infective endocarditis

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Editorial

Infective Endocarditis: New Spectra, Same Severity

Infective endocarditis is a rare disease with a high rate of serious complications and can often be seen as a syndrome. A cold assessment of data published internationally shows us that despite all the technological advances and an early trend towards surgical intervention, there was no great reduction in clinical outcomes, especially mortality, but a more detailed search for information may bring us other points of view.

The article by Jorge MS et al. corroborates the idea of early diagnoses and interventions in this broad spectrum of patients, and observing the epidemiological change of patients over the years is a fundamental key to a broad reading of the management of contemporary infective endocarditis.

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Review Article

Infective Endocarditis: Still More Challenges Than Convictions

Catarina Sousa et al. Fausto J. Pinto

Abstract

After fourteen decades of medical and technological evolution, infective endocarditis continues to challenge physicians in its daily diagnosis and management. Its increasing incidence, demographic shifts (affecting older patients), microbiology with higher rates of Staphylococcus infection, still frequent serious complications and substantial mortality make endocarditis a very complex disease. Despite this, innovations in the diagnosis, involving microbiology and imaging, and improvements in intensive care and cardiac surgical techniques, materials and timing can impact the prognosis of this disease. Ongoing challenges persist, including rethinking prophylaxis, improving the diagnosis criteria comprising blood culture-negative endocarditis and prosthetic valve endocarditis, timing of surgical intervention, and whether to perform surgery in the presence of ischemic stroke or in intravenous drug users. A combined strategy on infective endocarditis is crucial, involving advanced clinical decisions and protocols, a multidisciplinary approach, national healthcare organization and health policies to achieve better results for our patients.

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Original Article

Epidemiological Profile of Patients with Infective Endocarditis at three Tertiary Centers in Brazil from 2003 to 2017

Renato Lott Bezerra et al. Lucas Sousa Salgado Yago Machado da Silva Gustavo Guimarães Rocha Figueiredo … Raimundo Matos Bezerra Filho Eduardo Luís Guimarães Machado Isabel Cristina Gomes Ângelo Geraldo José Cunha

Abstract

Background

Infective endocarditis (IE) is a disease with high morbimortality and an increasing incidence. With improved diagnosis and treatment, a number of epidemiological changes have been reported over time.

Objectives

We sought to describe the epidemiological profile, mortality predictors, and analysis of a possible microbiological transition in patients admitted to three tertiary centers in Brazil.

Methods

In this cross-sectional retrospective study, data from 211 patients with definite or probable IE were analyzed according to the modified Duke criteria between 2003 and 2017. The association between categorical variables was assessed using the chi-square or Fisher’s exact test, and binary logistic models were built to investigate mortality. We considered p <0.05 statistically significant.

Results

The median age of the sample was 48 (33-59) years old, 70.6% were men, and the most prevalent pathogen was Staphylococcus spp. (19%). Mortality was 22.3%, with increasing age being the leading risk factor for death (p = 0.028). Regarding the location of the disease, native valves were the most affected site, with the aortic valve being more affected in men than women (p = 0.017). The mean number of cases of Staphylococcus spp. (τ = 0.293, p = 0.148) and Streptococcus spp. (τ = -0.078, p = 0.727) has remained stable over the years.

Conclusion

No trend towards reduced or increased mortality was evident between 2003 and 2017. Although Staphylococcus spp. were the most prevalent pathogen, the expected epidemiological transition could not be observed.

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Prosthetic Aortic Valve Endocarditis by Neisseria Elongata after Bentall Procedure: When Multimodality Imaging is Key to Diagnosis

Mariana Brandão et al. Pedro Gonçalves-Teixeira Pedro Ribeiro Queirós Nuno Dias Ferreira Marco Oliveira

A diabetic 65-year-old male with previous Bentall procedure and mechanical aortic valve prosthesis presented with fever and abdominal pain, along with systolic murmur (III/VI) and elevated inflammatory markers. Abdominal computed tomography (CT) revealed splenic infarction. Transesophageal echocardiogram (TEE) was negative for vegetations. Given the persistent suspicion of infective endocarditis (IE) with peripheral embolism, empirical antimicrobial therapy was initiated. The patient subsequently presented with complete atrioventricular block, requiring temporary transvenous pacing. An epicardial pacemaker was later implanted.

At the time, cardiac CT revealed an irregular-shaped hypoattenuating mass attached to the ventricular side of the prosthetic suture ring, consistent with vegetation (), interfering with the normal opening of one of the prosthesis discs (). Repeat TEE also showed a small highly mobile vegetation and an annular abscess in the prosthetic aortic valve (). Blood cultures were positive for Neisseria elongata, confirming the diagnosis of prosthetic valve endocarditis (PVE); antimicrobial therapy was tailored. Despite early improvement, the patient later presented with de novo ataxia and brain CT revealed infarction in the right vertebrobasilar territory. New sets of cultures remained negative and coagulation levels were within therapeutic range. A small vegetation persisted on cardiac CT and TEE, and inflammatory infiltrate was apparent at the mitro-aortic curtain.

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Fatal Infective Endocarditis in a Patient with Cardiac Resynchronization Therapy

Oscar Fabregat-Andrés et al. Bruno Bochard-Villanueva

Author contributions

Conception and design of the research, Acquisition of data and Critical revision of the manuscript for intellectual content: Fabregat-Andrés O, Bochard-Villanueva B; Writing of the manuscript: Fabregat-Andrés O.

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Artigo Original

Echocardiographic findings in patients with suspected infective endocarditis

Marcelo Luiz Campos Vieira et al. Max Grinberg Pablo M. A. Pomerantzeff José L. de Andrade Alfredo J. Mansur

OBJECTIVE: To assess the echocardiographic findings in patients with suspected infective endocarditis. METHODS: Two hundred sixty-two patients with suspected infective endocarditis underwent transthoracic and transesophageal echocardiographic investigation. Images of vegetations, valvular abscesses, and acute periprosthetic insufficiency were analyzed, and the correlation with clinical and laboratory data, diagnostic category, and hospital evolution was assessed. RESULTS: The diagnosis of endocarditis was categorized as defined in 127 (47.8%) episodes, possible in 81 (30.4%), and rejected in 58 (21.8%). In patients with the defined diagnosis, the following images were identified: 135 vegetations, 37 abscesses, and 6 periprosthetic insufficiencies. Vegetations were more frequent in patients with endocarditis due to streptococci of the viridans group and enterococci (P=0.02), and with symptom duration < 10 days (P=0.001). Abscesses were more frequent in patients with symptom duration < 10 days (P=0.001). Periprosthetic insufficiency was associated with a greater need for surgical treatment (P=0.001). In patients with the possible diagnosis of endocarditis, 8 echocardiographic images considered compatible with vegetations were identified. In patients whose diagnosis of endocarditis was rejected, no vegetations, valvular abscesses, or periprosthetic insufficiencies were demonstrated. CONCLUSION: Our echocardiographic findings varied according to the diagnostic category. The contribution to both the diagnosis and prognostic evaluation should consider the pretest probability of the diagnosis of infective endocarditis.

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Artigo Original

Infective endocarditis in adolescents. analysis of risk factors for in-hospital mortality

Nádia Barreto Tenório Aoun et al. Francisco Manes Albanesi Fº Maurício Bastos de Freitas Rachid Luíz André Vieira Fernandes José Augusto da Silva Messias

PURPOSE: To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old ( mean 15.5). METHODS: Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied. RESULTS: Infective endocarditismortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p=0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm³ and functional class, both at admission (p=0.01 and p=0.004, respectively), and the occurrence of embolic complications (p=0.03) as independent predictors of in-hospital mortality. CONCLUSION: Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S.aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.

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