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Complicated infective endocarditis necessitating ICU admission: clinical course and prognosis.

Karth G, Koreny M, Binder T, Knapp S, Zauner C, Valentin A, Honninger R, Heinz G, Siostrzonek P - Crit Care (2002)

Bottom Line: Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients.The APACHE-III score on admission did not differ statistically between the two groups (69 +/- 30 versus 84 +/- 34, P = 0.17).Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.

View Article: PubMed Central - PubMed

Affiliation: Resident, Department of Cardiology, University of Vienna, Austria. georg.delle-karth@univie.ac.at

ABSTRACT

Aim: To study incidence, clinical course and prognostic factors in patients admitted to medical intensive care units (ICUs) because of a complicated course of infective endocarditis.

Method: This was a retrospective multicenter observational study of 4106 patients admitted to four medical ICUs in one tertiary hospital and one university hospital between 1994 and 1999.

Results: Infective endocarditis was identified in 33 (0.8%) patients. Of these, 26 were male, mean age was 59 +/- 12 and APACHE-III score was 75 +/- 31. Reasons for transfer to the ICU were congestive heart failure in 64%, septic shock in 21%, neurological deterioration in 15% and cardiopulmonary resuscitation in 9%. Inotropes or vasoconstrictors were required in 73% and multiorgan failure developed in 64% of the patients. Prosthetic valve endocarditis was present in 21%. Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients. Transthoracic echocardiograms were diagnostic in only 33% and transesophageal studies were required in 91% to confirm diagnosis or fully to delineate the extent of disease. Surgical intervention was performed in 60% of the patients, and the remaining 40% were only treated medically. The APACHE-III score on admission did not differ statistically between the two groups (69 +/- 30 versus 84 +/- 34, P = 0.17). In-patient mortality was 84% in patients treated medically, and 35% in surgically treated patients. Using multivariate analysis, acute renal failure on admission was identified as the independent single predictor for in-patient death (OR 5, 95% CI 1.04-24.03, P = 0.04).

Conclusion: The prognosis for patients with infective endocarditis requiring admission to a medical ICU is serious. Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.

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Related in: MedlinePlus

Transesophageal long axis view in a patient with severe heart failure and mitral incompetence showing a large vegetation (at arrows) attached to the posterior mitral valve leaflet. LA, left atrium; LV, left ventricle; MV, mitral valve; Veg, vegetation.
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Figure 1: Transesophageal long axis view in a patient with severe heart failure and mitral incompetence showing a large vegetation (at arrows) attached to the posterior mitral valve leaflet. LA, left atrium; LV, left ventricle; MV, mitral valve; Veg, vegetation.

Mentions: The echocardiogram was indicative for IE in all patients. Typical findings are presented in Figures 1 and 2. Diagnosis of IE was established by transthoracic study in 11 (33%) patients and by transesophageal echocardiography in 22 (67%) patients. However in eight patients with an already diagnostic transthoracic echocardiography, additional trans-μ esophageal echocardiography was required for complete assessment of extent of disease. Valvular vegetations were seen in 25 (76%) patients, of whom 13 had aortic valve involvement, 10 had mitral valve involvement and two had combined aortic and mitral valve involvement. Transesophageal findings missed by the initial transthoracic echocardiography were valvular vegetations in 17 cases, flail leaflets in two cases, and abscess formation in 10 cases. Maximum diameter of the vegetation was >10 mm in 12 patients and <10 mm in 13 patients. There was a trend towards a higher risk of subsequent systemic embolism in patients with a vegetation size >10 mm (OR 5.5, 95% CI 0.96–31.43, P = 0.07). Cavities indicating abscess formation were found in 18 patients (54%). Severe valvular regurgitation (grade 3 or 4) of the aortic valve (n = 13) and/or mitral valve (n = 8) was present in 20 (60%) patients.


Complicated infective endocarditis necessitating ICU admission: clinical course and prognosis.

Karth G, Koreny M, Binder T, Knapp S, Zauner C, Valentin A, Honninger R, Heinz G, Siostrzonek P - Crit Care (2002)

Transesophageal long axis view in a patient with severe heart failure and mitral incompetence showing a large vegetation (at arrows) attached to the posterior mitral valve leaflet. LA, left atrium; LV, left ventricle; MV, mitral valve; Veg, vegetation.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC111181&req=5

Figure 1: Transesophageal long axis view in a patient with severe heart failure and mitral incompetence showing a large vegetation (at arrows) attached to the posterior mitral valve leaflet. LA, left atrium; LV, left ventricle; MV, mitral valve; Veg, vegetation.
Mentions: The echocardiogram was indicative for IE in all patients. Typical findings are presented in Figures 1 and 2. Diagnosis of IE was established by transthoracic study in 11 (33%) patients and by transesophageal echocardiography in 22 (67%) patients. However in eight patients with an already diagnostic transthoracic echocardiography, additional trans-μ esophageal echocardiography was required for complete assessment of extent of disease. Valvular vegetations were seen in 25 (76%) patients, of whom 13 had aortic valve involvement, 10 had mitral valve involvement and two had combined aortic and mitral valve involvement. Transesophageal findings missed by the initial transthoracic echocardiography were valvular vegetations in 17 cases, flail leaflets in two cases, and abscess formation in 10 cases. Maximum diameter of the vegetation was >10 mm in 12 patients and <10 mm in 13 patients. There was a trend towards a higher risk of subsequent systemic embolism in patients with a vegetation size >10 mm (OR 5.5, 95% CI 0.96–31.43, P = 0.07). Cavities indicating abscess formation were found in 18 patients (54%). Severe valvular regurgitation (grade 3 or 4) of the aortic valve (n = 13) and/or mitral valve (n = 8) was present in 20 (60%) patients.

Bottom Line: Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients.The APACHE-III score on admission did not differ statistically between the two groups (69 +/- 30 versus 84 +/- 34, P = 0.17).Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.

View Article: PubMed Central - PubMed

Affiliation: Resident, Department of Cardiology, University of Vienna, Austria. georg.delle-karth@univie.ac.at

ABSTRACT

Aim: To study incidence, clinical course and prognostic factors in patients admitted to medical intensive care units (ICUs) because of a complicated course of infective endocarditis.

Method: This was a retrospective multicenter observational study of 4106 patients admitted to four medical ICUs in one tertiary hospital and one university hospital between 1994 and 1999.

Results: Infective endocarditis was identified in 33 (0.8%) patients. Of these, 26 were male, mean age was 59 +/- 12 and APACHE-III score was 75 +/- 31. Reasons for transfer to the ICU were congestive heart failure in 64%, septic shock in 21%, neurological deterioration in 15% and cardiopulmonary resuscitation in 9%. Inotropes or vasoconstrictors were required in 73% and multiorgan failure developed in 64% of the patients. Prosthetic valve endocarditis was present in 21%. Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients. Transthoracic echocardiograms were diagnostic in only 33% and transesophageal studies were required in 91% to confirm diagnosis or fully to delineate the extent of disease. Surgical intervention was performed in 60% of the patients, and the remaining 40% were only treated medically. The APACHE-III score on admission did not differ statistically between the two groups (69 +/- 30 versus 84 +/- 34, P = 0.17). In-patient mortality was 84% in patients treated medically, and 35% in surgically treated patients. Using multivariate analysis, acute renal failure on admission was identified as the independent single predictor for in-patient death (OR 5, 95% CI 1.04-24.03, P = 0.04).

Conclusion: The prognosis for patients with infective endocarditis requiring admission to a medical ICU is serious. Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.

Show MeSH
Related in: MedlinePlus