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Introduction and Aim: Infective endocarditis (IE) is associated with high morbidity and mortality. It is important to determine which factors increase the risk of poor outcome in order to enable early detection and aggressive treatment, including surgery. The aim of our study was to identify factors predicting complications and in-hospital mortality in patients with IE and to analyze conditions predisposing to surgery and its outcome., Methods: We performed a retrospective study including patients with IE who underwent transesophageal echocardiography in a tertiary hospital center (2006-2014)., Results: A total of 233 patients were analyzed (69.1% male; mean age 63.4±15.2 years; mean follow-up 28.4±30.7 months). The complication rate was 56.6% and in-hospital mortality was 16.3%. Independent predictors of mortality were chronic obstructive pulmonary disease (OR 4.89; CI 1.36-17.63; p=0.015), clinical course complicated by cerebral embolism (OR 9.38; CI 3.26-26.96; p<0.001), and IE due to Staphylococcus spp. (OR 3.78; CI 1.32-10.85; p=0.014) and non-HACEK Gram-negative bacilli (OR 12.85; CI 2.61-63.23; p=0.002). Surgery was performed in 36.9%. This group had higher percentages of males, younger patients, aortic valve IE, large vegetations, perivalvular extension, severe valvular regurgitation and heart failure. In patients with surgical indication (n=133), those who underwent surgery had lower in-hospital mortality (15.5% vs. 32.6%, p=0.028) and better long-term survival (log-rank p=0.029)., Conclusion: The results of this study may help to identify IE patients who are at increased risk of worse outcome, offering the opportunity to change the course of the disease and to improve prognosis with earlier and more aggressive intervention., (Copyright © 2018 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: This study aimed at identifying predictive variables for in-hospital mortality, calculating the probability of death and creating a risk index for death by infective endocarditis by comparing two methods using a Receiver Operating Characteristic (ROC) curve., Methods: A retrospective study was conducted of 186 consecutive cases of confirmed infective endocarditis divided into two groups: discharged (137) and in-hospital death (49). Based on the odds ratios obtained by multivariate analysis, the probability of death was calculated and a mortality risk index created., Results: Factors predictive of higher mortality (multivariate analysis) and the risk index, with their respective weights were: age >or= 40 years (OR = 4.16; 95%CI [1.63-10.80] - 4 points), class IV heart failure or cardiovascular shock (OR = 4.93; 95%CI [1.86-13.05] - 5 points), uncontrolled sepsis (OR = 5.97; 95%CI [1.95-18.35] - 6 points), conduction disorder (OR = 5.07; 95%CI [1.67-15.35] - 5 points), arrhythmia (OR = 8.17; 95%CI [2.60-25.71] - 8 points), valve with extensive damage or abscess or prosthesis (OR = 4.77; 95%CI [1.44-15.76] - 5 points) and large and mobile vegetation (OR = 4.36; 95%CI [1.55-12.90] - 4 points). Patients with scores between 0 and 10 had a mortality of 5.26% and scores over 20 of 78.9%., Conclusions: The higher the score, the higher the mortality rate. The mortality risk index may be used to estimate mortality in Infective Endocarditis.

Objective: To assess the major causes of surgical morbidity and mortality in patients with infective endocarditis operated upon in a regional cardiology center., Methods: Thirty-four patients underwent surgical treatment for infective endocarditis. Their ages ranged from 20 to 68 years (mean of 40.6) and 79% were males. Their NYHA functional classes were as follows: IV - 19 (55.8%) patients; III - 12 (35.2%) patients; II - 3 (8.8%) patients. Blood cultures were positive in only 32% of the cases. Eight patients had already undergone previous cardiac surgery, whose major indication (82.3%) was heart failure refractory to clinical treatment., Results: Four (11.7%) patients died at the hospital. Follow-up was complete in 26 (86%) patients. Five (14.7%) patients died later, 12, 36, 48, 60, and 89 months after hospital discharge. Of the 21 patients being currently followed up, 1 is in NYHA functional class III, and 5 in NYHA functional class II., Conclusion: A high degree of clinical suspicion, at an early diagnosis, and indication of surgical treatment prior to deterioration of left ventricular function and installation of generalized sepsis may improve prognosis.

Introduction and Objectives: Infective endocarditis (IE) is a disease with a high morbidity and mortality during the active phase and a considerable risk of complications during follow-up. The aim of this study is to describe the clinical features of IE associated with perioperative mortality in patients undergoing surgery and the short- and long-term prognosis of this disease after surgical treatment., Patients and Methods: The clinical files of 150 patients (pts) admitted to our institution between 1989 and 2001 and whose final diagnosis was IE (Duke criteria) were retrospectively reviewed. Thus all patients included underwent at least 1 transthoracic examination, and a transesophageal examination if indicated. The study population was 69 patients with IE, 62 of whom (90%) underwent prosthetic valve replacement and 7 (10%) underwent explanation of pacemaker electrocatheter. In the statistical analysis, quantitative variables are expressed as means +/- SD and qualitative variables as proportions (percentages). Differences in survival were determined using the Kaplan-Meier log rank method. Associations were considered statistically significant when the p value was < 0.05., Results: The mean age was 56 +/- 15 years. Thirty-five cases (51%) had prosthetic valve endocarditis, 30 (39%) had native valve IE and 7 (10%) pacemaker electrocatheter IE. Fifty-two patients (75%) had positive blood cultures. The most frequent agents were S. epidermidis (14.5%), S. aureus (14.5%), Enterococci (13%) and S. viridans (10%). Total perioperative mortality was 17.4% (n = 12), and surgical mortality was 19.4%. Our study shows a statistical tendency for higher mortality in diabetic patients (50% vs. 14%, p = 0.052) and in women (29% vs. 11%, p = 0.065). In multivariate analysis, the presence of heart failure was an independent predictor of perioperative mortality (OR = 11.4; 95% CI: 2.0-215.2; p = 0.024). Accumulated mortality in the first year was 28% and 5-year mortality was 48%., Conclusions: Prosthetic valve replacement in patients with IE is associated with high perioperative mortality (17.4%). Despite good early postoperative results, the mortality rate increases during the first year as well as the need for reoperation.

Purpose: To study the epidemiological, clinical, therapeutic and evolutive aspects of endocarditis in a group of patients aging 12 to 20 years-old (mean 15.5)., Methods: Thirty-three consecutive patients (14 males, 19 females) admitted with infective endocarditis were retrospectively studied., Results: Infective endocarditis mortality was 42%. Rheumatic heart disease was the predominant underlying condition in 63% of patients. Congenital heart disease (24%) and cardiac prosthesis (12%) were the other affections involved. The majority of patients (78%) were in functional class III and IV, with more deaths than the 22% who were in functional class I and II (p = 0.01). Staphylococcus aureus was the most frequently isolated agent (42% of the positive blood cultures, followed by Staphylococcus viridans, 21%). Multivariate analysis identified total leukocyte count above 10,000/mm3 and functional class, both at admission (p = 0.01 and p = 0.004, respectively), and the occurrence of embolic complications (p = 0.03) as independent predictors of in-hospital mortality., Conclusion: Rheumatic heart disease remains, as in adults, the main predisposing factor for infective endocarditis in adolescents, and S. aureus is, like in children, the leading agent. Mortality is high and functional class at hospital admission, embolic complications and leukocytosis are independent predictors of in-hospital mortality.

The factors leading to high postoperative mortality in active infectious endocarditis (IE) are poorly defined. We studied patients operated at an University Hospital between March 1978 and April 1992. We hypothesized that the summation of potential adverse factors would strongly increase mortality after surgery. We studied 39 patients (28 men), age range 13-70 years (mean +/- SD = 32 +/- 16) operated during active IE (time from onset 52 +/- 48 days). Predisposing factor: rheumatic valvar disease in 14 cases, intravenous drug use in 5. Affected valves: aortic in 14, mitral in 10, tricuspid in 8, multiple structures in 7. In most cases, S aureus (12) or Streptococcus sp (10) was isolated in blood cultures. Surgery was indicated in most patients because of heart failure (30), multiple embolic complications (17) or treatment failure (14). The possible adverse influence of specific demographic characteristics, clinical features and surgical variables was assessed by the Student t test or the chi 2 test. Also, multiple regression analysis was performed in order to identify independent adverse factors for increased mortality. Positive correlations were further investigated with the chi 2 test to assess whether an increasing number of adverse factors could identify a special subset of patients with markedly elevated death risk. Fourteen patients (36%) died after surgery. Emergency surgery (p = 0.001), the presence of coma 6 hours after surgery (p = 0.0015) and S. aureus infection (p = 0.023) were all associated with increased mortality. The presence of neurological complications was correlated with a high mortality (54% vs. 27%). However this increase was of dubious statistical significance (p = 0.097). Multiple regression analysis confirmed S. aureus and emergency surgery as independent adverse factors for increased mortality. When put together, an increasing number of adverse factors was highly predictive of a fatal outcome, even after exclusion of that evaluated after surgery (level of consciousness). Patients with two or three adverse factors had a very high mortality rate (> 76.9%). Mortality following surgery for active IE is increased in patients operated on an emergency basis especially if the infection is caused by S. aureus. The presence of neurological complications may also be associated with worse outcome. Early consideration of surgery should reduce the high mortality in patients with active IE.

Purpose: To analyse, retrospectively, 83 patients with infective endocarditis (IE) that were operated during the acute phase of the disease and to identify possible subgroups with distinct mortality., Methods: Between 1985 to 1990, 83 patients comprised the subject of this analysis. Fifty-one (61%) were male, aged between 3 months to 71 years, mean of 31.4 +/- 16.7 years., Results: We could identify two subgroups that were most frequently operated on: the left side IE and the Staphylococcus aureus; and 77 (43%) had left sided IE (p < 0.001). When discriminated accordingly to the specifically etiologic agent (Staphylococcus aureus) this difference continues to be statistically significant: of 29 left sided IE by this agent 13 (45%) were operated on, whereas from 22 right sided IE by the same agents, just 3 (14%) were operated on (p < 0.05). The two major etiologic agents did not show any statistically significant difference in the number of patients that needed to be operated on: on those 51 patients with Staphylococcus aureus IE, 16 (31%) were treated surgically, while from the 60 patients with Streptococcus viridans, 22 (37%) underwent to surgical procedure (p- NS). The mortality in the patients treated by surgery was 32%, and those with Staphylococcus aureus IE were responsible for 46% of the total surgical deaths., Conclusion: Surgical treatment were most frequently used in the patient with left sided IE independently of the etiologic agent.

Purpose: To analyze the clinical, laboratory and pathological aspects of 20 cases of infectious endocarditis (IE) who died. The authors compared patients with diagnosis before death of IE and those with diagnosis was made after autopsy., Methods: Twenty patients who died with IE between April 1982 and November 1991 were studied. We looked for the clinical aspects (fever, cardiac murmurs, anemia, splenomegaly, embolic events and skin manifestation), laboratory aspects (hemocultures), echocardiographic and anatomopathologic features (valvar vegetations events and embolic accidents founded at autopsy). The sample was divided in two sub-groups: A--with clinical diagnosis of IE before and B--without diagnosis before death., Results: Group A--9 patients aged 8-58 years, 3 men, all them with cardiac murmurs, fever and anemia, 5 with splenomegaly. Hemocultures were done in 7 patients and positive in 1. Echocardiogram with valvar vegetation were found in 4 out of 5 patients (80% positive). At autopsy mitral valve vegetation were present in 7, aortic 3, tricuspid 3. One patient showed the exposure of three valves and two of 2 valves. Embolic events were found in 4. Group B--11 patients most of them older then 50 years (54.5%) (p < 0.05) 5 men, all them presented fever and anemia. Cardiac murmurs in 6 (54%) and none with splenomegaly. In one case hemoculture and echocardiogram, were done and were negative. Anatopathologic study showed compromise of mitral valve in 5, aortic 4, tricuspid 2, pulmonary 1. Two patients had 2 valves compromised. In one case a mural vegetation (right atrium) was found. Embolic events were present in 2 cases., Conclusion: In group B a significant number of patients (p < 0.05) were older than 50 years and presented his symptoms as an acute illness. We concluded that older patients with compromised general state and fever with or without embolic events IE must be remember.

Purpose: To characterize the occurrence of bacteremia during delivery and to verify the necessity of prophylaxis against infective endocarditis., Methods: The authors collected hemoculture of 100 women, 15,30 and 45 minutes after delivery. The data were collected from May 1992 until May 1993. The positive hemocultures were followed by antibiogram., Results: Seven hemocultures were positive: six for Staphylococcus, one for Candida sp, Penicilium sp, Clandosporum sp and Aspergillus sp that were found in association. Four patients had prematures amniorrhexis, longer than 6 hours before delivery (p < 0.05). Six patients had labor longer than 6 hours after admission (p < 0.05). The authors did not observe differences related to vaginal delivery with or without forceps or cesarean section. The samples were all sensible to cefalotin at the antibiogram., Conclusion: Labor and delivery is a high risk procedure for bacteremia and so for ineffective endocarditis in susceptible patients. The statistical analysis recognize as risk factors labor longer than 6 hours inside the hospital and premature amniorrhexis. We propose the use of intravenous cefalotin 1g 60 minutes before expulsion and repeated 6 and 12 hours later.

Purpose: Study of clinical features and etiologic agents, treatment and mortality of patients with infective endocarditis (IE)., Patients and Methods: 300 episodes of IE occurring in 288 patients, ages ranged between 0.2 and 78 (mean 30.76) years; 185 (62%) episodes occurred in males., Results: a) etiologic agents: viridans group streptococci in 93 (31%) episodes, enterococci en 21 (7%), group D-non enterococci in 19 (6%) (13 S. bovis), other streptococci in 14 (5%), Staphylococcus aureus in 59 (20%), Staphylococcus epidermidis in 14 (5%), gram-negative bacteria in 16 (5%), gram-positive bacteria other than streptococci and staphylococci and staphylococci in 8 (3%), fungi in 4 (1%). The etiologic agents were not identified in 52 (17%) episodes; b) underlying cardiac diseases: valvular heart disease in 119 (40%) episodes, congenital heart disease in 37 (12%), prosthetic heart valves in 69 (23%), other heart diseases in 6 (2%). There was no evidence of previous heart disease in 69 (23%); c) treatment: surgical treatment was undertaken in 102 (34%) episodes. The frequency of surgical treatment in relation to the etiologic agents ranged between 1% (non-group D streptococcus) and 62% (negative blood cultures). The frequency of operation in relation to underlying heart disease ranged between 17% (other heart diseases), 19% (congenital heart disease) and 54% (prosthetic heart valve); d) mortality: 78 (26%) patients died, 56 (28%) of the 198 submitted to medical treatment and 22 (21%) of the 102 submitted also to surgical treatment. The mortality in the different groups of etiologic agents ranged between 5% (non group D streptococcus) and 62% (gram-positive bacteria other than streptococci ans staphylococci); in relation to the underlying with other heart disease, 19% in valvular heart disease patients, 21% in patients with congenital heart disease, 23% in patients without known heart disease and 43% in patients with prosthetic heart valves., Conclusion: The mortality associated with IE remains still high in spite of modern treatment; the mortality is different in relation to the cardiac status before the IE.

Purpose: To analyse clinical aspects, diagnosis and treatment of infective endocarditis (IE), in order to guide medical procedures and indicate the surgical treatment., Patients and Methods: 83 patients were submitted to clinical treatment of IE between January 1980 and December 1987; clinical aspects, laboratory and pathologic-anatomy findings, the site of infection and the entrance of micro-organism were studied., Results: 37 (44.6%) patients were males. Fever was present in 75 (90.4%) cases, cardiac murmur in 76 (91.5%), splenomegaly in 28 (33.7%) and heart failure (III and IV) in 32 (39.8%) patients. Blood culture was positive in 55.5%; staphylococcus 50% of blood cultures; anemia was present in 66 cases (79.5%) and high serum mucoprotein in 58 (92%); echocardiography was 85.7% positive. The mortality was 39.76%; congestive heart failure was the main cause of death; 78.1% of these ones occurred in the first 15 days of antibiotic-therapy. The mitral valve was the one most impaired and the most frequent entrance of micro-organisms in oropharynx., Conclusion: Congestive heart failure, sepsis and systemic embolisms were the main complications that led the patient to death in course of IE, usually before 15 days of antibiotic-therapy. In these cases, we may hypothesize that prompt surgical treatment could have diminished the mortality of IE.

Objective: to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results., Design: retrospective analysis on clinical data, surgery and follow up., Setting: patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon., Patients and Interventions: sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis., Measurements and Results: the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals., Conclusion: the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

Purpose: Study of clinical features and etiologic agents, treatment and mortality of patients with infective endocarditis (IE)., Patients and Methods: 300 episodes of IE occurring in 288 patients, ages ranged between 0.2 and 78 (mean 30.76) years; 185 (62%) episodes occurred in males., Results: a) etiologic agents: viridans group streptococci in 93 (31%) episodes, enterococci en 21 (7%), group D-non enterococci in 19 (6%) (13 S. bovis), other streptococci in 14 (5%), Staphylococcus aureus in 59 (20%), Staphylococcus epidermidis in 14 (5%), gram-negative bacteria in 16 (5%), gram-positive bacteria other than streptococci and staphylococci in 8 (3%), fungi in 4 (1%). The etiologic agents were not identified in 52 (17%) episodes; b) underlying cardiac diseases: valvular heart disease in 119 (40%) episodes, congenital heart disease in 37 (12%), prosthetic heart valves in 69 (23%), other heart diseases in 6 (2%). There was no evidence of previous heart disease in 69 (23%); c) treatment: surgical treatment was undertaken in 102 (34%) episodes. The frequency of surgical treatment in relation to the etiologic agents ranged between 1% (non-group D streptococci) and 62% (negative blood cultures). The frequency of operation in relation to underlying heart disease ranged between 17% (other heart diseases), 19% (congenital heart disease) and 54% (prosthetic heart valve); d) mortality: 78 (26%) patients died, 56 (28%) of the 198 submitted to medical treatment and 22 (21%) of the 102 submitted also to surgical treatment. The mortality in the different groups of etiologic agents ranged between 5% (non-group D streptococci) and 62% (gram-positive bacteria other than streptococci and staphylococci); in relation to the underlying heart disease, the mortality was 16% in patients with other heart disease, 19% in valvular heart disease patients, 21% in patients with congenital heart disease, 23% in patients without known heart disease and 43% in patients with prosthetic heart valves., Conclusion: The mortality associated with IE remains still high in spite of modern treatment; the mortality is different in relation to the different etiologic agents and in relation to the cardiac status before the IE.