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Infective Endocarditis Presentation, Etiology, and Outcome
Study Questions:
What are the findings with and outcomes of patients with infective endocarditis (IE)?
Methods:
The European Society of Cardiology (ESC) EurObservational Research Program (EORP) European Endocarditis Research Registry (EURO-ENDO) is a multicenter observational study of patients presenting with definite or possible IE to hospitals in Europe and ESC-affiliated/nonaffiliated countries. From January 2016 through March 2018, centers were asked to include consecutive patients aged >18 years who presented with IE during a 1-year period. Participating centers were identified by the European Association of Cardiovascular Imaging as either high-level IE centers (high-volume [≥20 patients per year] with expertise in IE diagnosis, management, imaging, and surgical therapy); or low-volume centers (<20 patients per year) without surgical facilities. Inclusion criteria were a diagnosis of definite IE or possible IE considered and treated as IE based on ESC 2015 IE diagnostic criteria. Data were collected at inclusion and during hospitalization; including demographics, patient history, Charlson comorbidity index, echocardiographic findings, use of other imaging techniques (computed tomography [CT] scan, 18F-fluorodeoxyglucose positron emission tomography CT [18F-FDG PET/CT], leucocyte scintigraphy), medical therapy, complications (embolic, infectious, and hemodynamic), theoretical indications for surgery, and in-hospital mortality.
Results:
The study included a prospective cohort of 3,116 adult patients (2,470 from Europe, 646 from non-ESC countries) admitted to 156 hospitals in 40 countries. IE was native (NVE) in 1,764 (56.6%) patients, prosthetic (PVIE) in 939 (30.1%), and cardiac device-related (CDRIE) in 308 (9.9%). IE was community-acquired in 2,046 (65.7%) patients. Microorganisms involved were staphylococci in 1,085 (44.1%) patients, oral streptococci in 304 (12.3%), enterococci in 390 (15.8%), and Streptococcus gallolyticus in 162 (6.6%). 18F-FDG PET/CT was performed in 518 (16.6%) patients and had cardiac uptake (major criterion) in 222 (42.9%) patients, with a better sensitivity in PVIE (66.8%) than in NVE (28.0%) and CDRIE (16.3%). Embolic events occurred in 20.6% of patients, and were significantly associated with tricuspid or pulmonary IE, documented presence of a vegetation, and Staphylococcus aureus IE. According to ESC guidelines, cardiac surgery was indicated in 2,160 (69.3%) patients, but ultimately performed in only 1,596 (73.9%) of them. In-hospital death occurred in 532 (17.1%) patients and was more frequent in PVIE. Independent predictors of mortality were Charlson comorbidity index, creatinine >2 mg/dl, congestive heart failure, vegetation length >10 mm, cerebral complications, abscess, and failure to undertake surgery when indicated.
Conclusions:
The authors concluded that IE is a life-threatening disease, with frequent lethal outcome despite profound changes in its clinical, microbiological, imaging, and therapeutic profiles.
Perspective:
During 4 months in 2001, The Euro Heart Survey screened for moderate or severe heart valve disease in 92 centers in 25 European countries. Of 5,001 patients identified in the survey, 159 patients had active IE (74% NVE, 26% PVIE); a previous publication described those patients and their outcomes (Tornos P, et al., Heart 2005;91:571-5). The present study describes a much larger and more modern survey of IE. PVIE is more prevalent and CDRIE is now described; current organisms, imaging techniques (including 18F-FDG PET/CT), and surgical interventions (with persistent underutilization of mitral valve repair for mitral NVE) are described. Outcomes remain very poor, with in-hospital mortality of 17% for the whole group, 20% for PVIE, 16% for NVE, and 15% for CDRIE. These data underscore the malignant nature and the need for aggressive management of IE.
Keywords: Cardiac Surgical Procedures, Creatinine, Diagnostic Imaging, Echocardiography, Endocarditis, Endocarditis, Bacterial, Enterococcus, Fluorodeoxyglucose F18, Heart Failure, Heart Valve Diseases, Hemodynamics, Hospital Mortality, Positron-Emission Tomography, Staphylococcus, Staphylococcus aureus, Streptococcus, Tomography, Emission-Computed
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