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Beyond initial positive in-hospital outcome in patients with endocarditis

An article from the e-journal of the ESC Council for Cardiology Practice

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.

Myocardial Disease


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.

Conclusion:


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.

References


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VolumeNumber:

Vol8 N°30

Notes to editor


J Zamorano, C Almería, L Perez Isla, JL Rodrigo
University Clinic San Carlos, Madrid

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.