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Infective endocarditis can negatively impact prognosis of congenital heart disease and has a 10-15% incidence of mortality. New guidelines recommend prophylaxis of infective endocarditis only for high-risk group (cyanotic congenital heart disease, valvular prosthesis, previous endocarditis) and for some specific invasive dental procedures. New guidelines are focused mainly on oral and cutaneous hygiene. Native shunts and valvular disease are no more targets for prophylaxis. More than half of the physicians do not follow the new guidelines. High-velocity shunts like ventricular septal defect should be included in the at-risk congenital disease for infective endocarditis where prophylaxis should be applied. The new guidelines for prophylaxis of infective endocarditis did not impact on the incidence of infective endocarditis., (Copyright © 2017. Published by Elsevier Masson SAS.)

Unlabelled: Infective endocarditis (IE) is a serious disease for which diagnosis and treatment continue to develop. Purpose of work. To analyze trends in its epidemiologic, clinical, and microbiologic characteristics, as well as its treatment and outcome., Methods: Retrospective review of data of 135 patients admitted to our adult cardiology department from January 1981 through December 2011. IE was diagnosed according to the modified Duke Criteria. We defined 2 groups of patients according to their date of admission: group A (n = 55), patients admitted before 1995, and group B (n = 80), patients admitted in and after 1995., Results: The entire population was predominantly male, and their mean age was 38.5 ± 16 years, 36 years in group A and 44 years in group B. IE affected mainly native valves (90% group A, 74% group B; p<0.05). Prosthetic IE was more frequent in group B (20% vs 10%, p<0.05), and the portal of entry identified more often (59% vs 22%; p = 0.03). Blood cultures were negative in 78% of patients in group A vs 57.5% in group B (p = 0.04). The principal causative microorganism was streptococcus before 1995 and staphylococcus after 1995, but this difference was not significant. Heart failure was more frequent in group A (p = 0.05). Embolic events affected 27% of the patients in group A vs 32.5% in group B (p = 0.05). The rate of surgery (51% in group A vs 62.5% in group B) did not differ significantly. The in-hospital mortality rate was 53% in group A vs 11% in group B (p<0.001); operative mortality was also higher in group A (p<0.001)., Conclusion: Our work shows changes in the epidemiologic characteristics of IE that parallel changes in demographic and risk factors. The progress of diagnosis and surgery explains the better prognosis for this pathology today.

Objective: To determine clinical, echocardiographic features, management and outcomes of patients presenting peri aortic abscess complicating infective endocarditis (IE) and demonstrate the impact of periaortic abscess on morbidity and mortality of these patients., Methods: We have analyzed clinical, microbiological, echocardiographic aspects, therapies and outcomes of patients with aortic abscess occurring during IE, and we compared these data with those of patients presenting IE without peri aortic abscess in the same period in the cardiology department of the University Hospital of Marrakech from January 2006 to January 2010., Results: Above 56 cases of infective endocarditis, 16 patients had an aortic abscess. Mean age was 33 ± 11 years with a clear male predominance in the group IE with abscess versus IE without abscess. Heart failure was noted in all patients in periaortic abscess group, and was more severe in this group compared to control. Streptococcus and staphylococcus predominated with no significant difference between the two groups. Transthoracic echocardiography coupled with transesophageal echocardiography made the diagnosis of aortic abscess witch was isolated in 11 cases and associated with other complications in five cases. In terms of complications, splenic infarction was more frequent in the group with abscess (25 versus 2.5%, P<0.05). There was not a significant difference between the two groups for the others complications. Surgery associated with a double antibiotic therapy was the standard treatment with a variable delay for surgery of four days to four weeks. Hospital mortality in the acute phase was higher in periaortic abscess group (37% versus 10%, P<0.05). The evolution of survivors at six months was favorable., Conclusion: Periaortic abscess complicating IE is associated with a high morbidity and mortality in spite of modern approach as well as on medical or surgical treatment. It requires therefore a strict monitoring of patients with infective endocarditis., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

In industrialized countries, after the eradication of rheumatic fever, rheumatic valve diseases progressively disappeared and the proportion of post-rheumatic infective endocarditis significantly decreased. Intravenous drug use, prosthetic valves, age-related degenerative valve sclerosis, and invasive procedures have become the most important risk factors for infective endocarditis. These changes resulted in a decreased incidence of streptococcal endocarditis and an increased incidence of staphylococcal endocarditis.

Between January 1990 and December 2006, 93 patients with infective endocarditis on native valves were operated in the active phase of the disease. The average age of our patients was 32 years with a male ascendancy. The causal heart disorder was found in 89 % of the cases, dominated by rheumatoid arthritis. The germ in cause was isolated in 52.6 % of the cases. The operative indication was hemodynamic in 29 cases, infectious in nine cases, mixed in 29 cases and embolic in 26 cases. The average operating delay was of 13 days with regard to the beginning of the antibiotic treatment. We realized a valvular aortic replacement at 32 patients with reconstruction of the ring in six cases, a valvular mitral replacement at 29 patients, a mitroaortic replacement at 21 patients, a reconstructive mitral surgery in nine cases, a valvular tricuspid replacement in one case and a reconstructive tricuspid surgery in one case. The early mortality was 13 %. The follow-up was 89 % with an average recession of 3.1 years and a late mortality of 5 %. The aim of this study is to analyze the immediate and late results of the surgery of infective endocarditis in the active phase and to bring to light the prognostic factors of mortality., (Copyright (c) 2009 Elsevier Masson SAS. All rights reserved.)

Background: Prosthetic valve endocarditis (PVE) is a serious complication of valve surgery., Aim: The aim of this study is to determine the diagnostic and therapeutic management for PVE., Methods: It's a retrospective study about 14 cases of PVE operated in the department of cardiovascular surgery of la Rabta hospital between January 1996 and December 2006., Results: In two cases, surgery was performed emergent, in the remnant cases surgery was elective. The coagulase-negative staphylococcus (CNS) is the predominant cause of these PVE.Surgery consisted on seven mitral prosthesis replacements and seven aortic prosthesis replacements.Hospital mortality was 50%., Conclusion: In conclusion attention should be made to prevent endocarditis when possible. In case of PVE, an early diagnosis a leads to earlier application of appropriate therapies and improved outcome.

The year 2005 has been rich in publications concerning valvular heart disease. In France, this year has been dominated by the publication of the French Society of Cardiologists' guidelines on the operative and interventional indications for acquired valvular heart disease: discussed and accepted formal indications based on the evidence in the literature. Non-ischaemic mitral insufficiency has been the subject of a major study that showed the high prognostic significance of echographic measuring of the area of the regurgitating orifice; patients with a surface > or =40 mm2 had a worse long-term prognosis and should undergo surgery early. The prognostic significance of BNP in valvular heart disease, such as mitral insufficiency and aortic stenosis, also became apparent. BNP is being used more and more for risk stratification for these conditions. The significance of anti-arrhythmic surgery combined with a mitral procedure has confirmed the harmful effect of atrial fibrillation, before and after the mitral surgery. The first randomised study into the use of statins to slow the progression of aortic stenosis was unfortunately disappointing, despite the various unrandomised studies that had opened a therapeutic pathway for this pathology, for which the prevalence is continually rising due to the ever increasing life expectancy. In mitral stenosis, a randomised study showed the long-term value of mitral commissurotomy in percutaneous mitral valvuloplasty, giving identical long-term results, in terms of mitral area, to those obtained with the classic Inoué balloon. In infectious endocarditis, surveys have confirmed the seriousness of this pathology as well as the slight advances in its prophylaxis. Other studies have confirmed the frequency and the severity of emboli, endocarditis due to Staphylococcus aureus, and the low risk of recurrence for endocarditis with the more and more accepted short course antibiotic treatment for patients undergoing surgery. Of course, this selection of publications is limited and by necessity subjective.

Background: Propionibacterium acnes, a gram positive, anaerobic, skin commensal bacillus, is too often considered a biologic fluid contaminant, of blood cultures in particular. Its implication has been shown in various infections, including brain abscess, ocular infections, osteitis, and acne. It is also the cause of infective endocarditis (IE)., Methods: Retrospective, observational study of 11 patients with P. acnes IE, hospitalised between 1993 and 2001 at the Louis Pradel Hospital, Lyon-Bron, and review of 20 published cases., Results: P. acnes IE is rare, though its prevalence is probably underestimated. It is most likely to affect men (71%), and affects all ages (children 4/31 cases). An entry point, probably cutaneous, is rarely confirmed. P. acnes IE often develops on valve prosthesis (42%), and embolisms are common (61%). The infective site is usually aortic (55%). The often-subtle symptoms and slow growth of the organism in vitro complicate the diagnosis, which is often made at a late stage, when valvular and peri-valvular destruction has become major. Despite the high sensitivity of P. acnes to most antimicrobials, a surgical intervention is very often needed (81%). The mortality is relatively high (15% to 27%). Examination of pathologic specimens by polymerase chain reaction increases the sensitivity and speed of its detection. The identification of P. acnes in a biologic specimen, valvular tissue in particular, requires a thorough knowledge of the clinical context before concluding to contamination, and mandates close surveillance of the patient. P. acnes can be the cause of IE long before it has been detected.

This retrospective study describes 100 cases of infective endocarditis (IE), collected between 1980 and 2004. Patients were subdivided into 2 groups, according to the use of trans-esophageal echocardiography (TOE) in the institution where the study was performed: group A (GA=55 patients, between 1980 and 1991) and group B (GB=45 patients, between 1992 and 2004). The IE cases of 59 men and 41 women were analyzed. Patients had a mean age of 33 years (range 15-75 years). An underlying heart disease was involved in all cases, mainly rheumatic heart disease (93% of cases). Native valve endocarditis (NVE) was seen in a majority of cases (93%), and the localization of IE was aortic in 36 cases, mitral in 36 cases, mitro-aortic in 26 cases and mitro-aortic-tricuspid in 2 cases. Prosthetic valve endocarditis (PVE) occurred in 12 cases. Blood cultures were positive in 31 cases, with 14 staphylococcal infections (3 in GA and 11 in GB) (p < 0.05), of which 6 were coagulase-negative; 13 were streptococci and 4 were Gram negative bacilli. All patients had a transthoracic echocardiography (TTE), and patients in group B also had a TOE. Seventeen patients had a favorable outcome without need of a surgical intervention. Early surgery was necessary in 71 cases (85.5%), and elective surgery in 12 cases (14.5%). Mortality while awaiting surgery was 27%, and has been decreasing for the past decade (41.8% in GA and 8.9% in GB) [p < 0.05]. Postoperative mortality after early surgery intervention was 13.6% (6 among 44 patients), and it was 8.3% (1 among 12 patients) after elective surgery intervention. Overall mortality was 34%: 27 deaths with NVE (30.7% [27/88]), and 7 deaths with PVE (58.3% [7/12]) [NS]. Predictors of mortality in this observational study were positive blood cultures involving staphylococci, the presence of valve mutilations, unstable prostheses, and heart failure.

The aim of this retrospective study was to analyse cases of infectious endocarditis (IE) of native or repaired ventricular septal defects (VSD) to determine its incidence, the circumstances of its occurrences, the outcome and prognosis of this complication. From 1966 to 2002, 36 IE occurred in 19 boys and 17 girls: the age at diagnosis was 13.4 +/- 11.8 years; 26 had an isolated VSD and 10 had VSD associated with a minor lesion. Eleven of the 36 cases (30.5%) had been previously operated: repair of an isolated VSD with a patch in 5 cases, associated with a Crafoord procedure for coarctation of the aorta in 2 cases, three times with conservative treatment of associated aortic regurgitation (AR) and with ligature of patent ductus arteriosus (PDA) in 1 case. Twenty-five of the 36 cases (69.5%) had not been operated before: 21 isolated type 1 VSD; 2 VSD + AR, 1 VSD with PDA (undiagnosed), 1 VSD with valvular pulmonary stenosis (PS). The portal of entry was post-surgical in 7 out of 36 cases (19.4%): 4 VSD patches, 2 VSD patches + Crafoord and 1 VSD patch with ligature of PDA. The source of infection was dental in 14 out of the 36 cases (38.9%): one isolated VSD repair with residual shunt, 11 native VSDs, and 2 cases of unoperated VSD + AR. The other infectious causes (15 = 41.7%) were ENT (2 cases), skin (2 cases), gastrointestinal (2 cases), pulmonary (1 case) or unknown (8 cases), on operated lesions (3 VSD patches + AR) or native lesions (12 cases: 10 isolated VSDs, 1 VSD with PSD and 1 VSD with PS). Twelve episodes occurred (33.3%) despite antibiotic prophylaxis, 7 out of 7 post-surgical and 5 out of 14 dental cases. The commonest localisation was the tricuspid valve (10 cases, always in isolated VSD). Embolism was observed in 60% of right heart endocarditis (always multiple) and in 55% of IE of the left heart (single embolism). Early surgery was required in 6 patients (16.7%). The risk of early surgery was higher in patients with VSDs associated with other lesions (4 out of 10 = 40%) than in isolated VSD (2 out of 26, 7.7%, p = 0.027). Thirteen patients underwent secondary surgery after an average interval of 2.96 years, median 0.86 years (from 4 months to 22.8 years) for VSD repair (10 cases), aortic valve replacement (2 cases) and aorto-aortic conduit (1 case). The global follow-up period was 7.4 +/- 8.3 years, from 28 days to 27.9 years (median 3.3 years). Five deaths were observed on average 3.7 +/- 6.2 years after the episode of IE (median 6 months): 2 were early, occurring less than 6 months after IE and directly related to the infective episode. The survival was 97.1% at 1 month, 94.3% at 6 months, 91.4% at 1 year and 86.6% at 5 and 10 years after IE. VSD is a benign cardiac lesion, the prognosis of which can be severely compromised by infectious endocarditis: surgical repair reduces the risk but does not totally exclude it because of minor associated abnormalities. Prophylactic antibiotic therapy and the diagnosis of latent infectious problems, particularly dental, remains essential before and after cardiac surgery.

Between 1990 and 2002, 32 patients with mean age of 34 years has been treated for an aortic infective endocarditis on native valve. All the patients had recognised heart disease before developing the infection. 24 patients are operated for aortic valve replacement. The hospital mortality was 15.6% (5 patients). The mean follow-up was 47.4 months. The survival rate was 75%. Aortic infective endocarditis remains a serious affection with poor prognosis, despite the contribution of echocardiography and advances in antimicrobial therapy and cardiac surgery. Significants morbidity and mortality are usually caused by sequele of the disease rather than by the infection itself.

Objective: To study clinical course and prognostic factors of infective endocarditis., Patient and Methods: Infective endocarditis was identified in 126 consecutive patients (criteria of DURACK). Of these, 73 were male, mean age was 29.9 + 15 years, 98 (77.7%) had past history of cardiac disease. The evolution has been marked by 38 deaths (30%) in spite of the recourse to surgery (69 patients). The mean follow-up period was 52 months, the event-free survival was 61% at 5 years., Results: By univariate analysis the predictors of bad prognosis: Large vegetations > 10 mm, delay of apyrexia > 10 days presence of a neurological accident and the absence of surgical treatment. Multivariate analysis: Vegetation > 10 mm (OR 1.97, 1-4.1, p = 0.05), presence of a neurological accident (OR:2.76, 1.32-5.76, p = 0.007) and the absence of surgical treatment (OR: 5.03, 2-11.4, p < 0.001)., Conclusion: Infective endocarditis remains a serious affection, identification of patients with poor prognosis should lead to early surgical referral: this attitude provides good immediate and long-term results.

The aim of this study was to evaluate the influence of age on the prognosis of infectious endocarditis. A retrospective study from 1987 to 1997 of 136 patients with infectious endocarditis on native, prosthetic valves or cardiac pacing catheter was performed. The outcome was analysed with the help of general practitioners. Two groups of patients were compared: 87 patients of 65 years of age or more (Group 1) and 49 patients under 65 years of age (Group 2). With a follow-up period of 5 years, the global mortality was 35%, but greater in Group 1 (p = 0.06). Cardiac failure was the main cause of death. The mortality was significantly higher in patients who were not operated (p < 0.002). The authors conclude that age of over 65 does not significantly worsen the prognosis of infectious endocarditis. The absence of surgery seems to be an indirect factor of a poor prognosis. Long-term follow-up of patients is necessary to diagnose and treat cardiac failure at an early stage and to consider referral for surgery.

The incidence of infective endocarditis (20 to 160 cases per million inhabitants yearly) increases with age; it does not seem to be decreasing over time. There is no previously known heart disease in 30% of the patients, a native valve disease in 30 to 60%, a prosthetic valve in 15-20%. Streptococci remain the leading microorganisms. Digestive streptococci and staphylococci are increasing. Iatrogenic portals of entry are in progression. During the hospital stay, case fatality ratio varies from 13 to 20%. After endocarditis, the patient remains at risk of late cardiac surgery and of recurrence. Survival after 5 years is approximately 85%.

The prognostic factors of 122 patients suffering from prosthetic valve endocarditis between 1978 and 1992 were studied by univariate and multivariate analysis. The principal causative organisms were Staphylococcus aureus (33%), streptococci (20%), coagular-negative staphylococci (12%), enterococci (10%) and gram-negative bacilli (9%). The 4 month survival rate was 66% (42 deaths). The main predictive factor for death was infection with S. aureus (75% vs 15% with other organisms). In S. aureus infection, multivariate analysis identified the following predictive factors for death: a prothrombin ratio less than 30% (RR = 8.3), mediastinitis (RR = 4.9), cardiac failure (RR = 4.4) and septic shock (RR = 2.6). In cases of infection with other organisms, the following factors were predictive of death: a prothrombin ratio of less than 30% (RR = 32.26), renal failure (RR = 7.31) and cardiac failure (RR = 6.07). In patients with S. aureus infection, survival was better after than without surgery: 9/20 (45%) versus 0/20 (p < 0.001). In infection with other organisms, there was no difference in a survival after surgical (89%) or medical therapy (81%). Chronic endocarditis relapses over 1 to 5 years was observed in 9 cases. All patients were reoperated a total number of 18 times with 5 deaths. Very prolonged antibiotic therapy is recommended in these patients. The authors conclude that endocarditis not due to S. aureus and without complications may be treated medically. Rapid reoperation is necessary in all other cases.

Between 1983 and 1991, 104 patients (average age: 52 +/- 13 years) with aortic endocarditis (94 on native and 10 on prosthetic valves), were operated, 81 before the end of antibiotic therapy. Blood cultures were negative in 17 patients, identified a streptococcus in 49 patients, a staphylococcus in 16 patients, and a Gram negative or other organism in 22 patients. The following complications were observed before surgery: severe cardiac failure in 67 patients, renal failure in 24 patients, conduction defects in 13 patients, neurological complications in 13 patients, systemic or coronary embolism in 12 patients. Aortic valve replacement was performed in all patients, associated with mitral valve replacement in 25 patients and tricuspid valve replacement in 1 patient. Twelve patients died after surgery (11/81 of early operations, 1/23 operated later; NS). During a follow up of 3.5 +/- 2.8 years, there were 24 late deaths, 12 of non cardiovascular causes. Of the 20 variables tested, 3 were related to perioperative and late mortality (age, cardiac and renal failure). The 5 year survival (58.1 +/- 5.7%) is identical to that of the period 1970-1982 despite a very significant drop in perioperative mortality. Some of the causes of late mortality (older age of patients, changes in the infecting organisms) provide little hope of improving the prognosis in the near future. Others suggest that earlier surgery could improve the long term prognosis.

The authors report the results of a multicenter study which recensed 59 cases (46 men, 13 women, average age 59.8 +/- 14 years) of valve ring abscesses defined by echocardiographic criteria alone (20 cases) or by echocardiographic and/or operative criteria (39 cases). The site of abscess was aortic (53 cases), mitral (5 cases) and tricuspid (1 case). The abscess complicated a prosthetic valve in 34 cases, occurred with a non-pathological valve in 11 cases or a pathological valve in 14 cases. Taking the 39 operated patients as a reference, the diagnostic sensitivity of transthoracic echocardiography was 25% and that of transoesophageal echocardiography: 88%. Bacterial vegetations were diagnosed with a sensitivity of 55% for transthoracic and 88% for transoesophageal echocardiography. The mediocre results of transthoracic echocardiography make transoesophageal echocardiography mandatory when there is a clinical suspicion of abscess: transoesophageal echocardiography should be systematic in prosthetic valve endocarditis and widely employed in native aortic valve endocarditis. The clinical outcome of these cases was: 39 cases were operated: global mortality of 23%, and 18 cases were treated medically, surgery having been declined for various reasons: old age (2 patients), operative risk (1 patient), patient refusal (4 patients), general condition considered to be too good to justify surgery (11 cases, including 6 sterilised abscesses diagnosed some time after the acute infectious phase). The outcome of these 18 patients, who form the biggest non-operated series of valve ring abscesses to date, was studied in detail: 4 died (18% mortality), 1 was operated secondarily for progressive valve dehiscence and 13 had a favourable outcome with an average follow-up period of 2 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Infective endocarditis remains a common condition for pathologists interested in cardiology who fortunately examine more infected valves excised surgically (66 in 1992) than observed at autopsy after death from this condition (2 in 1992). The authors discuss the elementary valvular lesions (ulceration and vegetations), the severity of which affects the prognosis, and the special aspects of these ulcerating vegetations with respect to their location (aortic, mitral, pulmonary and tricuspid), to the type of underlying valvular disease (rheumatic, myxoid or calcific) and infecting organism. The extravalvular complications are then reviewed: annular abscess (and possible extensions), purulent pericarditis, parietal endocarditis, myocarditis and coronary embolism. The authors attempt to answer questions about infective endocarditis from the pathologist's viewpoint: the difference between acute and subacute endocarditis, the reality of infective lesions of "healthy hearts", the role of the pathologist in the detection of pathogenic organisms, the evolution of lesions after sterilisation. The particular situation of prosthetic valve (biological or mechanical) endocarditis is treated in detail. The role and possibilities of surgery, the value of which is now universally accepted (the mortality of severe infective endocarditis has been lowered from 50-60% to 10-20% by a good operative strategy) are emphasised throughout.

Among 841 autopsies realized between january 1982 and september 1988, by the Pathological the department of Amiens University Hospital the ten patients dead of infectious endocarditis have been autopsied. Macroscopic and microscopic observations have two cases of acute endocarditis and eight of subacute endocarditis. For the two patients dead of acute endocarditis, autopsy affirms the cardiovascular etiology of death. For the eight cases of subacute endocarditis, necropsic findings differs from the germs. In the three cases where the germ is a Staphylococcus aureus, the diagnosis of endocarditis was made before death and the cardiovascular etiology of death was affirmed by autopsy. For the other germs (3 Streptococcus sp, 1 Salmonella typhimurium, and 1 germ unknown), the diagnosis of endocarditis was made by autopsy, but necropsy disclosed the cause of death in only two cases.

The epidemiological characteristics of infective endocarditis in France were established in a one-year survey of strictly defined cases. The incidence of the disease is 18 cases per year and per million inhabitants, i.e. 970 cases annually. Patients are generally treated in Teaching Hospitals (80% of the cases were at the end of the hospitalization period). The predominant pathogens are the streptococci non groupable in 40.4% of the cases (group D in 21.9%) and the staphylococci (20.8%). Patients with group D streptococci endocarditis are the older ones (mean age: 60 years). Staphylococcal endocarditis occurs in younger patients (mean age: 43 years), especially after cardiac valve prosthesis or unrecognized cardiac valve disease, and it is the most serious form, with a 45% mortality rate (overall mortality rate: 21%). One quarter of the patients undergo a surgical operation.

The results obtained in a series of 142 patients operated upon, between December 1978 and December 1987, for infective endocarditis on native valve are reported. 61 patients (group 1) had acute progressive endocarditis and 81 patients (group 2) had subacute old-standing endocarditis. In group 1 patients, hospital mortality (i.e. occurring during the first 30 post-operative days) was 11.5 p. 100. During a mean follow-up period of 37.6 months (1.5 to 104.5 months), the survival rates were 52 p. 100 at 72 months and 37.4 p. 100 at 104.5 months. Mechanical desinsertion without persistence or relapse of the infective process, and recurrent endocarditis accounted for 27.8 p. 100 of deaths of known cause. Prognosis was better in group 2 patients. Hospital mortality was 4.9 p. 100, and during a mean follow-up period of 58 months (2 to 124 months) the survival rates were 84 p. 100 at 72 months and 73.4 p. 100 at 124 months. 60 p. 100 of late deaths of known cause were due to heart failure. In native valve infective endocarditis the post-operative diagnosis depends upon the pre-operative haemodynamic status, and the assessment of this status (notably with echocardiography) is a crucial element in the decision to operate.

A longitudinal study of a 32-year period (1954-1987) involving 2038 patients with congenital heart defects followed by the same physician yielded 54 cases of infective endocarditis (IE). Complex cyanogenic cardiopathies were particularly exposed to the risk of infection (8.2 IE for 1000 patient-years), then came ventricular septal defects (2.4), tetralogy of Fallot (2.3), aortic stenosis (2.0) and atrioventricular canal (1.7). The risk was smaller in patients with Eisenmerger complex (1.2), persistent arterial canal (1.4) and coarctation (0.7). Patients under 10 years of age (16.7%) were less affected than young adults in the 20-29 years age-group (33.4%). The organisms most frequently isolated were streptococci (42%); staphylococci ranked second (23%). Less common organisms were found in 14% of the cases, and blood cultures were negative in 21%. Systemic prophylaxis with penicillin V, introduced 16 years ago, seems to have almost halved the incidence of infective endocarditis due to penicillin-sensitive organisms.

This study was based on the analysis of 41 cases of infectious endocarditis of native valves operated during the acute phase. Patients with bacteriological cures, prosthetic valve endocarditis and endocarditis on congenital non-valvular lesions were excluded. There were 32 men and 9 women with an average age of 49 years. The valve lesions were aortic incompetence, mitral incompetence, mitro-aortic disease and mitro-tricuspid disease. Fourteen patients had preexisting valvular disease (rhumatic in 12 and congenital in 2 cases). These patients were in an advanced clinical state at the time of operation: 23 Class IV, 16 Class III and 2 Class II operated for systemic embolism. The surgical indications were severe cardiac failure in 30 cases, systemic embolism in 2 cases and persistance of septicaemia with worsening cardiac function in 9 cases. The causal organism was isolated from blood cultures in 34 cases (83%) and from the excised valve in 13 cases. The early postoperative mortality during the first month was 5 patients (3 cases of aortic incompetence associated with mitral incompetence and 2 cases of aortic incompetence alone). Death was caused in most cases by irreversible cardiac failure related to the advanced preoperative cardiac failure. All the other patients were followed up for 1 to 102 months (average 44 months). There were 7 late postoperative deaths. The mortality rate was 3.4% per patient year including patients undergoing chronic haemodialysis. The actuarial survival was 79% at 78 months excluding the operative mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Between January 1978 and December 1984, 141 cases of acute native valve endocarditis were treated surgically in the Department of Thoracic and Cardiovascular Surgery of the Pitié Hospital. The diagnostic criteria of acute native valve endocarditis were the duration of treatment (antibiotic therapy for less than 40 days), the characteristic operative appearances of the lesions, and the results of anatomo-pathological examination of the excised valves. The infecting organism was not isolated in 35% of cases. The aortic valve was the commonest site of infection (65.2% with a high incidence of abscess of the aortic ring, irrespective of the causal organism. The operative mortality was 5.6%. This depended mainly on the preoperative haemodynamic status of the patient. The duration of antibiotic therapy prior to surgery did not seem to be relevant. The 3 years survival rate was 78%. The secondary reoperation rate was 7%. There was a higher incidence of secondary perivalvular regurgitation in patients who had previously had an abscess of the aortic ring.

Over a 5-year period (1982-1986) 176 cases of infective endocarditis on prosthesis (IEP) were recorded in 40 cardiology departments. 65 p. 100 of the patients were male, and the mean age of the population was 51 years. Mechanical prostheses were involved in 57 p. 100 of the cases and bioprosthesis in 43 p. 100. There was a high proportion of initial indications for bacterial endocarditis (18 p. 100) and for reoperation on prosthesis (10 p. 100). IEP developed early in 40 cases and late in 139 cases; 19 (48 p. 100) of the early IEPs were staphylococcal, while 31 p. 100 of late IEPs were streptococcal (p less than 0.01). 143 patients were reoperated upon within less than 1 month in 41 p. 100 of the cases, with a pre-operative antibiotic therapy of less than 10 days in 39 p. 100. Reoperation was performed in stage IV or as an emergency in 45 p. 100 of the cases. Abscesses were three times more frequent with aortic prostheses than with mitral prostheses (58 p. 100 vs 20 p. 100, p less than 0.001). Vegetations were more frequent on mechanical prostheses than on bioprostheses (43 p. 100 vs 31 p. 100, NS). The operative mortality rate was 25 p. 100; the mortality rate of unoperated patients was even higher (31 p. 100). The survival rate in operated IEP was 51 p. 100 at 30 months, as against 46 p. 100 at 12 months in unoperated IEP.(ABSTRACT TRUNCATED AT 250 WORDS)

The prognostic factors in infective endocarditis patients who underwent surgery in the acute stage were evaluated from the records of 189 cases of native valve endocarditis operated upon between 1970 and 1986. Surgery had been performed before June 30, 1982 in 105 patients (group 1) and since July 1, 1982 in 84 patients (group 2). Group 2 only differed from group 1 in that the proportion of negative blood cultures was lower (13.7% vs 35%; p less than 0.01) and that of subjects older than 70 was higher (11.6% vs 5.7%; p less than 0.01). 105 patients (66 in group 1, 39 in group 2) had been operated upon during the first 6 weeks of antibiotic therapy ("early surgery"), while 84 patients (57 in group 1, 27 in group 2) had been operated upon between 7 and 24 weeks from the beginning of antibiotic therapy ("semi-early surgery"). Hospital mortality was 23.6% in group 1 (29/123) as against 10.6% in group 2 (7/66; p less than 0.05). The difference in mortality between the two groups was significant only in early surgery patients (33.3% vs 7.7%; p less than 0.01) and in patients operated upon while the infection was active with presence of pathogens in valve cultures (47.4% vs 7.7%; p less than 0.05). A study of mortality factors showed that the operative prognosis did not depend on the type of valve replacement performed or on the pathogen involved, but solely on the degree of cardiac failure before surgery. The post-hospital course was evaluated in group 1 patients followed up during 61.8 months on average.(ABSTRACT TRUNCATED AT 250 WORDS)

Through a retrospective study on 57 patients, the authors have studied the diagnosis signs, the clinical course, and the factors which affect the prognosis of bacterial endocarditis. Echocardiography has allowed them to establish a diagnosis with 72 p.c. of cases and the bacteriological investigations with 42 p.c. Out of these endocarditides, 39 were found on natural valves, 6 were associated with congenital cardiopathies, 9 followed the replacement of a valvula, and 3 were associated with endomyocardial fibrosis. Cardiac insufficiency (56 p.c.), and renal insufficiency (24 p.c.) were prevailing. The discussion turns on the diagnosis factors and the factors involved in the prognosis. Considering that the death rates were 64 p.c. with the patients who had undergone medical treatment and 14 p.c. with those who had undergone operations, the relevance of the surgical treatment has been emphasized.

The authors report 7 cases of endocarditis on cardiac pacing catheters observed out of a total of 2 950 primary implantations and 1 600 pacemaker replacements. This is a rare condition (0.15%) but carries a poor prognosis as it usually occurs in elderly patients and demands aggressive management. The presence of multiple pacing catheters and surgical contamination due to manipulation of the pulse generator (reimplantation, pacemaker replacement) are predisposing factors. The infecting organism in these cases was a staphylococcus. One case of metastatic infection was also observed (acinetobacter). Ablation of the septic endocarditic material under effective, prolonged, double antibiotherapy is essential. Recently implanted electrodes were withdrawn by simple traction in 2 cases. This manoeuvre was attempted initially in all cases but stopped when chest pain or runs of ventricular extrasystoles occurred. Open heart explantation of pacing electrodes adherent to the ventricular apex was performed in 5 patients. Cardiopulmonary bypass without cardiac standstill enabled dissection of the fibrous rings surrounding the catheter after purging the blood from the atrial and ventricular cavities. In one patient, associated tricuspid valve endocarditis was found and valvular replacement was performed with a bioprosthesis. Endocardial pacing was replaced by epicardial pacing in patients with permanent AV block. The prognosis of this condition is poor; there were 2 deaths in this series of 7 patients.