title: Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis.
abstract: OBJECTIVE
  To assess long-term outcomes and the management of critical left-sided infective endocarditis (IE) and evaluate the impact of surgery.
  
  
  RESULTS
  Among the 198 patients included prospectively for IE across 33 adult intensive care units (ICU) in France from 1 April 2007 to 1 October 2008, 137 (69%) were dead at a median follow-up time of 59.5 months. Characteristics significantly associated with mortality were: Sepsis-related Organ-Failure Assessment (SOFA) score at ICU admission [Hazard ratio (HR), 95% Confidence Interval (CI) of 1.43 (0.79-2.59) for SOFA 5-9; 2.01 (1.05-3.85) for SOFA 10-14; 3.53 (1.75-7.11) for SOFA 15-20; reference category SOFA 0-4; P = 0.003]; prosthetic mechanical valve IE [HR 2.01; 95% CI 1.09-3.69, P = 0.025]; vegetation size ≥15 mm [HR 1.64; 95% CI 1.03-2.63, P = 0.038]; and cardiac surgery [HR (95%CI), 0.33 (0.16-0.67) for surgery ≤1 day after IE diagnosis; 0.61 (0.29-1.26) for surgery 2-7 days after IE diagnosis; 0.42 (0.21-0.83) for surgery >7 days after IE diagnosis; reference category no surgery; P = 0.005]. One hundred and three (52%) patients underwent cardiac surgery after a median time of 6 (16) days. Independent predictors of surgical intervention on multivariate analysis were: age ≤60 years [Odds ratio (OR) 5.30; 95% CI (2.46-11.41), P < 0.01], heart failure [OR 3.27; 95% CI (1.03-10.35), P = 0.04], cardiogenic shock [OR 3.31; 95% CI (1.47-7.46), P = 0.004], septic shock [OR 0.25; 95% CI (0.11-0.59), P = 0.002], immunosuppression [OR 0.15; 95% CI (0.04-0.55), P = 0.004], and diagnosis before or within 24 h of ICU admission [OR 2.81; 95% CI (1.14-6.95), P = 0.025]. SOFA score calculated the day of surgery was the only independently associated factor with long-term mortality [HR (95% CI) 1.59 (0.77-3.28) for SOFA 5-9; 3.56 (1.71-7.38) for SOFA 10-14; 11.58 (4.02-33.35) for SOFA 15-20; reference category SOFA 0-4; P < 0.0001]. Surgical timing was not associated with post-operative outcomes. Of the 158 patients with a theoretical indication for surgery, the 58 deemed not fit had a 95% mortality rate.
  
  
  CONCLUSIONS
  Mortality in patients with critical IE remains unacceptably high. Factors associated with long-term outcomes are the severity of multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and surgical treatment. Up to one-third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. The strongest independent predictor of post-operative mortality is the pre-operative multiorgan failure score while surgical timing does not seem to impact on outcomes.
authors: Service de Réanimation Médicale, Institut de Cardiologie, Université Paris VI-Pierre et Marie Curie, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.
authors: Mariana
authors: M
authors: Mirabel
authors: Romain
authors: R
authors: Sonneville
authors: David
authors: D
authors: Hajage
authors: Emmanuel
authors: E
authors: Novy
authors: Florence
authors: F
authors: Tubach
authors: Philippe
authors: P
authors: Vignon
authors: Pierre
authors: P
authors: Perez
authors: Sylvain
authors: S
authors: Lavoué
authors: Achille
authors: A
authors: Kouatchet
authors: Olivier
authors: O
authors: Pajot
authors: Armand
authors: A
authors: Mekontso-Dessap
authors: Jean-Marie
authors: JM
authors: Tonnelier
authors: Pierre-Edouard
authors: PE
authors: Bollaert
authors: Jean-Pierre
authors: JP
authors: Frat
authors: Jean-Christophe
authors: JC
authors: Navellou
authors: Herve
authors: H
authors: Hyvernat
authors: Ali Ait
authors: AA
authors: Hssain
authors: Jean-François
authors: JF
authors: Timsit
authors: Bruno
authors: B
authors: Megarbane
authors: Michel
authors: M
authors: Wolff
authors: Jean-Louis
authors: JL
authors: Trouillet
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016638:Critical Illness; D003430:Cross-Sectional Studies; D004638:Emergency Treatment / Q000401:mortality / Q000706:statistics & numerical data; D004696:Endocarditis / Q000401:mortality / Q000601:surgery*; D005260:Female; D005602:France / Q000453:epidemiology; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality / Q000706:statistics & numerical data; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Heart valve disease; Intensive care; Valve surgery