Endocarditis

IJCS

Editorial

Infective Endocarditis Epidemiology Over Time: An Analysis of a National Registry Between 1996 and 2023

One of the approaches of studying diseases is how they evolve over time in different scenarios. Time may refer to years, decades, even centuries; scenarios may refer to different geographic peculiarities, epidemiological conditions, clinical and surgical therapeutic medical facilities available, access to proper health care, access to the diagnosis, and access to the treatment.

Infective endocarditis has been subject to this approach over time after the description of the disease in seventheenth century. Among the historical outstanding contributions were the three famous Gulstonian Lectures delivered by William Osler. As a rare disease, incidence of infective endocarditis was estimated to be between 3 and 10 episodes per 100,000 person-years in different surveys. Decades ago, institutional reports of large series of patients over time were traditional in the literature.^– Some of these series were published before the advent of large epidemiological studies that were feasible due to new technologies related to data science and data analyses. More recent reports have studied the changing nature of the disease over time: in France, in an American county, in England, in Italy, in Europe, in an international collaboration, and in one Brazilian institution over a four-decade period.

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IJCS

Case Report

PET-CT in Infectious Endocarditis Diagnosis

Matheus Werlang Donadel et al. Laura Werlang Donadel Laura Cristina Pudell Eduardo Hunsche Grossman Gabriel Blacher Grossman

Introduction

A 63-year-old male patient, with a history of mitral valve replacement with a bioprosthesis in 2019 due to native valve dysfunction secondary to bacterial endocarditis, and under regular medical follow-up since the procedure, presented to the cardiology emergency department with a complex clinical case. The patient reported a two-week history of fever (with temperature peaks of 38°C), night sweats, dry cough, weight loss, cervical pain when moving the neck, increased urinary frequency and urinary incontinence. At presentation, there were no classic cardiovascular symptoms, signs of valve dysfunction, or embolic phenomena. Notably, he had recently undergone a dental procedure without antibiotic prophylaxis. He denied symptoms such as rhinorrhea or pharyngitis. His physical and cardiovascular examinations were unremarkable.

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IJCS

Original Article

Endocarditis – A 27-Year Epidemiological Analysis of Mortality in Brazil

Leticia da Costa Santana Silva et al. Luana Yasmim Fernández Avelaneda Castanheira Maria Dalila Santos Salim Ruy Felipe Melo Viegas … Gilson Fernandes Ruivo Sheila Cavalca Cortelli Davi Romeiro Aquino Taciana Mara Rezende Fortes Viégas

Abstract

Background:

Infective endocarditis (IE) is frequently caused by viridans streptococci. Short-term in-hospital mortality in high-income settings ranges from 11% to 25%. In Brazil, rheumatic heart disease remains a leading valvular substrate; however, its declining prevalence in developing nations has limited country-specific analyses.

Objective:

To describe the epidemiological profile of mortality from IE in Brazil, characterizing its magnitude and temporal trend.

Methods:

We conducted a retrospective, exploratory epidemiological study with descriptive and analytic components using data from the Mortality Information System of the Department of Informatics of Brazil’s Unified Health System. Chi-square tests of independence were applied (p < 0.05), and results were summarized in tables and figures. Variables included International Statistical Classification of Diseases and Related Health Problems, 10th Revision categories, year of death, region, and sex.

Results:

From 1996 to 2022, 40,157 deaths associated with IE were recorded in Brazil (chi-square = 1,701.43). The Southeast region accounted for the greatest burden, with 21,429 deaths (53.36%; chi-square = 15,236.00). By sex (chi-square = 999.32), men were more affected than women (55.57% [22,315] vs 44.41% [17,835]); in 0.02% of records, sex was unspecified.

Conclusions:

IE remains a condition of national and international concern, with substantial mortality in Brazil over the last 27 years. This overview of mortality patterns highlights regional disparities and sex differences and can inform public-health strategies and evidence-based interventions.

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IJCS

Editorial

Risk Stratification in Patients Hospitalized With Infective Endocarditis Undergoing Cardiac Surgery: How Sharp Are We?

Ana Margarida Martins et al. Catarina Sousa

Infective endocarditis (IE) is an infrequent yet life-threatening and disabling condition, with an estimated incidence between 3 and 12 cases per 100,000 subjects per year.^, Recent epidemiological studies have suggested a rising trend in the incidence of IE, potentially attributable to factors such as an aging population and a growing group of susceptible patients with congenital heart disease, intracardiac prosthesis or devices, and chronic renal failure on dialysis. Limited information is available concerning Brazil’s temporal trends on IE incidence and clinical outcomes. The primary source of evidence regarding the IE scenario in Brazil stems from single or multicenter observational studies.^– Analyzing available data, it appears that IE predominantly affects younger male patients in Brazil. The most prevalent microbial culprits are Staphylococcus, followed by Enterococcus and Streptococcus species; rheumatic heart disease is an important underlying heart condition as well.

The diverse clinical spectrum of IE, coupled with the substantial risk of complications and the limited availability of randomized clinical trials on IE, justify that it continues to be a prognostic challenge. Despite the unquestionable diagnostic and therapeutic advances in the management of IE in recent decades, its prognosis is still marked by high rates of complications and significant in-hospital mortality. In developed countries, IE is associated with mortality rates of approximately 20%,^,, whereas in low- and middle-income countries, the mortality of IE ranges from 15% to 30%. The predominant focus in studies on IE has been the evaluation of clinical factors that may influence the course of the disease. In one of these studies, a machine learning-based analysis identified peripheral stigmata, nosocomial IE, the absence of vegetation, and surgery in the presence of neurologic complications as characteristics associated with higher in-hospital mortality.

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IJCS

Case Report

Bentall-De Bono Reoperation Associated With Pseudoaneurysm and Infectious Endocarditis

Janayna Rabelato et al. Iuri Betuel Gomes Antonio Adnaldo da Silveira Maia Daniel Chagas Dantas … Antonio Flávio de Almeida Mario Issa

Abstract

We present the case of a 55-year-old patient who underwent the Bentall-De Bono procedure with mechanical prosthesis in 2005 and was admitted to the emergency department in July 2020 with mixed shock. Complementary exams showed an abscess involving the prosthetic tube, two thirds of the aortic valve circumference and the left ventricle, with a neocavity of about 45 mm in diameter from the aortic sinus to the ascending aorta. The patient underwent surgical repair, with a new procedure using the Bentall-De Bono technique, now associated with coronary artery bypass grafting with a great saphenous vein graft between the aorta and the anterior descending artery. Culture of samples collected intraoperatively showed Staphylococcus epidermidis. The patient received antibiotic therapy for 30 days, evolving favorably, and is under regular outpatient follow-up.

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IJCS

Original Article

Analysis of the SHARPEN Score in the Prediction of In-Hospital Mortality of Patients With Infective Endocarditis Undergoing Cardiac Surgery

Mateus Correa Lech et al. Joel Stefani Lucas Fernando Fabra Miguel Gus Fernando Pivatto Júnior

Abstract

Background

The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out.

Objective

To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores.

Methods

Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant.

Results

A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores.

Conclusions

The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

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IJCS

Editorial

Surgical Mortality in Infective Endocarditis: Is There a Gender Paradox?

Daniel Seabra et al. Cristina Gavina

Cardiovascular diseases (CVD) represent a global pandemic. Although mortality due to CVD has been decreasing with improvement in diagnosis and treatment, it remains the most frequent cause of death worldwide both in men and women.

Gender impacts several key aspects in CVD, such as epidemiology, pathophysiology, clinical manifestations, disease progression, response to treatment and prognosis, in areas like coronary artery disease and heart failure. However, few studies analyzed the influence of gender in infectious endocarditis (IE) management and outcomes.^,

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IJCS

Original Article

Gender Based Analysis of a Population Series of Patients Hospitalized with Infective Endocarditis in Portugal – How do Women and Men Compare?

Catarina Sousa et al. Paulo Jorge Nogueira Fausto J. Pinto

Abstract

Background:

The impact of gender on the outcome of patients hospitalized with infective endocarditis (IE) is not fully understood.

Objective:

To verify the association between gender and the clinical profile of patients hospitalized with IE, treatment strategies, and clinical outcomes.

Methods:

This is a retrospective nationwide study of patients hospitalized with IE, based on hospital admissions between 2010 and 2018 in Portugal. Descriptive statistics were used to present variables. An inferential analysis was performed using multiple logistic regression. A 95% confidence interval and a 5% significance level were considered.

Results:

In total, 3266 (43.1%) women and 4308 (56.9%) men were hospitalized with IE. The women were older (76 vs 69 years old, p<0.001), more frequently presented arterial hypertension (39.8% vs 35.4%, p<0.001) and atrial fibrillation (29.5% vs 21.2%, p<0.001), and had less cardiovascular comorbidities. Acute heart failure was more common in women (32.9 vs 26.9%, p<0.001) and acute renal failure (13.6% vs 11.7%, p<0.001) and sepsis (12.1% vs 9.1%, p<0.001), in men. Women were less likely to undergo cardiac surgery (OR 0.48 – 95%CI 0.40–0.57, p<0.001) and had a higher postoperative mortality (OR 1.84, 95% CI 1.19–2.84, p=0.006). In-hospital mortality rates were comparable between genders (20.3% vs 19.6%, p=0.45).

Conclusions:

Women were less likely to undergo cardiac surgery when hospitalized with IE, and the female gender was a predictor factor for postoperative mortality. Overall, in-hospital mortality was not influenced by gender. Further research is necessary to fully clarify the impact of gender on IE management and outcomes.

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IJCS

Case Report

Coxiella Burnetti Infective Endocarditis – Detection and Cure

Manuel Martins Barbosa et al. Carla Dias Elsa Araújo Raquel Costa

Introduction

Infective endocarditis (IE) is one of the first diagnostic hypotheses for patients admitted for acute heart failure and evidence of infection. Blood samples are collected for culture, and empiric, broad-spectrum antimicrobial therapy is initiated. Emergent cardiac surgery may be required depending on the severity of the case.

These procedures reduce bacteremia and improve clinical condition, which, in turn, may lead to discontinuation of diagnostic investigation in the presence of blood culture-negative endocarditis. Some of these patients, however, will have another episode of endocarditis.

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ABC

Original Article

Infective endocarditis: surgical therapy

Luís Sérgio de Moura Fragomeni et al. Fabiano Fernandes Vieira Júlio Cesar de Mello Bajerski Roque Paulo Falleiro … Gustavo Hoppen Iselso Sartori

OBJECTIVE: To assess the major causes of surgical morbidity and mortality in patients with infective endocarditis operated upon in a regional cardiology center. METHODS: Thirty-four patients underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and 79% were males. Their NYHA functional classes were as follows: IV – 19 (55.8%) patients; III – 12 (35.2%) patients; II – 3 (8.8%) patients. Blood cultures were positive in only 32% of the cases. Eight patients had already undergone previous cardiac surgery, whose major indication (82.3%) was heart failure refractory to clinical treatment. RESULTS: Four (11.7%) patients died at the hospital. Follow-up was complete in 26 (86%) patients. Five (14.7%) patients died later, 12, 36, 48, 60, and 89 months after hospital discharge. Of the 21 patients being currently followed up, 1 is in NYHA functional class III, and 5 in NYHA functional class II. CONCLUSION: A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

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ABC

Original Article

Immunologic evaluation in infective endocarditis

Wilma C. Neves Forte et al. Aline C. Mario Adilson da Costa Luciana S. Henriques … Carla L. Gonzales Roberto A. Franken

OBJECTIVE: To analyze the immune response in peripheral blood of patients with infective endocarditis. METHODS: We studied 10 patients with infective endocarditis, age range from 20 to 50 years-old, males and females, and 20 healthy subjects in the same age range. The diagnosis of the disease was based on the clinical picture, echocardiogram, and hemoculture based upon samples drawn and tested before the treatment started. The were no history of atopy or malnutrition, no autoimmune disease, and they were not using any immunosuppressant or antibiotic medication. RESULTS: The patients with endocarditis had significantly higher T and B lymphocyte, CD4+ and CD8+ cell counts, IgM and IgG serum levels, and C4 component of the complement than the control group; no significant difference concerning serum IgA and neutrophil oxidative metabolism; a significant decrease in C3, chemotaxis, and monocyte phagocytosis;cryoglobulins were detected in 66.6% of patients and they were formed by IgG, IgM, IgA, C3, and C4. CONCLUSION: The patients with infective endocarditis were immunocompetent in most sectors of immune response and, at a certain moment, an autoimmune component may be present.

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