title: Infective endocarditis in children: native valve preservation is frequently possible despite advanced clinical disease.
abstract: BACKGROUND
  Recent reports describing surgical experiences with childhood IE are sparse. We sought to determine patient-specific characteristics and their impact on outcome for children with infective endocarditis (IE) undergoing surgical intervention. We therefore reviewed all cases of culture-proven IE referred for surgical intervention at our institution over the last three decades.
  
  
  METHODS
  Of 15,124 cardiovascular surgical procedures performed between 1978 and 2007 at our institution on children under the age of 18, only 30 (0.2%) were undertaken for a primary diagnosis of IE. All 30 children underwent chart review and retrospective risk-hazard analysis.
  
  
  RESULTS
  Median patient age was 9.8 years (range 10 weeks to 17.5 years). Underlying congenital cardiac lesions were present in 22 (77%) and previous intra-cardiac repair in 9 (30%). Septic emboli occurred in 13 (46%), causing permanent strokes in 4 (14%). Streptococcus viridans and Staphylococcus aureus were the predominant organisms. S. viridans was associated with underlying congenital lesions (p<0.01). S. aureus was associated with abscess formation (p<0.03), clinical sepsis (p<0.04), acute deterioration (p<0.01), prolonged hospitalization (p<0.01) and death (p<0.01). Aortic, mitral and tricuspid valves were involved with equal frequency, more than the right ventricular outflow tract. Two valves were involved in 30%. The native valve was preserved at operation in 22 (73% cases). Univariate predictors for valve replacement included increased leaflet thickening (p<0.01) and occurrence of septic embolization (p=0.02), whereas moderate/severe valvular regurgitation was not significant. Five-year freedom from IE-related death and re-intervention was 84% and 80%, respectively. At latest follow-up 96% of patients are NHYA I.
  
  
  CONCLUSIONS
  Children undergoing surgery for infective endocarditis frequently have advanced disease with embolic complications and double valve involvement. However, preservation of the native valve is frequently possible. Need for valve replacement is suggested by leaflet thickening and embolization. Despite the advanced pathology, survival and functional outcomes are favorable.
authors.affiliation: Department of Surgery, Division of Cardiovascular Surgery, The Hospital for Sick Children, University of Toronto School of Medicine, Toronto, Canada.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Hickey
authors.forename: Gordon
authors.initials: G
authors.lastname: Jung
authors.forename: Cedric
authors.initials: C
authors.lastname: Manlhiot
authors.forename: Andreas G
authors.initials: AG
authors.lastname: Sakopoulos
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Caldarone
authors.forename: John G
authors.initials: JG
authors.lastname: Coles
authors.forename: Glen S
authors.initials: GS
authors.lastname: Van Arsdell
authors.forename: Brian W
authors.initials: BW
authors.lastname: McCrindle
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D004697:Endocarditis, Bacterial / Q000175:diagnosis / Q000382:microbiology / Q000601:surgery*; D004812:Epidemiologic Methods; D006330:Heart Defects, Congenital / Q000601:surgery; D006349:Heart Valve Diseases / Q000382:microbiology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007223:Infant; D018579:Patient Selection; D011379:Prognosis; D013203:Staphylococcal Infections / Q000601:surgery; D013290:Streptococcal Infections / Q000601:surgery; D016896:Treatment Outcome; D034363:Viridans Streptococci