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Carlos-A. Mestres, MD, PhD, FETCS Consultant Cardiovascular Surgery Hospital Clínico. University of Barcelona Barcelona. Spain. Infective endocarditis is an uncommon disease associated to significant morbidity and mortality. As in any infection within the cardiovascular surgery,

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Carlos-A. Mestres, MD, PhD, FETCS

Consultant

Cardiovascular Surgery

Hospital Clínico. University of Barcelona

Barcelona. Spain


Infective endocarditis is an uncommon disease

associated to significant morbidity and mortality.

As in any infection within the cardiovascular surgery,

early diagnosis and aggresive management are

indicated

Infective endocarditis is a medical & surgical disease

which must be managed by a multidisciplinary

team with shared interests


The Team

The Hospital Clinico of Barcelona Endocarditis Study

Group is a multidisciplinary group specifically

dedicated to the study and treatment of infective

endocarditis and cardiovascular infections operational

for 25 years

Infectious Diseases (6), Cardiovascular Surgery (3), Microbiology (3),

Surgical Pathology (1), Echocardiography (2)


The Team

* Infectious Diseases

J.M.Miró, A.Moreno, A. Del Río, N. De Benito, X.Claramonte, J.P.Horcajada

* Cardiovascular Surgery

C.A.Mestres, R.Cartañá, S.Ninot, J.L.Pomar

* Microbiology

M.Almela, F.Marco, C.García

* Surgical Pathology

J.Ramírez, N.Pérez

* Echocardiography

J.C.Paré, M.Azqueta, M.Sitges


Infective Endocarditis

What have we learned?

What have we changed?

What are we doing?

Where are we going?

An overview


A - Short Courses of Therapy for Infective Endocarditis

B - Infective Endocarditis in Drug Abusers (IVDAs)

C – Surgical experience


Potential number of candidates for short-courses of therapy

for right-sided MSSA endocarditis in IVDAs at the

Hospital Clínic of Barcelona, Spain (1979-98)

Types of endocarditis

in IVDAs

MSSA

N (%)

N

- Right-sided IE

- Left-sided IE

- Mixed IE

Total

142

46

16

204

104 (73%)

16 (35%)

10 (64%)

130 (64%)

2 wk Tx*

40%

* According to methicillin-susceptibility, HIV status and CD4 cell counts (>200/µL)


Short Courses of Therapy for Infective Endocarditis

CONCLUSIONS

5. Patients allergic to penicillin who must receive vancomycin with or without an aminoglycoside must be treated during 4 wks

6. In our 25-year experience, one of every five episodes of native valve IE (general population + IVDAs) and almost one of every two episodes of IE in IVDAs were considered potential candidates for these short courses (2 wks) of therapy


Infective Endocarditis in IVDAs & HIV infection

SUMMARY

1. The incidence of IE in IVDA in the AIDS era is decreasing probably due to the change of the drug administration habits in order to avoid HIV-infection

2. HIV-infected IVDA have a higher ratio of right-sided IE and S. aureus endocarditis than HIV-negative IVDA with IE

3. Mortality between HIV-infected or non-HIV-infected IVDA with IE is similar. However, mortality among HIV-infected IVDA is higher in IVDA with less than 200 CD4+ cells/µL or with AIDS criteria


Infective Endocarditis in IVDAs & HIV Infection

SUMMARY

4. IVDA with non-complicated MSSA right-sided IE can be succesfully treated with an IV short-course regimen of nafcillin or cloxacillin plus an aminoglycoside during 2 weeks, although the addition of an aminoglycoside may be avoided or reduced to the first 3-7 days

5. Tricuspid valve replacement using mitral homografts can be a safely alternative to tricuspid valvulectomy for those IVDA with endocarditis who need right heart surgery

“Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1)”

Mestres CA et al. Eur J Cardio-thorac Surg 2003; 23:1007-1016


Epidemiology

1990 - 2000

Diagnosis of IE 421

IV (IVDA) drug abuse 104

General population 317

Native IE 213

PVE 75

Pacemaker/AICD 29

Admissions/yr >50


“Infective endocarditis in intravenous drug abusers and HIV-1 infected patients”

J.M.Miró, A. del Río, C.A.Mestres

Infect Dis Clin North Am 2002; 16:273-295

“Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature”

J.E.Losa, J.M.Miró, A. Del Río, A.Moreno-Camacho, F.Gracia, X.Claramonte, F.Marco, C.A.Mestres, M.Azqueta, J.M.Gatell and the Hospital Clinic Endocarditis Study Group

Clin Microbiol Infect 2003; 9:45-54

“Surgical treatment of pacemaker and defibrillator lead endocarditis. The impact of electrode lead extraction on outcome”

A.del Río, I.Anguera, J.M.Miró, L.Mont, Fowler VG Jr, M.Azqueta, C.A.Mestres and the Hospital Clinic Endocarditis Study Group

Chest 2003; 124:1451-1459


NVE 387 - ADVP 237 - PVE 130 - PM 49 - HIV-1 infected patients”All 803


PVE 132 HIV-1 infected patients”


S.aureus HIV-1 infected patients” 274


ICE HIV-1 infected patients”

Presumed intravascular catheter source by region

International Collaborationon Endocarditis


Specific indications HIV-1 infected patients”

Mechanical valve

Young, “good” ring, cured IE

Bioprosthesis

Elderly (?), “good” ring, cured IE

Homograft

Complicated IE, abscess, annular destruction


The complicated root HIV-1 infected patients”

  • Root abscess

  • Aorto-cavitary fistula


Aorto-cavitary fistulae HIV-1 infected patients”


The spanish aorto cavitary fistula endocarditis working group

L770 - AORTO-CAVITARY FISTULIZATION IN COMPLICATED ENDOCARDITIS. CLINICAL AND ECHOCARDIOGRAPHIC FEATURES OF 76 CASES (1992-2001) AND PROGNOSTIC FACTORS OF MORTALITY

42nd ICAAC. San Diego, CA. September 27-30, 2002

The Spanish Aorto-cavitary Fistula Endocarditis Working Group


No clinical infective endocarditis (IE) series have been performed studying the development of aorto-cavitary fistulas (ACF) as a result of spread of infection from valvular tissue towards perivalvular structures. Our aims were to investigate the clinical, echocardiographic and microbiologic features and prognostic factors of in-hospital mortality in patients with IE and ACF.

Retrospective and multicentre study at 11 Spanish and 1 North-american Hospitals in patients with IE and ACF.


Spread of infection in infective endocarditis (IE) from valvular structures to the surrounding perivalvular tissue results in periannular complications.

Rupture of abscesses and pseudoaneurysms in the sinuses of Valsalva result in the development of aorto-cavitary fistulas and intracardiac shunts.

Aorto-cavitary fistula formation is an unusual complication of IE. An incidence of 1% of all cases of IE has been estimated. Fistulization of perivalvular abscesses occurs in 6-9% of cases.

Basic considerations


* Multicenter, international, retrospective, descriptive study performed between 1992 and 2001

* Infective endocarditis diagnosed according to Duke criteria

* Aorto-cavitary fistulization documented by TTE/TEE

* Univariate analysis of prognostic factors of mortality


ACF n Cases IE n Incidence % study performed between 1992 and 2001

General population

Native valve

Aortic

Mitral

Other

PVE

Aortic

Mitral

Other

Pacemaker

IV Drug abusers

OVERALL

69

38

38

--

--

31

31

--

--

--

7

76

3147

2105

1056

930

119

872

536

326

10

170

1534

4681

2.2

1.8

3.6

---

---

3.5

5.8

---

---

---

0.4

1.6


Clinical characteristics study performed between 1992 and 2001

NVE=45 PVE=31 All=76

Mean age (y)

Male gender

Previous valve disease

Comorbidity

Mechanical ventilation

IV drug abuse

Duration of symptoms (d)

Duration to Dx of ACF (d)

CHF

Neuro events

Renal failure

Peripheral emboli

Complete AV block

50.9±18.7*

36 (80%)

13 (28%)

18 (40%)

6 (13%)

7 (16%)

24.5±18.7

36.2±31.6

31 (69%)

8 (18%)

20 (44%)

8 (18%)

5 (11%)

60.2±13.4*

20 (65%)

31 (100%)

9 (29%)

1 (3%)

0

29.8±37.7

44.1±55.5

16 (52%)

4 (13%)

8 (26%)

7 (23%)

6 (19%)

54.7±17.2

56 (74%)

44 (59%)

27 (36%)

7 (9%)

7 (9%)

26.7±27.9

39.4±42.8

47 (62%)

12 (16%)

28 (37%)

15 (20%)

11 (14%)


Pathogens study performed between 1992 and 2001

NVE=45 PVE=31 All=76

Staphylococcus spp

S.aureus

CNS

Streptococcus spp

VGS

S.bovis

Other streptococci

Enterococcus spp

Culture negative

Other (HACEK)

17 (38%)*

13 (29%)*

4 (9%)*

16 (35%)

10 (22%)

2 (4%)

4 (9%)

2 (4%)

5 (11%)

7 (15%)

18 (58%)*

3 (10%)*

15 (48%)*

9 (29%)

5 (16%)

--

4 (13%)

2 (6%)

--

2 (6%)

35 (46%)

16 (21%)

19 (25%)

25 (33%)

15 (20%)

2 (3%)

8 (10%)

4 (5%)

5 (6%)

9 (12%)

NVE vs PVE groups (p<0.05)


Echocardiography study performed between 1992 and 2001

Diagnostic yield of TTE and TEE


Native study performed between 1992 and 2001

N=45

Prosthetic

N=31

Total

N=76

Echo findings

Patients with vegetations

Mean maximal veg. size (mm)

Vegetations > 10 mm

Patients with abscess

Mean maximal abscess diameter

Abscess > 10 mm

Ventricular septal defect

Mean EF (%)

Mean LVEDD (mm)

Multivalvular infection

96 %*

11.5

49 %

71 %

10 mm

44 %

21 %

62.5

55.2

33 %

65 %*

12.1

70 %

87 %

15 mm

67 %

19 %

60.5

54.4

26%

83 %

11.7

56 %

78 %

12 mm

54 %

20 %

61.7

54.9

30 %

*Native vs prosthetic, p < 0.05


Fistulized sinus of Valsalva (SV) study performed between 1992 and 2001

Right SV

Left SV

Non coronary SV

Fistulized cardiac chamber (%)

Right atrium

Right ventricle

Left atrium

Left ventricle

Multiple

Moderate/severe regurgitation

Native

N=45

Prosthetic

N=31

Total

N=76

Echo findings

44%

35%

20%

18%

31%

22%

13%

11%

64%*

26%

42%

32%

16%

16%

32%

19%

13%*

26%*

37%

38%

25%

17%

25%

26%

16%

12%

49%

* Native vs prosthetic, p < 0.05


Surgical treatment study performed between 1992 and 2001

Time to surgery

< 24 hours

2 - 7 days

> 7 days

Closure of fistula (%)

Simple

Pericardial patch

Gore-tex patch

Valve replacement

Bioprosthesis

Mechanical

Homograft

Native

N=45

Prosthetic

N=31

Total

N=76

87%

33%

36%

31%

41%

46%

13%

95%

28%

49%

18%

87%

11%

52%

37%

41%

52%

7%

89%

19%

52%

19%

87%

24%

42%

34%

41%

48%

11%

92%

24%

50%

18%


In-hospital mortality study performed between 1992 and 2001

- Surgical group (N=66)

- Medical group (N=10)

Native

N=45

Prosthetic

N=31

Total

N=76

16 (36%)

13/39 (33%)

3/6 (50%)

15 (48%)

15/27 (55%)

0/4 (-)

31 (41%)

28 (42%)

3 (30%)

Medical

N=3

Surgical

N=28

Cause of death

- Multiorgan failure

- Sudden death

- Septic shock

- Cardiogenic shock

- Hemorrhage

33%

33%

-

33%

-

23%

10%

26%

19%

23%


Lost for follow-up study performed between 1992 and 2001

Follow-up (mo., mean, range)

Residual fistula

Late CHF

Late valvular replacement

Late death

Medical *

N=7

Surgical

N=38

2

4

36 (1-96)*

-

3

0

1

29 (1-144)*

5 (11%)

7 (16%)

5 (11%)

3 ( 7%)

* The 3 patients who died w/o surgery had fatal co-morbid conditions. The remaining

7 patients did not undergo surgery because they did not have cardiac failure,

severe valvular regurgitation and echocardiographical abscess.


Age > 65years study performed between 1992 and 2001

Male gender

Prosthetic endocarditis

Symtoms duration >30 d.

Moderate or severe CHF

Renal failure

Neurologic symptoms

S.aureus infection

Vegetation >10 mm

Patients with periannular abscess

Periannular abscess > 10 mm

Moderate or severe AR

Fistulized sinus of Valsalva

Fistulized cardiac chamber

EF <65%

Urgent or emergency surgery

OR – 95%CI p

2.8 (1.0-7.9)

0.8 (0.2-2.4)

2.5 (0.9-6.8)

0.8 (0.2-2.6)

2.2 (0.7-5.1)

1.8 (0.7-5.1)

0.6 (0.1-2.8)

1.2 (0.4-3.6)

1.2 (0.4-3.6)

1.6 (0.5-5.5)

2.3 (0.7-7.3)

0.8 (0.3-2.1)

-

-

1.1 (0.4-3.1)

2.7 (0.9-7.8)

0.05

0.6

0.07

0.7

0.15

0.2

0.5

0.8

0.7

0.4

0.14

0.7

0.9

0.2

0.8

0.06


Limitations study performed between 1992 and 2001

* Ascertainment bias – multicenter nature

* Severity of CHF higher – low-grade shunts

underdiagnosed

* High-risk profles of surgical candidate

* Not comparable to medically treated

* Not comparing medical and surgical patients


Abscesses vs fistulae study performed between 1992 and 2001



Actuarial freedom from death, heart failure requiring hospital admission and repeat surgery in patients with periannular complications surviving the index hospitalization. A. patients referred to surgical therapy


B. patients medically-managed hospital admission and repeat surgery in patients with periannular complications surviving the index hospitalization. A. patients referred to surgical therapy


* Aorto-cavitary fistulization in IE is an unfrequent event and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

* It was associated with staphylococci and streptococci native-valve IE and with coagulase-negative staphylococci prosthetic valve IE.

* In-hospital mortality was high even when most patients were referred to surgical treatment.

* Congestive heart failure identified the subgroup of patients with the worst prognosis.

Conclusions


  • Prosthetic valve endocarditis and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

  • What?

  • When?

  • Who?

  • Why?


Methods and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

* International Collaboration on Endocarditis Merged Database

* Large, multicenter, international registry of patients with definite

endocarditis by Duke criteria

* Clinical, microbiological, echocardiographic variables to determine

* Those factors associated with the use of surgery in PVIE

* Logistic regression analysis

* Propensity score to match surgery vs medical therapy


PVIE – Patient characteristics and occurs in patients with aortic endocarditis with high grade of local tissue destruction.


Complications and outcomes of patients with PVIE and occurs in patients with aortic endocarditis with high grade of local tissue destruction.


Propensity analysis of surgical treatment of PVIE and occurs in patients with aortic endocarditis with high grade of local tissue destruction.


Logistic regression analysis of variables independently and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

associated with in-hospital mortality in patients with PVIE

and matched propensity for surgical treatment


Conclusions and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

* Despite the frequent use of surgery for the treatment of PVIE

this condition continues to be associated with high in-hospital

mortality

* After adjustment for factors related to surgical intervention,

brain embolism and S. aureus infection were independently

associated with in-hospital mortality and a trend toward a

survival benefit of surgery was evident


Echocardiographic (TTE) Follow-up and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

Year Patient TTE TTE FU Last TTE NYHA

Before After (Yrs)

1991 AMG Veg 28 mm Mild TR 13 Severe TR II

Large RV

1991 RPO Veg 22 mm Severe TR 13 Severe TR II

Severe TR Large RV Large RV

Large RV

1992 PER Veg 30 mm Severe TR 5 Severe TR I

Severe TR Ruptured Large RV

chordae

1994 JLF Veg 22 mm Mild TR 1 Mild TR I

1996 JFG Veg 28 mm Mild TR 1 Severe TR I

Severe TR


Echocardiographic (TTE) Follow-up and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

Year Patient TTE TTE FU Last TTE NYHA

Before After (Yrs)

2001 ERA Severe TR Trivial TR pod Po Death

2002 LML Veg 20 mm Trivial TR pod Po Death

Severe TR Large RV

Large RV

2002 JGR Veg 30 mm Mild TR 2.5 Mild TR I

Severe TR


Outcomes and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

Year Patient FU Drug addiction Recurrent HIV Outcome

(Yrs) relapse endocarditis stage

1991 AMG 6 Yes 14 mos B3 Alive

(Corynebacterium spp) Late Reop

1991 RPO 6 Yes 48, 58, 63 mos B2 Alive

(MSSA all cases) No Reop

1992 PER 5 No No A2 Alive

Late Reop

1994 JLF 2.5 Yes No A3 Death

Overdose

1996 JFG 8.5 Yes 7, 12 mos A2 Alive

(MSSA) No reop


Year Patient FU Drug addiction Recurrent HIV Outcome and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

(Yrs) relapse endocarditis stage

2001 ERA PO N N C3 Death

2002 LML PO N N B2 Death

2002 JGR 2.5 N No A1 Alive


The most complex situation and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

Fibrous Skeletal destruction


Acute pectoralis major myositis in an and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

otherwise healthy young male


25-year-old male and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

Smoker ½ pack/day

Occasional recreational drugs. NO iv abuse

Job: Waiter. Physically fit. Contact sports (judo, full-contact…)

  • In the past 2 years 4 episodes of abscess requiring surgical drainage (hand, foot, knee, axilla)

  • No other personal nor familiar medical history of interest

  • 5-day left upper limb and upper left chest pain accompanied by high-degree fever (39°C), chills and malaise


Aortic root replacement with a 20-22 mm cryopreserved aortic homograft

Intraoperative findings: Massive AR due to perforation of the right coronary cusp on a morphologically normal aortic valve. Full root subaortic abscess extending towards the left atrial roof

Aortic cross-clamp 73 min – CPB 189 min

Left ventricular failure and myocardial edema after CPB. Sternum open. Intraaortic ballon pump support


Outcome i

Postop unstable hemodynamics. Urgent TTE showed anterior-septoapical hypokinesia

Urgent coronary angiogram showed 70% LMCA stenosis with remaining normal coronaries

August 12, 2004: Off-pump LIMA-LAD bypass graft and delayed sternal closure

August 12, 2004 2/2 + blood cultures (ORSA)

Outcome - I


Outcome ii

Early favourable postop. Improved condition, no congestive heart failure

August 14, 2004, 2/2 negative blood cultures. Trasnsferred to ward August 22, 2004. Good condition with low-degree fever (37°C)

August 24, 2004 new control TTE

Outcome - II


Surgery ii

September 1, 2004 – Homograft replacement with a 21 mm SJM Toronto-Root porcine heterograft

Surgical findings: Subaortic circumferential detachment of the normal functioning homograft. Extensive lesions of the entire fibrous body. Left atrial fistula

Post-repair severe mitral regurgitation

Profound left ventricular failure. LVAD Abiomed BVS-5000 implanted

All samples to Microbiology

Surgery - II


Outcome iv

September 2, 2004 – Unstable under maximal intropic support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation

September 3, 2004 – Orthotopic heart transplantation

Outcome - IV


Final diagnosis support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation

1. Community-acquired ORSA myositis

2. Acute aortic root ORSA infective endocarditis

3. Heart transplantation


Endocarditis and heart transplantation

1: Galbraith AJ et al. support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999; 18:805-806

2: Blanche C et al. Heart transplantation for Q fever endocarditis. Ann Thorac Surg. 1994; 58:1768-1769

3: Pulpon LA et al. Recalcitrant endocarditis successfully treated by heart transplantation. Am Heart J 1994; 127:958-960

4: Park SJ et al. Heart transplantation for complicated and recurrent early prosthetic valve endocarditis. J Heart Lung Transplant. 1993; 12:802-803.

5: DiSesa VJ et al. Heart transplantation for intractable prosthetic valve endocarditis. J Heart Transplant. 1990; 9:142-143

Endocarditis and Heart Transplantation


Endocarditis and heart transplantation1

“Heart transplantation could be an alternative, not a contraindication, when in Infective Endocarditis all other measures have failed” (1)

Endocarditis and Heart Transplantation

Galbraith AJ Cardiac transplantation for prosthetic valve endocarditis

in a previously transplanted heart. J Heart Lung Transplant. 1999 Aug;18(8):805-6


Conclusions contraindication, when in Infective Endocarditis all other measures have failed” (1)

* IE is a very serious pathology

* It is not popular

* Highly demanding

* Suboptimal results

* Team approach

* Risk takers


Parsonnet score contraindication, when in Infective Endocarditis all other measures have failed” (1)

Single centre – Subjective factors – Overestimates risk

Cleveland score

Single centre – Excludes non CABG – Leads to gaming

EuroScore

Large multicentre database – Fit for all adult cardiac

surgical patients – Even correlates with STS


EuroSCORE contraindication, when in Infective Endocarditis all other measures have failed” (1)

Additive

Score % mortality

0 – 2

3 – 5

6 – 8

9 – 11

12>

0.88 – 1.51

2.62 – 3.51

6.51 – 8.37

14.02 – 19.12

31.00 – 42.32


EuroSCORE contraindication, when in Infective Endocarditis all other measures have failed” (1)

Its predictive accuracy has been established

Only the additive model has been validated

Inconsistencies among the additive and logistic

models when applied to the high-risk patients


Cross-over point contraindication, when in Infective Endocarditis all other measures have failed” (1)


Reasons to predict mortality in Cardiac Surgery contraindication, when in Infective Endocarditis all other measures have failed” (1)

1. Helping to determine indications for surgery

2. Quality monitoring

Additive EuroScore works well for most purposes


Considerations contraindication, when in Infective Endocarditis all other measures have failed” (1)

The relationship between risk factors is not additive

Combined impact of two or more factors on operative

risk may be more than simple sum

Logistic score more realistic


The reality contraindication, when in Infective Endocarditis all other measures have failed” (1)

* Infective endocarditis is a high-risk situation

* There is lack of data regarding risk assessment

before valve surgery


Aim of the study contraindication, when in Infective Endocarditis all other measures have failed” (1)

To validate the EuroSCORE preoperative

stratification risk model in infective endocarditis


Population contraindication, when in Infective Endocarditis all other measures have failed” (1)

Period Jan 95 – Jan 04

Patients 147

Mean age 56.33 ± 15.95

Male gender 69.4%


Native valve IE contraindication, when in Infective Endocarditis all other measures have failed” (1)


Prosthetic valve IE contraindication, when in Infective Endocarditis all other measures have failed” (1)


Intravascular leads contraindication, when in Infective Endocarditis all other measures have failed” (1)


Characteristics contraindication, when in Infective Endocarditis all other measures have failed” (1)

Active endocarditis 91.2%

IV Drug addicts 10.9%

HIV+ 5.4%

ESR – HD 3.4%

Reoperation 27.2%


Pathogens contraindication, when in Infective Endocarditis all other measures have failed” (1)


Type of operation contraindication, when in Infective Endocarditis all other measures have failed” (1)

Emergency 29.9%

Urgent 21.8%

Elective 46.9%


EuroSCORE contraindication, when in Infective Endocarditis all other measures have failed” (1)

Additive

Range

Mean

Median

2 – 19

10.15 ±3.81

10


EuroSCORE contraindication, when in Infective Endocarditis all other measures have failed” (1)

Logistic

Range

Mean

Median

1.51 – 94.17% EM

25.59 ± 20.81

18.95


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)

Overall in-hospital mortality 32.7%

  • Intraoperative death

  • 30 days po

  • Regardless the length of stay


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)

Receiver operating characteristics (ROC) curves

Asymptotic 95% confidence interval

Area > 0.7 Good correlation

Area > 0.8 Very good correlation

Area > 0.9 Excellent correlation


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)


Results contraindication, when in Infective Endocarditis all other measures have failed” (1)


Aortic valve contraindication, when in Infective Endocarditis all other measures have failed” (1)


Homograft aortic contraindication, when in Infective Endocarditis all other measures have failed” (1)


Mitral valve contraindication, when in Infective Endocarditis all other measures have failed” (1)


Aortic prosthesis contraindication, when in Infective Endocarditis all other measures have failed” (1)


Mitral prosthesis contraindication, when in Infective Endocarditis all other measures have failed” (1)


Comments contraindication, when in Infective Endocarditis all other measures have failed” (1)

There is a very good correlation between logistic

EuroSCORE and mortality for the entire group

Division in subgroups yields a decrease in statistical

power but correlation is almost the same in all subgroups

The area is good in the prosthetic valve IE although non

significant by position


Comments contraindication, when in Infective Endocarditis all other measures have failed” (1)

The area is very good for Gram – and polymicrobial

although with low statistical power

There is statistical power for significance in the

Staphylococci and Streptococci groups


Limitations contraindication, when in Infective Endocarditis all other measures have failed” (1)

Small sample size

Statistical power decreases when analyzing subgroups

Just preliminary results


When to use Logistic EuroScore? contraindication, when in Infective Endocarditis all other measures have failed” (1)

  • To calculate a precise and realistic risk prediction for a very high-risk patient, particularly when the indication for surgery may not be clear

- To monitor quality of care in institutions where a substantial proportion of patients are of very high-risk

- To help in the further study of risk modelling by groups and institutions with a scientific interest in the subject

- To carry out normal stratification in institutions with easy availability of accesible information technology, especially where high-risk surgery forms a substantial part of the workload


The Future of risk stratification contraindication, when in Infective Endocarditis all other measures have failed” (1)

* Larger sample size

* More institutions involved

* Subgroup analysis (Pathogens, abscess…)

* Team approach

* The role of ICE

* Changing our approach to patients?

* Quality assurance


Conclusions contraindication, when in Infective Endocarditis all other measures have failed” (1)

* IE is a very serious pathology

* It is not popular

* Highly demanding

* Suboptimal results

* Team approach

* Risk takers


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