Embolic complications in bacterial endocarditis

Embolic complications are a major prognostic determinant in the clinical course of infective endocarditis (IE) with an incidence of about 30-50%. In order to analyze risk factors leading to embolism in native (NVE) and prosthetic valve endocarditis (PVE), we reviewed 177 consecutive patients; 43% were female, 57% male, PVE occurred in 24% of all patients all left-sided, among the NVE were 11% right-sided IE. Major embolic complications occurred in 40% of all patients. In NVE, a higher rate of embolic events (45% vs. 26%; p < 0.05), and a larger vegetation size compared to PVE was observed (14 +/- 6 mm vs. 11 +/- 5 mm; p < 0.05). The most important risk factor for embolic complications in NVE was Staphylococcus aureus (odds ratio 6.4). Furthermore, double valve endocarditis, fever, and mitral valve endocarditis were associated with the risk for embolism. In case of severe regurgitation the rate of embolic complications was reduced (54% vs. 77%; p < 0.05). In PVE, fever was a risk factor for embolic events. Staphylococcus aureus was also a frequent microorganism in embolism (45% vs. 22%). The in-hospital mortality was significantly increased in case of embolism (NVE 40% vs. 11%; p < 0.001; PVE 36% vs. 9% p < 0.05). About 50% of all embolic events occurred before admission. In NVE, due to high in-hospital mortality, the rate of patients with embolism undergoing surgery was lower (57% vs. 72%; p < 0.05); whereas in PVE no significant difference was observed. In patients with NVE, aspirin therapy because of coronary artery disease appeared to reduce the rate of embolic complications (11% vs. 47%). However, the low number of patients on aspirin (9%) does not allow recommendations regarding a potential benefit. In conclusion, identification of risk factors leading to embolism in IE may be useful in considering early surgical therapy. However, the high rate of embolic complications before hospital admission indicates a need for improving the diagnostic delay in the prehospital phase.     

Multiple promoters direct stimulus and temporal specific expression of brain-derived neurotrophic factor in the somatosensory cortex

Patients operated on for infective endocarditis (n = 69) at two regional hospitals between 1988 and 1994 are reviewed. 70% had a known valvular heart disease and 16% had prosthetic valve endocarditis. In 28% the offending microorganism was Staphylococcus aureus; in 26% Streptococcus viridans. Therapy was intended to be a six-week antibiotic course before operating, but 55% of the patients had to be operated on earlier. The postoperative course was uncomplicated in 59%, mortality was 16% and one-year survival 81%. Increased risk of death was associated with operating before the six-week course of antibiotics was completed (p = 0.005), with preoperative renal failure (p = 0.006) or lung failure (p = 0.008), with the growth of microorganisms from tissue samples extirpated during the operation (p = 0.01), with additional surgical procedures concomitant to valvular replacement (p = 0.02), S. aureus endocarditis (p = 0.03), and with the presence of paravalvular abscesses or intracardial fistulas (p = 0.03). The study shows that infective endocarditis is a serious disease. Wherever clinically feasible, all patients should be given antibiotics for six weeks before evaluating surgery. However, close surveillance of infection and haemodynamics is necessary to allow for the possibility of acute surgery before the development of organ failure. Special attention must be paid to cases of S. aureus endocarditis.     

Medical and nondental treatments of snoring and sleep apnea syndrome

BACKGROUND: Infective endocarditis remains a life-threatening disease, and its optimal management is of paramount importance. Transesophageal echocardiography (TEE) is useful for the diagnosis of endocarditis-induced lesions, but the prognostic significance of the method remains controversial. HYPOTHESIS: The purpose of this study was to relate clinical and TEE characteristics to the occurrence of mortality and/or systemic embolization in a consecutive series of 45 patients with a diagnosis of infective endocarditis. METHODS: All patients underwent at least one monoplane TEE. Clinical data, episodes of embolization, and echocardiographic characteristics were prospectively recorded. Stepwise logistic discriminant analysis was performed to identify the independent variables that best predicted three binary outcomes: systemic embolization, death, and systemic embolization and/or death. RESULTS: Twelve of the 45 patients (27%) died from the endocarditis. Significant univariate predictors of death were the presence of paravalvular abscess (p = 0.025), number of vegetations (p = 0.021), Staphylococcus aureus isolated in blood cultures (p = 0.002), medical treatment alone (p < 0.002), and systemic embolism (p < 0.001). In multivariate analysis, systemic embolism (chi 2 = 29.3; p < 0.01), echocardiographic evidence of paravalvular abscess (chi 2 = 5.6; p = 0.018), Staphylococcus aureus endocarditis (chi 2 = 5.5; p = 0.016), and medical treatment alone (chi 2 = 5.11; p = 0.024) emerged as optimal predictors of death. Systemic embolization occurred in 12 patients. Independent variables predicting systemic embolization were a total length of vegetations > 14 mm (p = 0.01), greater age (p = 0.02), and medical treatment alone (p = 0.03). When two or more vegetations were observed, the total length is the sum of the individual sizes. Independent risk factors for the development of systemic emboli and/or death as a combined end point were total length of vegetations on TEE (chi 2 = 6.4; p = 0.003) and medical treatment alone (chi 2 = 4.1; p = 0.047). CONCLUSIONS: High-risk patients may be identified by the combination of clinical variables and TEE characteristics.     

Incidence and prognosis of embolic events and metastatic infections in infective endocarditis

AIMS: In infective endocarditis, the true incidence of embolic events and metastatic infections remains unknown probably because a large number of events are asymptomatic. The consequences of the prognosis of such events have never been evaluated by a prospective follow-up. This study aimed to assess the incidence of symptomatic or asymptomatic embolic events and metastatic infections in definite infective endocarditis and to determine whether these events carry a risk of mortality. METHODS AND RESULTS: From January 1991 to December 1993, 102 patients with suspected or known infective endocarditis were referred to our institution. Among them, we selected 68 patients (50 males, 18 females, mean age = 52.7 years) exhibiting definite infective endocarditis according to the Duke University criteria. Blood cultures were positive in 49 cases (72%). Echocardiography revealed valvular vegetations in 55 cases (81%). Irrespective of the clinical presentation, patients were examined radiologically by cerebral computed tomography scanning (n = 60), magnetic resonance imaging (n = 3), abdominal computed tomography scanning (n = 32) or abdominal echocardiography (n = 20). Depending on the symptoms, thoracic computed tomography scanning (n = 22), pulmonary angiography (n = 2), ventilation-perfusion scintigraphy (n = 4), or gallium citrate radionuclide scanning (n = 7) were also performed. All patients were prospectively followed-up for a mean period of 21.4 +/- 17.5 months. In 35 patients (51%), 51 embolic or metastatic events were revealed, involving the central nervous system (n = 23), spleen (n = 7), kidney (n = 5), lung (n = 5), liver (n = 4), bone and joint (n = 4), iliac (n = 2) or mesenteric (n = 1) arteries. During the hospital stay, the mortality rate was higher in patients exhibiting embolic or metastatic events (20 vs 12%), but the difference did not reach statistical significance. Kaplan-Meier analysis demonstrated no difference in long-term follow-up. CONCLUSION: Our data suggest that embolic or metastatic events had a high incidence (51%) during infective endocarditis, but were not associated with significant attributable mortality.     

Infectious endocarditis and congenital heart defects in adults

BACKGROUND: Infective endocarditis still remains a cardiological menace. However, the type of predisposing diseases has changed: the incidence of rheumatic heart disease in advanced countries has declined, advances made in the surgical and medicamentous treatment of inborn heart disease are the reasons why we are encountering, with increasing frequency, infective endocarditis which develops on their background. METHODS AND RESULTS: The objective of the investigation was to assess the frequency of infective endocarditis and predisposing diseases. During the time interval between 1987 and 1991 16 patients (50% younger than 50 years) were hospitalized with the diagnosis of infective endocarditis. Rheumatic valvular damage and inborn heart disease were the predisposing factor in 25%. All patients were younger than 30 years (mean 24, range 18-30), and half the patients suffered from defects of the ventricular septum. Other defects were tetralogy of Fallot and inborn aortic stenosis. In 10% of the patients infective endocarditis developed on the background of a mitral valve prolapse with regurgitation. Echocardiographic examination confirmed the diagnosis in almost 70% by revealing vegetation. Bacteriological examination revealed the agent in 60%, most frequently it was Streptococcus viridans. The mortality rate in the group was 13%. CONCLUSIONS: The recorded incidence of infective endocarditis, 1.5 pro mille, is consistent with data in the literature. Corrected and not corrected heart disease plays an important role as predisposing disease. Despite the opportunity of intensive antibiotic treatment, the mortality remains high--13%.     

Characterization of progesterone membrane binding sites from porcine liver probed with a novel azido-progesterone radioligand

BACKGROUND: Global hospital mortality for infective endocarditis ranges from 13 to 40%. AIM: To compare clinical, microbiological, echocardiographic factors and complications between patients that died during an episode of infective endocarditis and those who survived. PATIENTS AND METHODS: We followed during their hospital stay, 129 patients, aged 14 to 74 years old, who had 131 episodes of infective endocarditis. Clinical assessment, echocardiography and microbiological study was done to all patients. Surgical indications were those derived from complications. RESULTS: Thirty three patients died during hospital stay (25.2%). There were no differences between survivors and deceased patients in the lapse between onset of symptoms and hospital admission, presence of fever, dyspnea or heart murmurs. Skin and mucosal septic manifestations occurred with higher frequency in deceased patients (57.1 and 24.3% respectively). Blood cultures were positive in 55% in survivors and 48% in those who died. The most frequent infecting organisms were staphilococci and streptococci. Vegetations were found with greater frequency in aortic position in both groups of patients. Deceased patients had a higher frequency of cardiac failure (84 and 65% respectively) and embolic episodes (77 and 46% respectively) than survivors. Antimicrobial treatment was successful in 94% of survivors and 15% of those who died. Forty percent of survivors and 54% of deceased patients were subjected to surgical procedures. CONCLUSIONS: The most important predictor of hospital mortality in this series of patients with infective endocarditis was antimicrobial treatment failure.     

Body site distribution of cutaneous malignant melanoma in relationship to patterns of sun exposure

AIM: To compare the clinical and morphological characteristics of patients with Streptococcus bovis endocarditis with those of patients with endocarditis caused by other microorganisms. METHODS: 177 consecutive patients (Streptococcus bovis, 22; other streptococci, 94; staphylococci, 44; other, 17) with definite infective endocarditis according to the Duke criteria were included. All patients underwent transthoracic and transoesophageal echocardiography. In 88 patients, findings from surgery/necropsy were obtained. RESULTS: S bovis endocarditis was associated with older patients, with a higher mortality (p = 0.04), and with a higher rate of cardiac surgery (p < 0.001) than other microorganisms, although embolic events were observed less often (p = 0.02). Pathological gastrointestinal lesions were detected in 45% of the patients. Multiple valves were affected in 68% of the patients with S bovis endocarditis and in 20% of those with other organisms (p < 0.001). Moderate or severe regurgitation occurred more often in S bovis endocarditis than with other microorganisms (p = 0.05). When surgery or necropsy was performed, infectious myocardial infiltration of the left ventricle was confirmed histopathologically in 36% of the patients with S bovis endocarditis and in 10% of those with other organisms (p = 0.002). CONCLUSIONS: S bovis endocarditis is a severe illness because of the more common involvement of multiple valves, and of the frequent occurrence of haemodynamically relevant valvar regurgitation and infectious myocardial infiltration.     

Surgery of infectious endocarditis

Thirty to fifty percent of patients with infective endocarditis are operated on during the active phase of the disease; this percentage is higher in case of some valvular localizations (aortic), in case of early prosthetic valve endocarditis, in case of some microorganisms (Staphylococcus aureus, gram-negative, fungus, intracellular microorganism). Operative death (at 30 days) is below 10% in native valve endocarditis, close to 50% in early prosthetic valve endocarditis, and below 20% in late prosthetic valve endocarditis. When active infective disease has been healed by medical treatment alone, half the patients need surgery in the first 2 years of follow-up; the indications for surgery are the functional status, the degree of valvular leaks and other lesions, the degree of ventricular dilatation.     

Hydrolysis of androgen receptor by cathepsin D: its biological significance in human prostate cancer

Risk factors, etiology, and outcome of 180 cases of infective endocarditis (IE) in the Slovak Republic for 5 years were prospectively studied in a national survey. According to the Duke Endocarditis Service Criteria (1994), 169 cases were considered definitive and 21 possible/probable. The aortic valve was infected in 46.7%, mitral in 47.2%, and tricuspidal/pulmonary in 6.1% of cases. The majority of endocarditis cases was caused by Staphylococcus aureus and coagulase-negative staphylococci (CNS) (33.3%); only 12.2% were due to viridans streptococci; 11.7% were due to Enterococcus faecalis; 6.1% due to Haemophilus spp.; 10.1% due to other organisms; and 26.7% were culture negative. Single positive cultures of CNS were not considered clinically significant. More than 25% of 180 patients were older than 60 years. Rheumatic fever was a risk factor in 35.5%, dental surgery in 20.5%, prior cardiosurgery in 7.8%, and neoplasia in 6.7%. All patients were treated with antimicrobials (average length of therapy was 29.5 days) and 33.3% of patients also had surgery (valvular prosthesis replacement). Forty (22.2%) died, and 140 (77.8%) survived at day 60 after the diagnosis of endocarditis was made. All 40 deaths were attributable to infection. Univariate analysis comparing deaths and survivors did not show significant differences in most of the recorded risk factors between both groups, except age > 60 (40.0% versus 21.4%, p < 0.05), staphylococcal etiology (55.0% versus 27.1%, p < 0.04), and antibiotic therapy < 21 days (without surgery) (65.0% versus 3.6%, p < 0.01). These risk factors were significantly more frequently associated with deaths. Viridans streptococcal IE and surgical therapy in addition to antibiotics were associated with lower mortality in comparison to staphylococcal endocarditis (p < 0.045) or to cases treated with antibiotics only (p < 0.05). In comparison to other nationally based surveys in Europe (Greece, Croatia, France), the percentage of culture-negative endocarditis and spectrum of pathogens differed significantly.     

Value of transthoracic echocardiography in predicting embolic events in active infective endocarditis. Duke Endocarditis Service

The purpose of this study was twofold: (1) to determine interobserver variability of echocardiographic characteristics of vegetations in patients with infective endocarditis, and (2) to assess the value of these vegetation characteristics in predicting embolic events. Although echocardiography contributes to the diagnosis of patients with infective endocarditis, its prognostic role in predicting embolic events is controversial. The echocardiograms of 41 patients with infective endocarditis were independently reviewed by 4 echocardiographers blinded to the clinical data. If a vegetation was present, the following characteristics were analyzed: involved site, size, mobility, shape, and pedunculated or sessile attachment. Each echocardiographer also made a "gestalt" estimate of embolic risk based on these vegetation characteristics. Interobserver agreement on vegetation characteristics and their relation to embolic events was then determined using kappa statistics and logistic regression analysis. Interobserver agreement was 98% with regard to echocardiographic vegetation presence and 97% with regard to the involved site. Of the 30 patients in whom vegetations were observed, complete observer agreement was achieved with regard to size in 22 (73%), mobility in 17 (57%), shape in 11 (37%), and attachment in 12 (40%). Vegetations with a maximal diameter of > 10 mm were associated with a 50% incidence of embolic events, compared with a 42% incidence of emboli in patients with vegetations measuring < or = 10 mm. Interobserver variability was great with respect to vegetation shape, mobility, and attachment characteristics. Echocardiographic vegetation characteristics were not helpful in defining the risk of embolic complications in patients with endocarditis.     

Epidemiological changes in infectious endocarditis. A prospective study, 1992-96

BACKGROUND: To know the present epidemiological situation of the infective endocarditis in our environment and its evolution in the last few years. RESULTS: The incidence of infective endocarditis was 0.85 per thousand patients admitted to hospital, with a mean age of 43 years. The predisposed factors more frequently found were: drug addiction (32%) and cardiac prosthetic valves (23%). In the greatest number of our patients the cardiac valves involved were: tricuspid (28%), mitral (27%) and prosthetic valves (23%). The causative organism were: S. aureus (19 cases), Streptococcus (15 cases) and S. epidermidis (11 cases). The echocardiography study resulted diagnostic in 90% of the patients, valve replacements were performed in 22% of the cases. The overall mortality rate was 10%. CONCLUSIONS: The current profile of infective endocarditis is characterized by a high incidence of parenterally drug addict patients or prosthetic valves carriers. Increase of the infections of S aureus and a decrease of Streptococcus infections, as well as a less overall mortality.     

Nonsteroidal antiinflammatory drugs are associated with both upper and lower gastrointestinal bleeding

We retrospectively evaluated antiinfective therapy for methicillin-sensitive (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA) endocarditis in 54 patients who had 57 treatment courses for the disease. Three treatments were assessed: 27 nafcillin-treated courses of MSSA endocarditis, 18 vancomycin-treated courses of MSSA endocarditis, and 11 vancomycin-treated courses of MRSA endocarditis. At baseline, patients with MSSA treated with vancomycin had more chronic conditions (p<0.01), a lower frequency of intravenous drug use (p<0.01), a lower hematocrit concentration (p<0.05), and a higher serum creatinine concentration (p<0.05) than the nafcillin group. Vancomycin-treated patients had a higher complication rate during therapy (p<0.05) and a longer duration in an intensive care unit (p<0.01) than the nafcillin group. The trend was for a higher complete response rate in the nafcillin group (74% vs 50%, p=0.12), but no difference in mortality (22% vs 28%, p=0.73). Patients with MRSA infection treated with vancomycin had higher mortality than those with MSSA who received that drug (55% vs 28%, p=0.24). Patients with vancomycin-treated MSSA endocarditis may have a poorer outcome than those who receive nafcillin, but this may be influenced by different or more severe clinical features.     

Serologic study in patients with streptococcal infective endocarditis

BACKGROUND: Infective endocarditis is a systemic disease in which there are a continuously antigenic stimulation of immunologic system. Streptococcus is still the most frequent cause of infective endocarditis. PATIENTS AND METHODS: We investigated the presence of antibody (AB), total and IgM by indirect immune fluorescence technique, in four groups of population: streptococcal infective endocarditis (SIE), streptococcal bacteraemia (SB), Staphylococcus aureus endocarditis, and healthy people. Antigens used were: 1) their own strain isolated from the blood of patients with SIE and SB ?homologous AB?, and; 2) seven species of Streptococcus: Streptococcus intermedius, Streptococcus salivarius, Streptococcus bovis, Streptococcus sanguis I, Streptococcus sanguis II, nutritional dependent streptococci and Enterococcus faecalis (heterologous AB). RESULTS: Homologous antibodies: titers > or = 1/512 were found in all patients with SIE and only in 2 with SB (sensitivity 100% and specificity 93%). IgM titer (threshold 1/32) was positive only in patients with SIE (sensitivity 75,5% and specificity 100%). The fall of the AB titer was continuous and slow, despite the good clinical evolution of patients. (AB titers were > or = 1/512 and IgM > or = 1/64 in 30% of patients 1 year later). Heterologous AB: in spite of statistically significant difference found in SIE versus the other groups, sensitivity of this test (threshold 1/256) is low, confidence interval include expected random value (50%), specificity is 88%. CONCLUSIONS: The utility of homologous AB for diagnosing infective endocarditis is demonstrated. On the contrary for heterologous AB, antigenic common fractions must be found in the different species.     

Infective endocarditis at a large community teaching hospital, 1980-1990. A review of 210 episodes

We studied 210 episodes of infective endocarditis in 204 patients. The prevalence of this disease in our series ranged from 0.32 to 1.30 (mean, 0.75) episodes per 1000 admissions per year. There were 115 male and 89 female patients, whose ages ranged from newborn to 91 years (median, 60-70). One-hundred-and-forty-eight episodes involved host valves and another 33 episodes occurred in intravenous drug users. There were 2 episodes of early and 27 episodes of late prosthetic valve endocarditis. Staphylococcus aureus accounted for 99 episodes (47.1%), alpha-hemolytic streptococci for 29 episodes (13.8%), enterococci for 11 episodes (5.2%), culture-negative endocarditis for 11 episodes (5.2%), and other organisms for 60 episodes (28.6%). Severe back pain was the chief complaint in 15 patients. 2-D echocardiography was performed in 164 episodes, results in 67 (40.9%) of which were positive. Valve surgery was performed in 29 episodes (23 host valves and 6 prosthetic valves). The overall mortality was 21.4%. Autopsy was performed in 22 of the 45 patients who died (48.9%). The mortality rate increased with age, (10.1% and 31.5% for patients < 60 years old and 60 years or older, respectively (p < 0.001).     

N-acetylcysteine prevents development of the hyperdynamic circulation in the portal hypertensive rat

Infective endocarditis, defined as pathologically or clinically definite by the Duke criteria, was observed in 14 transplant recipients at our institutions. In addition, we reviewed 32 previously reported cases in solid organ transplant recipients. The spectrum of organisms causing infective endocarditis was clearly different in transplant recipients than in the general population; 50% of the infections were due to Aspergillus fumigatus or Staphylococcus aureus, but only 4% were due to viridans streptococci. Fungal infections predominated early (accounting for six of 10 cases of endocarditis within 30 days of transplantation), while bacterial infections caused most cases (80%) after this time. In 80% (37) of the 46 cases in transplant recipients, there was no underlying valvular disease. Seventy-four percent (34) of the 46 cases were associated with previous hospital-acquired infection, notably venous access device and wound infections. Three patients with S. aureus endocarditis had had an episode of S. aureus bacteremia > 3 weeks prior to the diagnosis of endocarditis and had received treatment for the initial bacteremia of < 14 days' duration. The overall mortality rate was 57% (26 of 46 patients died), with 58% (15) of the 26 fatal cases not being suspected during life. Endocarditis is an underappreciated sequela of hospital-acquired infection in transplant recipients.     

Hospital practices influence the pattern of infective endocarditis

OBJECTIVE: To identify factors contributing to infective endocarditis at a major teaching hospital. METHODS: Retrospective review of clinical records of patients diagnosed with endocarditis by standard case definitions with respect to causative organisms, clinical features and outcome. RESULTS: One hundred and ninety-three episodes of endocarditis seen between 1979 and 1992 at Westmead Hospital, Sydney, were reviewed. In the 174 cases where the causative organism was isolated, 75 (43%) were Staphylococcus aureus and 50 (29%) were viridans streptococci. Nosocomial acquisition and/or inter-hospital transfer accounted for 83 episodes; 48 (58%) S. aureus (P < 0.001) and nine (11%) viridans streptococci (P < 0.001). In cases from the local community, viridans streptococci were more common than S. aureus (37% versus 25%); these included 18 episodes (14 S. aureus) in intravenous drug users. CONCLUSION: We conclude that, compared with community-acquired infections, the aetiology of endocarditis in a large teaching hospital is influenced strongly by the prevalence of nosocomial endocarditis and the need for interhospital transfer of complicated cases.     

A review of infectious endocarditis due to Candida

OBJECTIVE: As fungal endocarditis is a serious disease, frequently requiring cardiac surgery, a review was made of the experience of our Departments in this pathology. DESIGN: A retrospective analysis of clinical, echocardiographic and surgical data. SETTING: Patients studied in a tertiary care Hospital with cardiac surgery available. PATIENTS: Between 1984 and 1994 there were ten cases of candida endocarditis in nine patients, four male and five female, mean age--45 +/- 12 years (31-65). INTERVENTIONS: The following parameters were analysed: clinical (predisposing factors, clinical evolution, complications, therapy and mortality), echocardiographic (presence of vegetations, abscesses, valvular regurgitations). Patients studied in other Centres and referred to our Department only for examination (echocardiograms) were excluded from this analysis. RESULTS: Eight cases in seven patients were prosthetic valve endocarditis and two native valve endocarditis. No patient was drug addicted. Seven cases of prosthetic valve endocarditis developed less than one year after surgery and another had a gynecological fungal infection as the cause of the endocarditis. Four patients had had previous endocarditis. There were four embolic events and three developed heart failure. There were three perivalvular infections, six valvular regurgitations and only one case with huge vegetations on echocardiography. Nine patients were treated with amphotericin B, in five fluocytosin was added and in four ketoconazol, which was replaced by flukonazol in one patient. Therapy was continued for at least eight weeks. Six patients were operated during the acute stage and one died. One patient was operated on late after the infection. Three patients died during the active stage. In a follow up of 5.2 +/- 4.8 years (8 months to 8 years) there was one fatal candida endocarditis relapse, one fatal candida sepsis, one non cardiac death, one patient developed a periprosthetic leak and one had recurrent systemic embolization. Abscesses/pseudoaneurysms were found in five out of seven patients submitted to surgery. CONCLUSION: Candida infective endocarditis has a bad prognosis, specially in those patients not operated early; it develops in patients with predisposing factors, which in our series were a previous infective endocarditis (four patients) and/or a prosthetic valve implantation less than one year before; it has important morbidity with multiple embolic events, perivalvular involvement, valvular regurgitation and heart failure.     

Why is there an analytical culture in a medical laboratory?]

During a seven-year period (1998-94) 68 patients with infectious endocarditis were diagnosed at a university hospital. Staphylococcus aureus was the most common etiological agent (38%), followed by Streptococcus viridans (21%). In seven patients the diagnosis infectious endocarditis was first made during autopsy, all seven of them had the clinical diagnosis septicaemia. Surgery was performed on 41% of the patients. Case fatality was 34%. Case fatality was significantly higher for S aureus endocarditis than for S viridans endocarditis, 48% vs. 7% (p = 0.01). The advantages of transthoracic and transoesophageal echocardiography in the diagnosis and follow up of patients with infectious endocarditis is emphasized. In spite of these new diagnostic tools a definitive clinical diagnosis of infectious endocarditis was not made for 23% of the patients.     

Predicting survival in patients with early Alzheimer''s disease

BACKGROUND: The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. PATIENTS AND METHODS: Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery. RESULTS: In 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p < or = 0.000) than for unoperated patients or those who were operated after more than 8 days. CONCLUSION: An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.     

Clinical predictors of early embolic recurrence in presumed cardioembolic stroke

BACKGROUND: We determined clinical predictive factors of in-hospital embolic recurrence in presumed cardioembolic stroke patients by means of multivariate analysis based on clinical and neuroimaging prognostic variables assessed within 48 h of stroke onset. METHODS: Data of 347 consecutive patients with presumed cardioembolic stroke included in a prospective stroke registry were collected. Demographic characteristics, clinical events, and outcome in the recurrent and nonrecurrent embolization group were compared. The independent predictive value of each variable on the development of early embolic recurrence was analyzed in two multiple liner regression models - one based on eight demographic, anamnestic, and clinical variables and another based on 10 clinical, neuroimaging, and outcome variables. RESULTS: In-hospital recurrent embolization was diagnosed in 25 (6.9%) patients. The latency period was 12.1 days. The overall in-hospital mortality was 70.8% in the recurrent embolization group and 24.4% in the nonrecurrent embolization group (p < 0.001). Alcohol abuse, the combination of hypertension, valvular heart disease, and atrial fibrillation, nausea and vomiting, and previous cerebral infarction were predictors of recurrent embolization in the model based on clinical variables. In addition to these four variables, cardiac events were selected in the model based on clinical, neuroimaging, and outcome variables. CONCLUSIONS: A small number of clinical features that can be easily obtained on the patient's initial assessment may help clinicians to identify a subgroup of patients with cardioembolic stroke at the highest risk of developing early recurrent brain or systemic embolization.