Short-term Outcome of Patients with Infective Endocarditis: A Single-center Prospective Study.

OBJECTIVES: To investigate the short-term outcome of patients with infective endocarditis (IE). PATIENTS AND METHODS: We analyzed data from 42 patients with active endocarditis which underwent different cardiac surgeries. An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue and/or blood culture and acute inflammation Gram stains of sample tissue.
DESIGN: Collecting data of 42 patients prospectively.
SETTING: University hospital single center. PARTICIPANTS: Patients with IE from July 2014 to June 2016.
INTERVENTIONS: None. MEASUREMENT AND MAIN
RESULTS: We collected data of 42 patients in Imam Hospital which is a university-based 1700-bed center. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 mitral valve repair, and only one patient had experienced a subaortic web resection. Seven cases were addict; in which, 5 of them were intravenous abusers. There was 1 porphyric patient which suffered from pethidine reliability. Most of our cases underwent Bentall or tricuspid valve repair operation, and multivalve operation was more scarce.
CONCLUSIONS: We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.

INTRODUCTION

Although there were many developments and modifications in health care policies for more hygienic conditions, medical therapies, antibiotics, and sterility,[12] the infective endocarditis (IE), even so, endured as one of the most problematic conditions that have a same occurrence as the past years.[34] Despite the introduction of new antibiotics and prescription of the innovative regimens, up to 40% of the patients with such disease in contrast are candidates for surgical intervention.[5] There are many reviews in literature, which have documented a single valve repair or replacement with excellent outcomes. Notwithstanding, there is a lack of information on the patients who underwent a combined valve surgery or different simultaneous interventions. According to the researchers’ knowledge, there is only one paper, which reported such cases systematically; nevertheless, their work was a retrospective review of 21 years; this originates the question of having an integrated surgical procedure and echocardiography results. There were also some sporadic cases, which reported simultaneous repairs on the valves. The purpose of current study was to review the inhospital outcome of the IE patients at our referral hospital, and in particular, to establish medical and surgical interventions, echocardiography data, and their health status in short-term.

PATIENTS AND METHODS

We collected data of 42 patients in Imam Hospital, which is a university-based 1700-bed center from July 2014 to June 2016. A total of 42 patients (33 males, nine females), with an average age of 42.42 (minimum 22, maximum 77) years, were candidates for different type of surgery associated with IE. Our work was confirmed by the committee on human research and medical ethics of Tehran University of Medical Sciences. In addition to echocardiograms, the diagnosis of multiple valve endocarditis was approved by Duke criteria.[6] An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue. Details of patients’ characteristics are shown in Table 1. We had excluded the patients who did not match our active endocarditis criteria, explained formerly. Pre- and intra-operative transesophageal echocardiography was performed in all the patients; detailed description of the patients is categorized in Table 1.

Table 1

Patients characteristics

When surgery was performed for native aortic valve endocarditis, a mechanical or tissue valve is used if the infection was limited to the native aortic valve or to the aortic annulus. Valve choices were based on age, life expectancy, comorbidity, and compliance with anticoagulation therapy. A homograft was considered, whenever possible, in native aortic valve endocarditis when the infection was beyond the native aortic valve annulus. When technically feasible in native mitral valve (MV) endocarditis, MV repair (MVR) was used to treat native MV endocarditis like it was mentioned in the literatures.[7] Mechanical or tissue valves were sometimes used in native valve endocarditis in the tricuspid valve (TV) position when the valve cannot be repaired. In the presence of concomitant, aortic or mitral or TV endocarditis, either a tissue or mechanical valve was implanted in the aortic, mitral, and tricuspid positions. The choice of valve followed the same algorithm outlined independently for aortic, mitral, and TV endocarditis. When surgery of the mitral and TVs was indicated in multiple valve endocarditis, we performed mitral and TV repair (TVR) whenever feasible. There was a median sternotomy incision for all patients; ordinary myocardial protective principle like cooling and cardioplegic solution was used. A pulsatile cardiopulmonary bypass (CPB) with a roller pump (StÖckert, Munich, Germany) was utilized. By Using ringerlactate, voluven® together with a membrane oxygenator (Jostra Quadrox, Maquet Cardiopulmonary AG, Hirrlingen, Germany), the extracorporeal system was prepared. The extracorporeal system was prepared. We avoided using the solutions which contained glucose before and during CPB. To achieve an active clotting time under 480 s, a 3 mg/kg dose of heparin was induced intravascular. The main strategy in the operative room was to repair the valve, whenever possible. However, regardless of pulmonary artery pressure (PAP) level, when replacement was inevitable and complete septal leaflet resection was necessary, to prevent atrioventricular (AV) block after operation, we saw a double-layer stripe of the pericardium to the septal annulus with 5/0 Prolene as an anchoring point for replacement stitches. Autologous hand-made band annuloplasty was the fundamental part of every valve repair technique in our patients. Autologous hand-made band is made by a stripe of Dacron graft, four finger breadth long and 10 mm wide, covered by the same size stripe of the patient's pericardium. A reversed piece of saphenous vein could also be used to cover stripe of Dacron graft. Our favorable valve was the bioprosthetic valve of appropriate size.

RESULTS

Descriptive data are demonstrated as mean (minimum–maximum), and continuous variables are indicated in frequency and percentage. In our patient population, there were 33 (78.6%) males and 9 (21.4%) females. The minimum age was 22, and the maximum was 77 with an average of 42.42 years old. The mean weight was 68.46 kg. Average ejection fraction of our patients was 40.60%. Other blood therapy and kidney function details are shown in Table 1. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 MVR, and just one patient had experienced a subaortic web resection. Only 4 patients had hypertension, and the rest had normal pressure status. Only 3 patients had diabetes mellitus. Seven cases were addicted; in which, 5 of them were intravenous (IV) abusers. There was one porphyric patient who suffered from pethidine reliability. Most of our cases underwent Bentall or TVR operation, and multivalve operation was more scarce; the detail of operations is presented in Table 2 and Figure 1.

Table 2

Type of operations

Figure 1

Type of surgeries

Only one patient was explored after the main operation due to bleeding, and one patient had Intensive Care Unit (ICU) readmission. From the seven patients who died, one of them expired in the odd ratio, and the rest of them expired due to probable sepsis; the detail of expired patients’ echocardiography is demonstrated in Table 3. We had a patient with ischemic brain damage before arriving in the hospital due to apnea, which survived and had a suitable outcome after the surgery.

Table 3

Details of expired patients’ echocardiography

Despite all the improvements in the approaches to cure the IE cases, it still remained one of the most complicated and challenging areas within the health system which is associated with high morbidity and mortality.[8] Most of our patients suffered from a single valve endocarditis, as it was indicated by echocardiography; this was in line with most of the studies, which emphasized the scarcity of multivalve endocarditis. Although it is extremely rare to have a triple valve endocarditis, we had two cases in which their AV, MV, and TV were affected concomitantly and a case which experienced a Bentall, MV, and TV surgical intervention. Most of our patients (n = 19) had an involved MV. Other papers further indicated a high incidence of MV involvement.[9] Most of these patients, equally important, had an affected AV; this is different from the results of Yao et al., which had a more accompanying MV, aortic cases.[10]

A study by Rosenthal et al. showed that the IV abusers and addict patients had a more chance of ICU readmission and mortality.[11] There is a lack of detailed information on the outcome of the dependent patients.[12] In our study, only 1 of addicted patients expired; this was probably because of their age and comorbidity. The mean age of our addicted patients was 31.64 years old; with a minimum of 26 and maximum of 42 years old. The expired patient was 31 years old.

A research by Østerdal et al. discussed that a surgical intervention may be necessary in the patients with IE, but a redo operation is controversial.[13] From our 7 expired patients, 3 of them had been undergone a redo operation and 1 of these reoperated patients had have an ICU readmission. These results show that a redo operation probably is an independent risk factor of mortality; however, further analysis should be done with a more number of cases. It was mentioned in a study by Berglund et al. that ventricular septal defect (VSD) was associated with IE;[14] however, in our study, there were only three patients with VSD. Two cases out of three also required a TVR.

Although our study had many limitations, it solved most of the recent studies’ issues. An important limitation in other studies was a long period of data collection, which may lead to the development of surgical and antibiotic therapy that may affect the data analysis. Our study was integrated and because our center was a referral center in our region, the incidence of IE was high compared to that of other researchers. Another problem in other studies was being retrospective, which was not applied in our study because it was prospective. Our main limitation was the few numbers of patients; furthermore, we could not have a follow-up because of cultural status of our cases.

CONCLUSIONS

We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.