RESUMEN
BACKGROUND: Observational studies suggest that valvular surgery can reduce mortality in selected patients with infective endocarditis (IE). However, the benefit of this intervention according to frailty levels remains unclear. Our study aims to assess the effect of valvular surgery according to frailty status in this population. METHODS: We performed a retrospective study using the 2016-2019 National Inpatient Sample database. Adult patients with a primary diagnosis of IE were included. Frailty was assessed using the Hospital Frailty Risk Score. Inverse probability of treatment weighting (IPTW) was used to balance baseline differences between groups. RESULTS: A total of 53,275 patients with IE were included, with 18.3% underwent valvular surgery. The median age was 52 (34-68) years, with 41% females. Overall, 42.7% had low risk of frailty, 53.1% intermediate risk, and 4.2% high risk. After IPTW adjustment, in-hospital mortality was similar both for the entire cohort between valvular and non-valvular surgery groups (3.7% vs. 4.1%, p = .483), and low (1% vs. 0.9%, p = .952) or moderate (5.4% vs. 6%, p = .548) risk of frailty. However, patients at high risk of frailty had significantly lower in-hospital mortality in the valvular surgery group (4.6% vs. 13.9%, p = .016). Renal replacement therapy was similar between groups across frailty status. In contrast, surgery was associated with increased use of mechanical circulatory support and pacemaker implantation. CONCLUSIONS: Our findings suggest that there was no difference in survival between valve surgery and medical management in patients at low/intermediate frailty risk, but not for high-risk individuals.
Asunto(s)
Endocarditis , Fragilidad , Mortalidad Hospitalaria , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Fragilidad/complicaciones , Fragilidad/diagnóstico , Anciano , Endocarditis/cirugía , Endocarditis/mortalidad , Endocarditis/complicaciones , Factores de Riesgo , Medición de Riesgo/métodos , Adulto , Estados Unidos/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Enfermedades de las Válvulas Cardíacas/complicaciones , Tasa de Supervivencia/tendenciasRESUMEN
OBJECTIVE: The Glasgow prognosis score is a simple parameter calculated using serum levels of albumin and C-reactive protein. The aim of this study was to examine whether this parameter may predict ischemic stroke in patients with infective endocarditis. METHODS: A total of 80 patients who were diagnosed with definitive infective endocarditis according to Duke criteria between 2016 and 2023 were included in the study. Glasgow prognosis score was based on serum levels of albumin and C-reactive protein. In imaging methods, patients were divided into two groups according to whether they had a stroke or not. These two groups were compared in terms of biochemical parameters, and infective endocarditis findings on echocardiography and Glasgow prognosis score. RESULTS: We found that the results were statistically similar except for serum C-reactive protein (Group 1: 54.9±71.1 and Group 2: 39±70.7; p=0.03), neutrophil (Group 1: 19.8±10.8*109/L and Group 2: 13.3±7.3*109/L; p=0.014), albumin (Group 1: 2.3±0.6 and Group 2: 2.8±0.5; p=0.03), and Glasgow prognosis score (Group 1: median 2, min.-max. (1-2) and Group 2: median 1, min.-max. (0-1); p=0.004). In the receiver operating characteristics analysis, Glasgow prognosis score had 82.4% sensitivity and 58.3% specificity in predicting ischemic stroke if the Glasgow prognosis score cutoff was ≥1. In multivariate logistic regression analysis, chronic renal failure [odds ratio (OR): 1.098; 95% confidence interval: 1.054-1.964; p=0.044], age (OR: 1.050; 95%CI 1.006-1.096; p=0.024), and Glasgow prognosis score (OR: 0.695; 95%CI 0.411-0.949; p=0.035) were independent variables in predicting ischemic stroke. CONCLUSION: High Glasgow prognosis score is an independent predictor of ischemic stroke in patients with infective endocarditis. Glasgow prognosis score, determined using albumin and C-reactive protein levels, is a simple and practical index for predicting the prognosis of patients hospitalized with infective endocarditis.
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Proteína C-Reactiva , Accidente Cerebrovascular Isquémico , Albúmina Sérica , Humanos , Femenino , Masculino , Proteína C-Reactiva/análisis , Pronóstico , Persona de Mediana Edad , Accidente Cerebrovascular Isquémico/sangre , Accidente Cerebrovascular Isquémico/complicaciones , Albúmina Sérica/análisis , Anciano , Endocarditis/sangre , Endocarditis/complicaciones , Adulto , Ecocardiografía , Biomarcadores/sangre , Factores de Riesgo , Valor Predictivo de las PruebasRESUMEN
BACKGROUND: Splenic abscess is a serious complication associated with infective endocarditis. There is still contradicting evidence regarding the optimal treatment pathway including timing of valve intervention and the approach for managing splenic foci. CASE PRESENTATION: We present a case of a hybrid staged approach in which we successfully performed a laparoscopic splenectomy following percutaneous abscess drainage and a delayed aortic valve replacement. CONCLUSIONS: A multidisciplinary teamwork is fundamental in providing optimal care for patients with distant complications associated with infective endocarditis. Our hybrid approach seems safe and feasible.
Asunto(s)
Embolia , Endocarditis Bacteriana , Endocarditis , Enfermedades del Bazo , Humanos , Enfermedades del Bazo/cirugía , Enfermedades del Bazo/complicaciones , Absceso/etiología , Absceso/cirugía , Válvula Aórtica/cirugía , Endocarditis/complicaciones , Endocarditis/cirugía , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/cirugía , Embolia/complicacionesAsunto(s)
Endocarditis Bacteriana , Endocarditis , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Neoplasias , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/cirugía , Endocarditis/complicaciones , Endocarditis/diagnóstico por imagen , Endocarditis/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico por imagenRESUMEN
BACKGROUND: The scientific validity of the European Society of Cardiology's (ESC) infective endocarditis (IE) guidelines limiting provision of prophylactic antibiotics (AP) only to patients having cardiac anomalies (e.g., prosthetic valves) believed to place them at "high risk" of adverse events when undergoing high risk dental procedures (HRDP) is unclear. MATERIAL AND METHODS: A systematic review of studies conducted between 2017 and 2022 and catalogued in the PubMed database was undertaken to ascertain if this edict was associated with changes in IE incidence, development of infection in unprotected cardiac anomalies, developing infection and resultant adverse clinical outcomes. RESULTS: Retrieved were 19 published manuscripts, however of these, 16 were excluded because they did not bare upon the issues of concern. Among the three studies eligible for review were those in the Netherlands, Spain, and England. The results of the Dutch study denoted a significant increase in the incidence of IE cases over the projected historical trend (rate ratio: 1327, 95% CI 1.205-1.462; p<0.001) after the introduction of the ESC guidelines. The findings from the Spanish study evidenced the uniquely high in-hospital IE associated fatality rates suffered by patients having bicuspid aortic valves (BAV); 5.6% or mitral valve prolapse (MVP); 10%. The British study provided evidence that the incidence of fatal IE infection was significantly greater among an "intermediate risk" cohort of patients, (a group likely including those with BAC and MVP for which the ESC guidelines don't recommend AP), than among "high risk" patients (P = 0.002). CONCLUSIONS: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the "high risk" category so that AP are recognized as being needed prior to provision of HRDP.
Asunto(s)
Enfermedad de la Válvula Aórtica Bicúspide , Endocarditis Bacteriana , Endocarditis , Prolapso de la Válvula Mitral , Humanos , Prolapso de la Válvula Mitral/complicaciones , Prolapso de la Válvula Mitral/tratamiento farmacológico , Prolapso de la Válvula Mitral/epidemiología , Enfermedad de la Válvula Aórtica Bicúspide/complicaciones , Enfermedad de la Válvula Aórtica Bicúspide/tratamiento farmacológico , Endocarditis/prevención & control , Endocarditis/complicaciones , Endocarditis/tratamiento farmacológico , Antibacterianos/uso terapéutico , Odontólogos , Endocarditis Bacteriana/prevención & control , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/tratamiento farmacológicoRESUMEN
BACKGROUND: Blood culture-negative infective endocarditis is a potentially severe disease that can be associated with infectious agents such as Bartonella spp., Coxiella burnetti, Tropheryma whipplei, and some fungi. CASE PRESENTATION: Reported here are two cases of blood culture-negative infective endocarditis in patients with severe aortic and mitral regurgitation in Brazil; the first case is a 47-year-old white man and the second is a 62-year-old white woman. Bartonella henselae deoxyribonucleic acid was detectable in the blood samples and cardiac valve with vegetation paraffin-fixed tissue samples. Additionally, an investigation was carried out on patients' pets, within the context of One Health, and serum samples collected from cats and dogs were reactive by indirect immunofluorescence assay. CONCLUSIONS: Even though the frequency of bartonellosis in Brazil is unknown, physicians should be aware of the possibility of blood culture-negative infective endocarditis caused by Bartonella, particularly in patients with weight loss, kidney changes, and epidemiological history for domestic animals.
Asunto(s)
Infecciones por Bartonella , Bartonella henselae , Bartonella , Endocarditis Bacteriana , Endocarditis , Humanos , Animales , Gatos , Perros , Endocarditis Bacteriana/microbiología , Infecciones por Bartonella/complicaciones , Infecciones por Bartonella/diagnóstico , Infecciones por Bartonella/microbiología , Endocarditis/complicacionesRESUMEN
A regurgitação tricúspide (RT) importante está associada à alta morbidade e mortalidade. Como o tratamento cirúrgico da RT isolada tem sido associado à alta mortalidade, as intervenções transcateter na valva tricúspide (VT) têm sido utilizadas para o seu tratamento, com risco relativamente mais baixo. Há um atraso na intervenção da RT e provavelmente está relacionado a uma compreensão limitada da anatomia da VT e do ventrículo direito, além da subestimação da gravidade da RT. Nesse cenário, faz-se necessário o conhecimento anatômico abrangente da VT, a fisiopatologia envolvida no mecanismo de regurgitação, assim como a sua graduação mais precisa. A VT tem peculiaridades anatômica, histológica e espacial que fazem a sua avalição ser mais complexa, quando comparado à valva mitral, sendo necessário o conhecimento e treinamento nas diversas técnicas ecocardiográficas que serão utilizadas frequentemente em combinação para uma avaliação precisa. Esta revisão descreverá a anatomia da VT, o papel do ecocardiograma no diagnóstico, graduação e fisiopatologia envolvida na RT, as principais opções atuais de tratamento transcateter da RT e a avaliação do resultado após intervenção transcateter por meio de múltiplas modalidades ecocardiográficas.(AU)
Severe tricuspid regurgitation (TR) is associated with high morbidity and mortality. Given that surgical treatment of TR alone has been associated with high mortality, transcatheter interventions in the tricuspid valve (TV) have been used for its treatment, with relatively lower risk. There is a delay in intervention for TR, and this is probably related to a limited understanding of the anatomy of the TV and the right ventricle, in addition to an underestimation of the severity of TR. In this scenario, it is necessary to have comprehensive anatomical knowledge of the TV, the pathophysiology involved in the mechanism of regurgitation, and more accurate grading. The TV has anatomical, histological, and spatial peculiarities that make its assessment more complex when compared to the mitral valve, requiring knowledge and training in the various echocardiographic techniques that will often be used in combination for accurate assessment. This review will describe the anatomy of the TV, the role of echocardiography in the diagnosis, grading, and pathophysiology involved in TR; the main transcatheter treatment options currently available for TR; and the assessment of outcomes after transcatheter intervention by means of multiple echocardiographic modalities.(AU)
Asunto(s)
Humanos , Masculino , Femenino , Válvula Tricúspide/anatomía & histología , Insuficiencia de la Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/fisiopatología , Derrame Pericárdico/complicaciones , Insuficiencia de la Válvula Tricúspide/mortalidad , Ecocardiografía/métodos , Ecocardiografía Transesofágica/métodos , Ecocardiografía Doppler en Color/métodos , Ecocardiografía Tridimensional/métodos , Endocarditis/complicaciones , Reemplazo de la Válvula Aórtica Transcatéter/métodosRESUMEN
We report here an atypical case of acute sacroiliitis caused by Erysipelothrix rhusiopathiae revealing tricuspid endocarditis in a 53-year-old woman without medical history. She was admitted to Cayenne hospital because of intense right hip and thigh pain, associated with fever. A right sacroiliitis was visible on the computed tomography (CT) scan, confirmed on MRI. Transesophageal echocardiography revealed a large mobile tricuspid vegetation. Blood cultures were positive for E. rhusiopathiae. CT scan showed pulmonary alveolar opacities, consistent with septic emboli. Clinical improvement was obtained under ceftriaxone followed by ciprofloxacin for 6 weeks of treatment. We present a review of bone and joint infections caused by E. rhusiopathiae. So far, not a single case has been reported in Latin America.
Asunto(s)
Endocarditis , Infecciones por Erysipelothrix , Erysipelothrix , Sacroileítis , Animales , Femenino , Humanos , Persona de Mediana Edad , Infecciones por Erysipelothrix/diagnóstico , Ceftriaxona/uso terapéutico , Sacroileítis/complicaciones , Endocarditis/complicaciones , Ciprofloxacina/uso terapéuticoRESUMEN
INTRODUCTION: Splenic abscess secondary to endocarditis is a rare complication with high mortality. The treatment modality, splenectomy versus percutaneous drainage, and the best time, before or after valve replacement, are controversial. In the literature, there are only a few small case series about the subject. The objective of this study is to analyze the experience of a referral center in treating such condition. METHODS: Patients with splenic abscesses due to endocarditis from 2006 to 2020 were retrospectively analyzed. RESULTS: Thirteen patients (mean age 46 years old, 69% male) were identified. Eight patients (62%) had at least 2 comorbidities and 5 (38%) had a history of cardiac surgery. The diagnosis was incidental in 6 (46%). The mean time of abscess diagnosis after endocarditis definition was 14 days. Six patients (46%) had at least two organ dysfunctions. The median APACHE II score was 12 overall, and 24.5 in patients who died. Six patients (46%) had a valve replacement, and in two the abscess was diagnosed postoperatively. Of the other four patients, splenectomy was performed before the cardiac operation in three and at the same time in one. Splenectomy was performed immediately in 9 (69%) patients while three patients had percutaneous drainage (23%), one of which underwent splenectomy due to drainage failure. Exclusive antibiotic treatment was performed on only one patient. The median length of hospitalization was 24 days and mortality was 46%. CONCLUSION: Splenic abscess due to endocarditis is a life-threatening condition with controversial treatment that results in a prolonged length of stay and high mortality.
Asunto(s)
Absceso Abdominal , Endocarditis , Enfermedades del Bazo , Absceso/etiología , Absceso/cirugía , Antibacterianos/uso terapéutico , Brasil/epidemiología , Endocarditis/complicaciones , Endocarditis/diagnóstico , Endocarditis/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Raras/complicaciones , Enfermedades Raras/tratamiento farmacológico , Estudios Retrospectivos , Enfermedades del Bazo/etiología , Enfermedades del Bazo/cirugíaRESUMEN
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.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Staphylococcus/patogenicidad , Streptococcus/patogenicidad , Endocarditis/epidemiología , Brasil , Estudios Transversales , Estudios Retrospectivos , Factores de Riesgo , Endocarditis/complicaciones , Endocarditis/diagnósticoRESUMEN
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.
Após catorze décadas de evolução médica e tecnológica, a endocardite infeciosa continua a desafiar médicos no seu diagnóstico e manejo diário. O aumento da incidência, alterações demográficas (afetando pacientes mais idosos), microbiologia com taxas de infeção por Staphylococcus mais elevadas, com complicações graves ainda frequentes e uma mortalidade substancial tornam a endocardite uma doença muito complexa. Apesar de tudo, a inovação no seu diagnóstico, nomeadamente na área da microbiologia e imagem, e a melhoria nos cuidados intensivos e na cirurgia cardíaca (quanto às técnicas, materiais usados e momento de intervenção) podem ter um impacto no seu prognóstico. Os desafios persistem, incluindo repensar a profilaxia, melhorar os critérios de diagnóstico incluindo a endocardite com culturas negativas e endocardite de prótese valvar, o timing para a intervenção cirúrgica, e sua realização ou não na presença de acidente vascular cerebral isquêmico e em usuários de drogas intravenosas. Uma estratégia combinada na endocardite infeciosa é fundamental, incluindo decisões e protocolos clínicos avançados, um manejo multidisciplinar, organização e políticas de saúde que culminem em melhores resultados para os nossos pacientes.
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Procedimientos Quirúrgicos Cardíacos , Endocarditis Bacteriana , Endocarditis , Prótesis Valvulares Cardíacas , Infecciones Estafilocócicas , Endocarditis/complicaciones , Endocarditis/diagnóstico , Endocarditis/terapia , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/terapia , Prótesis Valvulares Cardíacas/efectos adversos , HumanosRESUMEN
A rare and difficult to diagnose case of subacute infective endocarditis caused by Bacillus cereus in a patient with systemic lupus erythematosus and Libman-Sacks endocarditis has been reported. Our aim is to highlight the importance of molecular methods such as MALDI-TOF and PCR to explain clinical and epidemiological issues about infections caused by unusual pathogen.
Asunto(s)
Endocarditis Bacteriana , Endocarditis , Lupus Eritematoso Sistémico , Bacillus cereus , Endocarditis/complicaciones , Endocarditis/diagnóstico , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico , Humanos , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnósticoRESUMEN
A endocardite de valva nativa é uma doença incomum, complexa, e de alta morbimortalidade. Requer tratamento clínico prolongado, com várias complicações possíveis, e o seu tratamento cirúrgico é complexo e tecnicamente difícil. O ecocardiograma transtorácico e transesofágico são fundamentais na avaliação da doença, inclusive seus achados são parte dos critérios diagnósticos de endocardite. Adicionalmente, o ecocardiograma tridimensional (3D) contribui com detalhamento anatômico na avaliação das estruturas cardíacas acometidas pela doença. Mostramos um caso em que é ilustrado o papel da ecocardiografia no diagnóstico e avaliação de complicações da endocardite, comparando as imagens do ecocardiograma 3D pré-operatórias, com os achados durante o ato cirúrgico. (AU)
Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings. (AU)
Asunto(s)
Humanos , Femenino , Persona de Mediana Edad , Endocarditis/complicaciones , Endocarditis/terapia , Endocarditis/diagnóstico por imagen , Válvula Mitral/patología , Insuficiencia de la Válvula Mitral/cirugía , Ecocardiografía/métodos , Gentamicinas/uso terapéutico , Vancomicina/uso terapéutico , Ecocardiografía Transesofágica/métodos , Ecocardiografía Tridimensional/métodos , Síndrome de Guillain-Barré/complicaciones , Hallazgos Incidentales , Cefepima/uso terapéutico , Ampicilina/uso terapéuticoRESUMEN
Neisseria elongata is part of the commensal microbiota of the oropharynx. Although it is not considered pathogenic to humans, N. elongata has been implicated in several cases of infective endocarditis (IE). Here, we report a case of IE caused by N. elongata subsp. nitroreducens (Nel_M001) and compare its genome with 17 N. elongata genomes available in GenBank. We also evaluated resistance and virulence profiles with Comprehensive Antibiotic Resistance and Virulence Finder databases. The results showed a wide diversity among N. elongata isolates. Based on the pangenome cumulative curve, we demonstrate that N. elongata has an open pangenome. We found several different resistance genes, mainly associated with antibiotic efflux pumps. A wide range of virulence genes was observed, predominantly pilus formation genes. Nel_M001 was the only isolate to present two copies of some pilus genes and not present nspA gene. Together, our results provide insights into how this commensal microorganism can cause IE and may assist further biological investigations on nonpathogenic Neisseria spp. Case reporting and pangenome analyses are critical for enhancing our understanding of IE pathogenesis, as well as for alerting physicians and microbiologists to enable rapid identification and treatment to avoid unfavorable outcomes.
Asunto(s)
Endocarditis Bacteriana , Endocarditis , Neisseria elongata , Endocarditis/complicaciones , Endocarditis/genética , Endocarditis Bacteriana/genética , Genómica , Humanos , Neisseria/genéticaRESUMEN
BACKGROUND: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome. OBJECTIVE: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality. METHODS: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05. RESULTS: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both). CONCLUSIONS: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.
FUNDAMENTO: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. OBJETIVO: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. MÉTODOS: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. RESULTADOS: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). CONCLUSÕES: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.
Asunto(s)
Endocarditis Bacteriana , Endocarditis , Infecciones por VIH , Endocarditis/complicaciones , Mortalidad Hospitalaria , Humanos , Pronóstico , Estudios RetrospectivosRESUMEN
Resumo Fundamento: Complicações neurológicas são comuns em pacientes com endocardite infecciosa (EI). Dados recentes sugerem que os eventos neurológicos são os principais determinantes do prognóstico e que a cirurgia é crítica para melhorar o resultado. Objetivo: Caracterizar pacientes com EI e complicações neurológicas e determinar preditores de embolização para o sistema nervoso central (SNC) e mortalidade. Métodos: Análise retrospectiva de pacientes internados em centro terciário com diagnóstico de EI no período de 2006 a 2016. Significância estatística foi definida por um valor de p <0,05. Resultados: Identificamos 148 episódios de EI, 20% dos quais tinham evidências de embolização do SNC. Em pacientes com embolização do SNC, 76% apresentaram acidente vascular cerebral isquêmico. Durante o seguimento, 35% foram submetidos à cirurgia e a mortalidade hospitalar e em um ano foi de 39%. Esses pacientes tiveram hospitalizações mais longas, mas não houve diferenças significativas em relação à mortalidade em pacientes com e sem embolização do SNC. Os preditores independentes de complicações neurológicas foram diabetes (p = 0,005) e ausência de febre na apresentação (p = 0,049). A cirurgia foi associada a menor mortalidade (0 vs. 58%; p = 0,003), enquanto os pacientes com choque séptico tiveram pior prognóstico (75 vs. 25%; p = 0,014). Na regressão multivariada de Cox, a infecção pelo vírus da imunodeficiência humana (HIV) foi o único preditor independente de mortalidade hospitalar e de 1 ano (p = 0,011 em ambos). Conclusões: Nessa população, a embolização para o SNC foi comum, mais frequentemente apresentada como acidente vascular cerebral isquêmico, e esteve associada a maior tempo de internação, embora sem diferenças significativas na mortalidade. Nos pacientes com embolização do SNC, os submetidos à cirurgia tiveram boa evolução clínica, enquanto os pacientes com choque séptico e infecção pelo HIV tiveram pior evolução. Esses resultados devem ser interpretados com cautela, levando em consideração que os pacientes com complicações mais graves ou mais frágeis foram provavelmente menos considerados para a cirurgia, resultando em viés de seleção.
Background: Neurological complications are common in patients with infective endocarditis (IE). Recent data suggest that neurologic events are a major determinant of prognosis, and that surgery is critical in improving the outcome. Objective: To characterize patients with IE and neurological complications and to determine predictors of embolization to the central nervous system (CNS) and mortality. Methods: Retrospective analysis of patients admitted to a tertiary center with the diagnosis of IE from 2006 to 2016. Statistical significance was defined by a p-value < 0.05. Results: We identified 148 episodes of IE, 20% of which had evidence of CNS embolization. In patients with CNS embolization, 76% presented with ischemic stroke. During follow-up, 35% were submitted to surgery and both in-hospital and one-year mortality were 39%. These patients had longer hospitalizations, but there were no significant differences regarding mortality in patients with and without CNS embolization. The independent predictors of neurological complications were diabetes (p=0.005) and the absence of fever at presentation (p=0.049). Surgery was associated with lower mortality (0 vs. 58%; p=0.003), while patients with septic shock had a poorer prognosis (75 vs. 25%; p=0.014). In multivariate Cox regression, human immunodeficiency virus (HIV) infection was the only independent predictor of in-hospital and 1-year mortality (p=0.011 in both). Conclusions: In this population, embolization to the CNS was common, more often presented as ischemic stroke, and was associated with longer hospitalization, although without significant differences in mortality. In patients with CNS embolization, those submitted to surgery had a good clinical evolution, while patients with septic shock and HIV infection had a worse outcome. These results should be interpreted with caution, taking into consideration that patients with more severe complications or more fragile were probably less often considered for surgery, resulting in selection bias.
Asunto(s)
Humanos , Infecciones por VIH , Endocarditis/complicaciones , Endocarditis Bacteriana , Pronóstico , Estudios Retrospectivos , Mortalidad HospitalariaAsunto(s)
COVID-19/patología , Embolia/patología , Endocarditis Bacteriana/patología , Endocarditis/patología , Síndrome de Dificultad Respiratoria/patología , Sepsis/patología , Adulto , Angiografía , COVID-19/complicaciones , COVID-19/diagnóstico por imagen , COVID-19/virología , Embolia/complicaciones , Embolia/diagnóstico por imagen , Embolia/virología , Endocarditis/complicaciones , Endocarditis/diagnóstico por imagen , Endocarditis/virología , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/virología , Resultado Fatal , Humanos , Pulmón/diagnóstico por imagen , Pulmón/patología , Pulmón/virología , Masculino , Respiración Artificial , Síndrome de Dificultad Respiratoria/complicaciones , Síndrome de Dificultad Respiratoria/diagnóstico por imagen , Síndrome de Dificultad Respiratoria/virología , SARS-CoV-2/crecimiento & desarrollo , SARS-CoV-2/patogenicidad , Sepsis/complicaciones , Sepsis/diagnóstico por imagen , Sepsis/virología , Tomografía Computarizada por Rayos XRESUMEN
Abstract Mitral valve aneurysm is a rare and uncommon complication of infective endocarditis leading to a weakened mitral tissue. The most feared mitral valve aneurysm's complications are: perforation and severe mitral regurgitation. Multiple mechanisms have been suggested to explain the development of mitral valve aneurysm in aortic infective endocarditis including: local extension of the infection, the mitral kissing vegetation and aortic regurgitation. We report the case of a 29-year-old man who had infective endocarditis of a native aortic valve and the sub-aortic diaphragm complicated by a perforated mitral valve aneurysm diagnosed only by transesophageal echocardiogram. The patient had no sign of heart failure. We hypothesized that all those mechanisms lead to the developing of the mitral valve aneurysm in this case, but also the presence of the diaphragm favored the spread of the infection.
Resumen Una de las complicaciones poco comunes e inusuales de la endocarditis infecciosa son los aneurismas de la válvula mitral. Las complicaciones más temidas de estos últimos son la perforación y la insuficiencia mitral severa. Diferentes mecanismos pueden explicar el desarrollo de dicha insuficiencia en el contexto de una endocarditis infecciosa, incluyendo una extensión local, una vegetación sobre la válvula mitral y una insuficiencia aórtica. Nuestro caso clínico es el de un joven de 29 años diagnosticado de endocarditis infecciosa sobre su válvula aortica nativa con un diafragma subaortico complicado con un aneurisma de la válvula mitral perforado. El paciente no presentaba signos de insuficiencia cardíaca. Hemos supuesto que todos los mecanismos que hemos evocado anteriormente han llevado al desarrollo de dicho aneurisma, junto con la presencia del diafragma, elemento en favor de la diseminación de la infección.