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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Prof. Leopoldo Perez de Isla,
Prof. José-Luis Zamorano
To improve prognosis of patients with endocarditis, early diagnosis using echocardiography is key. In patients with potential diagnostic problems seen by transthoracic echocardiography, - prothetic valves, poor acoustic window or even recurrence of clinical symptoms such as fever, heart failure or embolic events -transesophageal echocardiography is needed. However, initial positive in-hospital outcome as a response to medical treatment must not lead us to consider the patient with endocarditis as low risk.
Reduced mortality and complications
Despite important advances in the management of patients with infective endocarditis in recent years, this disease remains life threatening. Early diagnosis resulting from ample use of echocardiography, improvements in antimicrobial treatment and combined medical-surgical aproaches have lead to reduced mortality and complications during the active phase of the disease. However, serious sequelae, namely valve incompetence, recurrence or relapse, congestive heart failure and death are a sizeable threat extending far beyond discharge after successful treatment of the active disease has been reached. Several studies have focused on the issue of short term survival, but data regarding mid and long term prognosis are scarce.
Nevertheless, a poor short, mid and long term prognosis
We studied prognosis in terms of morbidity and long term survival in patients who had been successfully managed with medical therapy during the in-hospital phase of the disease. In our hospital, we analysed the cases of 151 patients with endocarditis; 84 patients (56%) underwent surgery or died during the in-hospital phase of the disease and the remaining 67 patients (44%), received medical treatment only and were discharged clinically stable with the final diagnosis of healed infective endocarditis. In our study, complications occurred in 47 cases (70%) We analysed the need for surgery or death after discharge in those patients who received medical treatment only and did not need any surgical intervention during in-hospital phase. The average follow-up for the 67 patients was 28,98 weeks (95% CI: 15,38-42,6 weeks). Follow up event free survival was 25% at one year and 10% at two years. Thirty-five patients (52%) underwent late surgery to correct sequelae of the infection. Forty patients died of cardiovascular causes as a direct consequence of infective endocarditis itself or due to worsening of the underlying cardiac disease. Complications occurred in 47 cases (70%). Among them, congestive heart failure developed in 36% of patients, 28% had at least one embolic episode, 17% had an abcess or a pseudoaneurism and 13% had a cardiac rupture or perforation.
Important advances have been achieved in terms of diagnosis and treatment of infective endocarditis over the last 50 years which have lead to radical modifications in the clinical course and natural history of the disease. However, this infection still holds high rates of morbidity and mortality in different subgroups of patients. Our results show us that infective endocarditis is a disease with a poor short, mid and long term prognosis. The initial good response to medical treatment must not lead us to consider the patient as at low risk and we must carry out a cautious and close follow-up.
1. Moreno R, Zamorano J, Almeria C, Villate A, Rodrigo JL, Herrera D, Alvarez L, Moran J, Aubele A, Mataix L, De Marco E, Sanchez-Harguindey L. Influence of diabetes mellitus on short- and long-term outcome in patients with active infective endocarditis. : J Heart Valve Dis 2002 Sep;11(5):651-9. 2. Zamorano J, Sanz J, Moreno R, Almeria C, Rodrigo JL, de Marco E, Serra V, Samedi M, Sanchez-Harguindey L. Better prognosis of elderly patients with infectious endocarditis in the era of routine echocardiography and nonrestrictive indications for valve surgery : J Am Soc Echocardiogr 2002 Jul;15(7):702-7. 3. Zamorano J, Sanz J, Moreno R, Almeria C, Rodrigo JL, Samedi M, Herrera D, Aubele A, Mataix L, Serra V, Sanchez-Harguindey L. Comparison of outcome in patients with culture-negative versus culture-positive active infective endocarditis. Am J Cardiol 2001 Jun 15;87(12):1423-5 4. F.Delahaye,R. Ecochard, G de Gevigney, et al. The long term prognosis of infective endocarditis. Eur Heart J 1995;16:48-53. 5. Zamorano J, de Isla LP, Malangatana G, Almeria C, Rodrigo JL, Aubele A et al. Infective endocarditis: mid-term prognosis in patients with good in-hospital outcome. J Heart Valve Dis 2005;14:303–9. 6. Martinez-Selles M, Munoz P, Estevez A, Del Castillo R, Garcia-Fernandez MA, Rodriguez-Cre´ixems M et al. Long-term outcome of infective endocarditis in nonintravenous drug users. Mayo Clin Proc 2008;83:1213–7. 7. Hill EE, Herijgers P, Claus P, Vanderschueren S, Herregods MC, Peetermans WE. Infective endocarditis: changing epidemiology and predictors of 6-month mortality: a prospective cohort study. Eur Heart J 2007;28:196–203. 8. Habib G, Thuny F, Avierinos JF. Prosthetic valve endocarditis: current approach and therapeutic options. Prog Cardiovasc Dis 2008;50:274–81.
J Zamorano, C Almería, L Perez Isla, JL Rodrigo University Clinic San Carlos, Madrid
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