title: Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality.
abstract: OBJECTIVE
  To investigate the clinical features, echocardiographic characteristics, management, and prognostic factors of mortality of aorto-cavitary fistulization (ACF) in infective endocarditis (IE). Extension of infection in aortic valve IE beyond valvular structures may result in peri-annular complications with resulting necrosis and rupture, and subsequent development of ACF. Aorto-cavitary communications create intra-cardiac shunts, which may result in further clinical deterioration and haemodynamic instability.
  
  
  RESULTS
  In a retrospective multi-centre study over 4681 episodes of IE, a total of 76 patients with ACF [1.6%, confidence interval (CI) 95%: 1.2-2.0%] diagnosed by echocardiography or during surgery were identified. Fistulae were found in 1.8% of cases of native valve IE and in 3.5% of cases of prosthetic valve IE from the general population and in 0.4% of drug abusers. PVE was present in 31 (41%) cases of ACF. Transthoracic and transoesophageal echocardiography detected the fistulous tracts in 53 and 97% of cases, respectively. Peri-annular abscesses were detected in 78% of cases, fistulae originated in similar rates from the three sinuses of Valsalva, and the four cardiac chambers were equally involved in the fistulous tracts. Heart failure (HF) developed in 62% of cases and surgery was performed in 66 (87% CI 95% 77-93%) patients with a mortality of 41% (95% CI 30-53%) in the overall population. Multivariate analysis identified HF (OR 3.4, CI 95% 1.0-11.5), prosthetic IE (OR 4.6, CI 95% 1.4-15.4) and urgent or emergency surgical treatment (OR 4.3, CI 95% 1.3-16.6) as variables significantly associated with an increased risk of death. Major complications during follow-up (death, re-operation, or re-admission for HF) among the five operative survivors with residual fistulae occurred in 20 and 100% of patients at 1 and 2 years, respectively.
  
  
  CONCLUSIONS
  Aorto-cavitary fistulous tract formation is an uncommon but extremely serious complication of IE. In-hospital mortality was exceptionally high despite aggressive management with surgical intervention in the majority of patients. Prosthetic IE, urgent surgery, and the development of HF identify the subgroup of patients with IE and ACF that have significantly increased risk of in-hospital death.
authors.affiliation: Corporacio Sanitaria Parc Tauli-Hospital de Sabadell, Sabadell, Spain.
authors.forename: Ignasi
authors.initials: I
authors.lastname: Anguera
authors.forename: Jose M
authors.initials: JM
authors.lastname: Miro
authors.forename: Isidre
authors.initials: I
authors.lastname: Vilacosta
authors.forename: Benito
authors.initials: B
authors.lastname: Almirante
authors.forename: Manuel
authors.initials: M
authors.lastname: Anguita
authors.forename: Patricia
authors.initials: P
authors.lastname: Muñoz
authors.forename: Jose Alberto
authors.initials: JA
authors.lastname: San Roman
authors.forename: Aristides
authors.initials: A
authors.lastname: de Alarcon
authors.forename: Tomas
authors.initials: T
authors.lastname: Ripoll
authors.forename: Enrique
authors.initials: E
authors.lastname: Navas
authors.forename: Carlos
authors.initials: C
authors.lastname: Gonzalez-Juanatey
authors.forename: Christopher H
authors.initials: CH
authors.lastname: Cabell
authors.forename: Cristina
authors.initials: C
authors.lastname: Sarria
authors.forename: Ignacio
authors.initials: I
authors.lastname: Garcia-Bolao
authors.forename: M Carmen
authors.initials: MC
authors.lastname: Fariñas
authors.forename: Ruben
authors.initials: R
authors.lastname: Leta
authors.forename: Gabriel
authors.initials: G
authors.lastname: Rufi
authors.forename: Francisco
authors.initials: F
authors.lastname: Miralles
authors.forename: Carles
authors.initials: C
authors.lastname: Pare
authors.forename: Artur
authors.initials: A
authors.lastname: Evangelista
authors.forename: Vance G
authors.initials: VG
authors.lastname: Fowler
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Mestres
authors.forename: Elisa
authors.initials: E
authors.lastname: de Lazzari
authors.forename: Joan R
authors.initials: JR
authors.lastname: Guma
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000150:complications* / Q000000981:diagnostic imaging / Q000401:mortality; D001021:Aortic Valve; D004452:Echocardiography / Q000379:methods; D004697:Endocarditis, Bacterial / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality; D005260:Female; D006331:Heart Diseases / Q000150:complications* / Q000000981:diagnostic imaging; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D012850:Sinus of Valsalva; D013203:Staphylococcal Infections / Q000401:mortality; D013290:Streptococcal Infections / Q000401:mortality; D016157:Vascular Fistula / Q000150:complications* / Q000000981:diagnostic imaging