Ulrika Snygg-Martin

Cerebrovascular Complications in Patients with Left-Sided Infective Endocarditis Are Common: A Prospective Study Using Magnetic Resonance Imaging and Neurochemical Brain Damage Markers

Background. @nbsp; Cerebrovascular complications (CVCs) have remained a major therapeutic and prognostic challenge associated with infective endocarditis, and definite risk factors have not been fully elucidated. This prospective study was designed to the evaluate the total incidence of CVC associated with infective endocarditis and major risk factors. Methods. @nbsp; During 2 study periods, from June 1998 through April 2001 and from September 2002 through January 2005, patients were prospectively enrolled in the study regardless of neurological symptoms. Study patients underwent neurological examinations and magnetic resonance imaging of the brain, and cerebrospinal fluid analyses of inflammatory and neurochemical markers of brain damage (neurofilament protein and glial fibrillary acidic protein) were performed. Results. @nbsp; Sixty patients who experienced episodes of left-sided infective endocarditis were evaluated; 35% of these patients experienced a symptomatic CVC. Silent cerebral complications were detected in another 30% of the patients, and the total CVC rate was 65% (95% confidence interval, 58%-72%). Five percent of patients experienced their first neurological symptom after the initiation of antibiotic treatment without prior surgery. No new symptomatic CVCs were detected after 10 days of antibiotic treatment. No neurological deterioration was observed after surgery in patients who were established to have a symptomatic CVC preoperatively. A larger heart valvular vegetation size was a risk factor for both symptomatic and silent CVCs; Staphylococcus aureus etiology conferred a higher risk for symptomatic cerebral complication only. Conclusions. @nbsp; The use of sensitive methods of detection indicates that the incidence of CVC associated with infective endocarditis is high, but the risk for neurological deterioration during cardiac surgery after a CVC is lower than previously assumed. The major mechanism behind cerebral complications associated with infective endocarditis is cerebral embolization, although the dominant neurological symptoms vary considerably.

Swedish guidelines for diagnosis and treatment of infective endocarditis

Swedish guidelines for diagnosis and treatment of infective endocarditis (IE) by consensus of experts are based on clinical experience and reports from the literature. Recommendations are evidence based. For diagnosis 3 blood cultures should be drawn; chest X-ray, electrocardiogram, and echocardiography preferably transoesophageal should be carried out. Blood cultures should be kept for 5 d and precede intravenous antibiotic therapy. In patients with native valves and suspicion of staphylococcal aetiology, cloxacillin and gentamicin should be given as empirical treatment. If non-staphylococcal etiology is most probable, penicillin G and gentamicin treatment should be started. In patients with prosthetic valves treatment with vancomycin, gentamicin and rifampicin is recommended. Patients with blood culture negative IE are recommended penicillin G (changed to cefuroxime in treatment failure) and gentamicin for native valve IE and vancomycin, gentamicin and rifampicin for prosthetic valve IE, respectively. Isolates of viridans group streptococci and enterococci should be subtyped and MIC should be determined for penicillin G and aminoglycosides. Antibiotic treatment should be chosen according to sensitivity pattern given 2–6 weeks intravenously. Cardiac valve surgery should be considered early, especially in patients with left-sided IE and/or prosthetic heart valves. Absolute indications for surgery are severe heart failure, paravalvular abscess, lack of response to antibiotic therapy, unstable prosthesis and multiple embolies. Follow-up echocardiography should be performed on clinical indications.

Propionibacterium endocarditis: A case series from the International Collaboration on Endocarditis Merged Database and Prospective Cohort Study

Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with β-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.

Major Cerebral Events in Staphylococcus Aureus Infective Endocarditis: Is Anticoagulant Therapy Safe?

Objectives: To study the impact of anticoagulation on major cerebral events in patients with left-sided Staphylococcus aureus infective endocarditis (IE). Methods: A prospective cohort study; the use of anticoagulation and the relation to major cerebral events was evaluated separately at onset of admission and during hospitalization. Results: Overall, 70 out of 175 patients (40%; 95% CI: 33–47%) experienced major cerebral events during the course of the disease, cerebral ischaemic stroke occured in 59 patients (34%; 95% CI: 27–41%), cerebral infection in 23 patients (14%; 95% CI: 9–19%), and cerebral haemorrhage in 5 patients (3%; 95% CI: 0.5–6%). Patients receiving anticoagulation were less likely to have experienced a major cerebral event at the time of admission (15%) compared with those without anticoagulation (37%, p = 0.009; adjusted OR: 0.27; 95% CI: 0.075–0.96; p = 0.04). In-hospital mortality was 23% (95% CI: 17–29%), and there was no significant difference between those with or without anticoagulation. Conclusions: We found no increased risk of cerebral haemorrhage in S. aureus IE patients receiving anticoagulation. Anticoagulation was associated with a reduced risk of cerebral events before initiation of antibiotics. Data support the continuance of anticoagulation in S. aureus IE patients when indicated.

Warfarin therapy and incidence of cerebrovascular complications in left-sided native valve endocarditis.

Anticoagulant therapy has been anticipated to increase the risk of cerebrovascular complications (CVC) in native valve endocarditis (NVE). This study investigates the relationship between ongoing oral anticoagulant therapy and the incidence of symptomatic CVC in left-sided NVE. In a prospective cohort study, the CVC incidence was compared between NVE patients with and without ongoing warfarin. Among 587 NVE episodes, 48 (8%) occurred in patients on warfarin. A symptomatic CVC was seen in 144 (25%) patients, with only three on warfarin. CVC were significantly less frequent in patients on warfarin (6% vs. 26%, odds ratio [OR] 0.20, 95% confidence interval [CI] 0.06–0.6, p = 0.006). No increase in haemorrhagic lesions was detected in patients on warfarin. Staphylococcus aureus aetiology (adjusted OR [aOR] 6.3, 95% CI 3.8–10.4) and vegetation length (aOR 1.04, 96% CI 1.01–1.07) were risk factors for CVC, while warfarin on admission (aOR 0.26, 95% CI 0.07–0.94), history of congestive heart failure (adjusted OR 0.22, 95% CI 0.1–0.52) and previous endocarditis (aOR 0.1, 95% CI 0.01–0.79) correlated with lower CVC frequency.

The relationship between cerebrovascular complications and previously established use of antiplatelet therapy in left-sided infective endocarditis

Abstract Background: Cerebrovascular complications (CVC) in infective endocarditis (IE) are common. The only established treatments to reduce the incidence of CVC in IE are antibiotics and in selected cases early cardiac surgery. Potential effects of previously established antiplatelet therapy are under debate. Methods: In a prospective cohort study in Sweden and Demark, the influence of previously established antiplatelet therapy on CVC incidence and mortality in IE was assessed using logistic regression models. Results: Among 684 left-sided definite IE episodes, 23.0% were seen in patients on established antiplatelet therapy (96% acetylsalicylic acid). Patients on antiplatelet therapy were older and significantly more often had a history of congestive heart failure prior to IE diagnosis. No difference in CVC rate was seen between patients with and without ongoing antiplatelet therapy (23.6% vs 25.0%, adjusted odds ratio (AOR) 0.8, 95% confidence interval (CI) 0.48–1.5). Ischemic stroke, which occurred in 115 episodes (16.8%), was the most common cerebral lesion, and haemorrhagic complications were seen in 16 (2.3%) patients without correlation to chronic antiplatelet therapy. Unadjusted 1-y mortality was higher for patients on previously established antiplatelet therapy (33.8% vs 24.1%, odds ratio (OR) 1.6, 95% CI 1.1–2.4), but after adjustment for covariables associated with mortality an opposite statistical trend was seen (AOR 0.7, 95% CI 0.4–1.1). Conclusions: The incidence of symptomatic CVC in IE patients was not reduced by previously established antiplatelet therapy. One-y mortality was higher in patients on antiplatelet therapy in univariate analysis, but after multivariable modelling this association was lost.

One-year mortality in coagulase-negative Staphylococcus and Staphylococcus aureus infective endocarditis.

The aim of this study was to investigate in-hospital mortality and 12-month mortality in patients with coagulase-negative Staphylococcus (CoNS) compared to Staphylococcus aureus (S. aureus) infective endocarditis (IE). We used a prospective cohort study of 66 consecutive CoNS and 170 S. aureus IE patients, collected at 2 tertiary university hospitals in Copenhagen (Denmark) and at 1 tertiary university hospital in Gothenburg (Sweden). Median (range) C-reactive protein at admission was higher in patients with S. aureus IE (150 mg/l (1–521) vs 94 mg/l (6–303); p<0.001), which may suggest a more serous infection. CoNS was associated with prosthetic valve IE (49% vs 24%; p<0.001) and median diagnostic delay was longer in CoNS IE patients (20 d (0–232) vs 9 d (0–132); p<0.001). In-hospital mortality was equally high in both groups but 25% of the CoNS IE patients had died after 1 y compared to 39% of patients with S. aureus IE (p =0.05). In conclusion, CoNS IE was associated with a long diagnostic delay and high in-hospital mortality, whereas post-discharge prognosis was better in this group of patients compared to patients with IE due to S. aureus.

Surgical decision-making in aortic prosthetic valve endocarditis: the influence of electrocardiogram-gated computed tomography

OBJECTIVES The aim of this study was to investigate the value of electrocardiogram (ECG)-gated computed tomography (CT) in the surgical decision-making and preoperative evaluation in patients with aortic prosthetic valve endocarditis (PVE). METHODS Sixty-eight prosthetic valves in 67 patients with aortic PVE were prospectively evaluated with ECG-gated CT and transoesophageal echocardiography (TEE). Imaging findings considered indications for surgery were as follows: (i) abscess/pseudoaneurysm formation; (ii) prosthetic valve dehiscence; (iii) valve destruction with valvular regurgitation; (iv) large vegetations (>1.5 cm). The coronary arteries were evaluated with ECG-gated CT. Clinical data including surgical reports and mortality data were collected. RESULTS Fifty-eight of 68 cases had indication for surgery based on imaging findings (ECG-gated CT/TEE). In 8 of these cases (14%), there was indication for surgery based on CT but not on TEE findings (all had perivalvular pseudoaneurysms). In 11 cases (19%), there was indication for surgery based on TEE but not on CT findings [non-drained abscess (n = 5), prosthetic valve dehiscence (n = 4), large vegetation (n = 1), valve destruction (n = 1)]. In 31 of 32 patients with indication for preoperative coronary angiography, ECG-gated CT coronary angiography was diagnostic. In 1 patient, ECG-gated CT coronary angiography was inconclusive and invasive coronary angiography was performed. CONCLUSIONS In patients with aortic PVE, ECG-gated CT provides additional information over TEE regarding perivalvular extension of infection, which can influence surgical decision-making. Furthermore, ECG-gated CT provides a non-invasive coronary angiogram and can in most cases replace invasive coronary angiography in the preoperative evaluation.

Cystatin C in a composite risk score for mortality in patients with infective endocarditis: a cohort study

Objective To develop a multimarker prognostic score for infective endocarditis (IE). Design Retrospective case–control. Setting Secondary care. Single centre. Participants 125 patients with definite IE. Primary outcome measures 90-day and 5-year mortality. Results Mean age was 62.7±17 years. The 90-day and 5-year mortality was 10.4% and 33.6%, respectively. CysC levels at admission and over 20% increases in CysC levels during 2 weeks of treatment were prognostic for 90-day and 5-year mortality independent of creatinine estimated glomerular filtration rate. In multivariate analyses, CysC (OR 5.42, 95% CI 1.90 to 15.5, p=0.002) and age (OR 1.06, 95% CI 1.02 to 1.10, p=0.002) remained prognostic for 5-year mortality. NT-proBNP, TnT, C reactive protein and interleukin 6 were also linked to prognosis. A composite risk scoring system using levels of CysC, NT-proBNP, age and presence of mitral valve insufficiency was able to separate a high-risk and a low-risk group. Conclusions CysC levels at admission and increase in CysC after 2 weeks of treatment were independent prognostic markers for both 90-day and 5-year mortality in patients with IE. A multimarker composite risk scoring system including CysC identified a high-risk group.

РЕКОМЕНДАЦИИ ESC ПО ВЕДЕНИЮ БОЛЬНЫХ С ИНФЕКЦИОННЫМ ЭНДОКАРДИТОМ 2015

The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)