 1970 patients undergoing isolated primary mitral valve repair (n = 367, 19%) or replacement (n = 1603, 81%) for active infective endocarditis between 1998 and 2010 in New York and California states. The primary outcome was long‐term survival. Secondary outcomes were recurrent endocarditis and mitral reoperation. Median follow‐up time was 6.6 years (range 0–12), and last follow‐up date was December 31, 2015. Results: Mitral valve repair rates increased from 10.7% to 19.4% over the study period (P < .001). Patients undergoing mitral repair were younger (55 ± 15 vs 57 ± 15 years, P = .005), less likely to have congestive heart failure (46.3% vs 57.1%, P < .001), and less likely to have staphylococcal infections (21.3% vs 32.0%, P < .001). Twelve‐year survival was 68.8% (95% confidence interval [CI], 62.5%‐74.3%) after mitral repair, versus 53.5% (95% CI, 50.6%‐56.4%) after replacement (adjusted hazard ratio, 0.71; 95% CI, 0.57–0.88; P = .002). Mitral repair was associated with lower rate of recurrent endocarditis at 12 years than replacement (4.7% [95% CI, 2.8%‐7.2%] vs 9.5% [95% CI, 8.0–11.1%]; P = .03), and similar rate of reoperation (9.1% [95% CI, 6.2%‐12.8%] vs 8.6% [95% CI, 7.1%‐10.4%]; P = .12). Conclusions: In active endocarditis, mitral valve repair is associated with better survival and lower risk of recurrent infection compared with valve replacement and should be the surgery of choice when feasible.

Survival and long-term outcomes after mitral valve replacement in patients aged 18 to 50 years

Objective To provide long‐term data on survival and major morbidity after mitral valve replacement in patients aged 18 to 50 years. Methods Retrospective analysis of 2727 patients aged 18 to 50 years who underwent isolated mitral replacement in California and New York from 1997 to 2006. Median follow‐up time was 12.4 years (maximum 15.0 years). The primary endpoint was mortality; secondary endopoints were stroke, major bleeding, and reoperation. Propensity matching yielded 373 patient pairs. Results Bioprosthetic valve use increased from 10% to 34% between 1997 and 2014 (P < .001). Among propensity score‐matched patients, actuarial 15‐year survival was 74.3% (95% confidence interval [CI], 69.0%‐78.7%) after bioprosthetic versus 80.8% (95% CI, 75.1%‐85.3%) mechanical valve replacement (hazard ratio [HR], 1.67; 95% CI, 1.21‐2.32, P = .002). At 15 years after mitral valve replacement, the cumulative incidence of stroke was similar (9.1% [95% CI, 6.0%‐13.0%] vs 9.7% [95% CI, 6.7‐13.4]; HR, 0.95 [95% CI, 0.57‐1.59]); the cumulative incidence of major bleeding events was similar (7.9% [95% CI, 5.0%‐11.5%] vs 11.5% [95% CI, 7.6%‐16.2%]; HR, 0.78 [95% CI, 0.46‐1.32]); and the cumulative incidence of reoperation after bioprosthetic valve replacement was greater (19.9% [95% CI, 15.4%‐24.8%] vs 5.7% [95% CI, 3.5%‐8.7%]; HR, 20.3 [95% CI, 4.0‐102.8]), respectively. Conclusions The significant survival benefit associated with mechanical mitral valve replacement in adults ≤50 years may be due to the practice of implanting bioprostheses in sicker patients or those judged less likely to comply with long‐term medication despite adjustment for baseline characteristics in propensity score matching.

Extracorporeal Membrane Oxygenation in New York StateCLINICAL PERSPECTIVE: Trends, Outcomes, and Implications for Patient Selection

Background—Utilization of extracorporeal membrane oxygenation (ECMO) is expanding despite limited outcome data defining appropriate use. Methods and Results—To quantify determinants of early and 1-year survival after ECMO in adult patients, we conducted a retrospective cohort analysis of 1286 patients aged ≥18 years who underwent ECMO in New York State from 2003 to 2014. Median follow-up time was 4.9 months (range, 0–12 months). ECMO utilization increased from 13 patients in 8 hospitals in 2003 to 330 patients in 30 hospitals in 2014. Compared with patients undergoing ECMO before 2009, later patients were older (54.4 versus 52.3 years; P=0.013) and more likely to have major comorbidity including chronic kidney disease (25.2% versus 13.2%; P=0.02) and liver disease (20.0% versus 10.7%; P=0.001). In the overall cohort, 30-day mortality was 52.2% (95% confidence interval, 49.5–54.9). Mortality at 30 days was 65.2% for patients aged ≥75 years (n=73/112) and 74.6% in patients who required cardiopulmonary resuscitation (n=91/122). Survival at 1 year was 38.4% (95% confidence interval, 35.7–41.0). The 30-day mortality and 1-year survival improved across the study period. In multivariable analysis, earlier year of ECMO, lower hospital volume, indication for ECMO after a cardiac procedure, cardiopulmonary resuscitation before ECMO placement, and age >65 years were independent predictors of worse survival. Conclusions—Outcomes of ECMO have improved despite increasing comorbidity. Extreme mortality after ECMO in elderly patients and patients requiring cardiopulmonary resuscitation indicates that less invasive therapeutic or palliative modalities may be more appropriate in this end-of-life setting.Background— Utilization of extracorporeal membrane oxygenation (ECMO) is expanding despite limited outcome data defining appropriate use. Methods and Results— To quantify determinants of early and 1-year survival after ECMO in adult patients, we conducted a retrospective cohort analysis of 1286 patients aged ≥18 years who underwent ECMO in New York State from 2003 to 2014. Median follow-up time was 4.9 months (range, 0–12 months). ECMO utilization increased from 13 patients in 8 hospitals in 2003 to 330 patients in 30 hospitals in 2014. Compared with patients undergoing ECMO before 2009, later patients were older (54.4 versus 52.3 years; P =0.013) and more likely to have major comorbidity including chronic kidney disease (25.2% versus 13.2%; P =0.02) and liver disease (20.0% versus 10.7%; P =0.001). In the overall cohort, 30-day mortality was 52.2% (95% confidence interval, 49.5–54.9). Mortality at 30 days was 65.2% for patients aged ≥75 years (n=73/112) and 74.6% in patients who required cardiopulmonary resuscitation (n=91/122). Survival at 1 year was 38.4% (95% confidence interval, 35.7–41.0). The 30-day mortality and 1-year survival improved across the study period. In multivariable analysis, earlier year of ECMO, lower hospital volume, indication for ECMO after a cardiac procedure, cardiopulmonary resuscitation before ECMO placement, and age >65 years were independent predictors of worse survival. Conclusions— Outcomes of ECMO have improved despite increasing comorbidity. Extreme mortality after ECMO in elderly patients and patients requiring cardiopulmonary resuscitation indicates that less invasive therapeutic or palliative modalities may be more appropriate in this end-of-life setting.

LONG-TERM BENEFITS OF REPAIR VERSUS REPLACEMENT FOR ACUTE NATIVE MITRAL VALVE ENDOCARDITIS

Background: Guidelines recommend repair over replacement for native mitral valve infective endocarditis (IE). Data is limited to small series: we therefore evaluated state-wide outcomes. Methods: From mandatory state databases we identified 3,976 adults who had mitral surgery for IE between 1998-

SYNTAX score may predict the severity of atherosclerosis of the ascending aorta

Background The objective of this study was to investigate the association of the coronary SYNTAX score with the degree of atherosclerosis of the ascending aorta in patients who underwent coronary artery bypass grafting (CABG). Methods A total of 152 patients (mean age 65 years, 66% male) were analyzed who underwent isolated CABG with both SYNTAX score and the intraoperative 5-point scale grading of the severity of atherosclerosis in the ascending aorta available. The patient were stratified into low, intermediate, and high SYNTAX score groups [≤22 (n=36), 22-33 (n=42), and ≥33 (n=76)]. Results The mean SYNTAX score was 31±11. Patient demographics and comorbidity were comparable in each group. The prevalence of severe atherosclerosis (Grade ≥III) in the ascending aorta was 17.5% (n=27) in the whole population and was different in each group with higher prevalence in higher score groups (8.3% vs. 9.5% vs. 26.3%, P=0.018). After adjusting for age, sex and other relevant comorbidity, SYNTAX score remained a predictor of severe atherosclerosis [adjusted OR 1.63, 95% CI: 1.01-2.62, P=0.046 (per 10 point increase); adjusted OR 5.20, 95% CI: 1.15-23.5, P=0.032 (high vs. low score)]. Conclusions SYNTAX score was associated with the severity of atherosclerosis in the ascending aorta. Patients with high scores have a 5 times higher chance of severe disease compared to patients with low scores and should warrant preoperative and intraoperative comprehensive assessment of the ascending aorta.