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Canadian Journal of Cardiology

Short- and Long-term Outcomes of Medically Treated Isolated Left-Sided Endocarditis: A Retrospective Study With 5-Year Longitudinal Follow-up

Published:November 05, 2019DOI:https://doi.org/10.1016/j.cjca.2019.10.039

      Abstract

      Background

      A retrospective study of medically treated isolated left-sided infective endocarditis (LSIE) patients identifying predictors of outcomes with nonoperative management was undertaken.

      Methods

      Medical records of 135 Manitoban medically managed LSIE patients from January 2004 to December 2016 were reviewed. Five-year survival for 135 patients and hospitalization data till March 2016 for 65 patients were collected from the Manitoba Centre for Health Policy.

      Results

      In-hospital mortality was 44%. Patients with surgical indications were more likely to die in-hospital than those without (53% vs 24%; P = 0.002). Survival at 1 and 5 years was 43% and 23%, respectively. All-cause readmission at 1 and 5 years was 64% and 84%, respectively. At 1 and 5 years, readmission from major adverse events (heart failure, stroke, endocarditis) was 25% and 47%, and from recurrent endocarditis was 17% and 26%, respectively. Severe valvular regurgitation was a risk factor for in-hospital mortality (odds ratio, 3.52; P = 0.022), poor long-term survival (hazard ratio [HR], 2.57; P < 0.001), and recurrent endocarditis (HR, 5.93; P < 0.001). Prosthetic valve endocarditis was a risk factor for poor long-term survival (HR, 2.11; P = 0.002). Streptococcus viridans group was associated with better rates of in-hospital mortality (odds ratio, 0.28; P = 0.018) and long-term survival (HR, 0.34; P < 0.001).

      Conclusions

      Nonoperative management of LSIE carries a poor prognosis but may have a role in select cases. Surgical management remains the mainstay for patients with clear surgical indications, including severe regurgitation and prosthetic valve endocarditis. Further prospective analyses are required to better delineate appropriate patient selection for nonsurgical management.

      Résumé

      Introduction

      Nous avons entrepris une étude rétrospective auprès de patients ayant une endocardite infectieuse isolée du cœur gauche (EICG) traitée médicalement pour déterminer les prédicteurs des résultats cliniques de la prise en charge non opératoire.

      Méthodes

      Nous avons passé en revue les dossiers médicaux de 135 patients manitobains ayant une EICG prise en charge médicalement de janvier 2004 à décembre 2016. Nous avons collecté les données sur la survie après 5 ans de 135 patients et les données d’hospitalisation jusqu’en mars 2016 de 65 patients du Manitoba Centre for Health Policy.

      Résultats

      La mortalité intrahospitalière était de 44 %. Il était plus probable que les patients candidats à l’intervention chirurgicale meurent à l’hôpital que les patients non-candidats (53 % vs 24 %; P = 0,002). La survie après 1 an et la survie après 5 ans étaient respectivement de 43 % et de 23 %. La réadmission toutes causes confondues après 1 an et la réadmission toutes causes confondues après 5 ans étaient respectivement de 64 % et de 84 %. Après 1 an et après 5 ans, la réadmission respective en raison d’événements indésirables majeurs (insuffisance cardiaque, accident vasculaire cérébral, endocardite) était de 25 % et de 47 %, et en raison d’une endocardite récidivante était de 17 % et de 26 %. La régurgitation valvulaire grave constituait un facteur de risque de mortalité intrahospitalière (rapport de cotes, 3,52; P =0,022), de faible survie à long terme (rapport de risque [RR], 2,57; P < 0,001) et d’endocardite récidivante (RR, 5,93; P < 0,001). L’endocardite sur prothèse valvulaire constituait un facteur de risque de faible survie à long terme (RR, 2,11; P = 0,002). L’endocardite à streptocoques viridans était associée à de meilleurs taux en matière de mortalité intrahospitalière (rapport de cotes, 0,28; P = 0,018) et de survie à long terme (RR, 0,34; P < 0,001).

      Conclusions

      La prise en charge non opératoire de l’EICG conduit à un mauvais pronostic, mais peut avoir un rôle à jouer dans certains cas. La prise en charge chirurgicale demeure la pierre angulaire de la prise en charge des patients chez qui les indications opératoires sont évidentes, notamment dans les cas de régurgitation grave et d’endocardite sur prothèse valvulaire. D’autres analyses prospectives sont nécessaires pour procéder à la sélection appropriée des patients à orienter vers la prise en charge non chirurgicale.
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