carlos-a. mestres, md, phd, fetcs consultant cardiovascular surgery

Infective endocarditis and surgery

C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006

Carlos-A. Mestres, MD, PhD, FETCS

ConsultantCardiovascular Surgery

Hospital Clínico. University of BarcelonaBarcelona. Spain



Infective endocarditis is an uncommon diseaseassociated to significant morbidity and mortality.

As in any infection within the cardiovascular surgery,early diagnosis and aggresive management are

indicated

Infective endocarditis is a medical & surgical diseasewhich must be managed by a multidisciplinary

team with shared interests



The Team

The Hospital Clinico of Barcelona Endocarditis Study Group is a multidisciplinary group specifically

dedicated to the study and treatment of infective endocarditis and cardiovascular infections operational

for 25 years

Infectious Diseases (6), Cardiovascular Surgery (3), Microbiology (3),Surgical Pathology (1), Echocardiography (2)



The Team

* Infectious Diseases J.M.Miró, A.Moreno, A. Del Río, N. De Benito, X.Claramonte, J.P.Horcajada

* Cardiovascular Surgery C.A.Mestres, R.Cartañá, S.Ninot, J.L.Pomar

* Microbiology M.Almela, F.Marco, C.García

* Surgical Pathology J.Ramírez, N.Pérez

* Echocardiography J.C.Paré, M.Azqueta, M.Sitges



Infective Endocarditis

What have we learned?What have we changed?What are we doing?Where are we going?

An overview



A - Short Courses of Therapy for Infective Endocarditis

B - Infective Endocarditis in Drug Abusers (IVDAs)

C – Surgical experience



Potential number of candidates for short-courses of therapy for right-sided MSSA endocarditis in IVDAs at the

Hospital Clínic of Barcelona, Spain (1979-98)

Types of endocarditisin IVDAs

- Right-sided IE- Left-sided IE- Mixed IE Total

MSSAN (%)N

1424616

204

104 (73%)16 (35%)10 (64%)

130 (64%)

2 wk Tx*40%

* According to methicillin-susceptibility, HIV status and CD4 cell counts (>200/µL)



6. In our 25-year experience, one of every five episodes of native valve IE (general population + IVDAs) and almost one of every two episodes of IE in IVDAs were considered potential candidates for these short courses (2 wks) of therapy

Short Courses of Therapy for Infective EndocarditisCONCLUSIONS

5. Patients allergic to penicillin who must receive vancomycin with or without an aminoglycoside must be treated during 4 wks



Infective Endocarditis in IVDAs & HIV infectionSUMMARY

2. HIV-infected IVDA have a higher ratio of right-sided IE and S. aureus endocarditis than HIV-negative IVDA with IE

1. The incidence of IE in IVDA in the AIDS era is decreasing probably due to the change of the drug administration habits in order to avoid HIV-infection

3. Mortality between HIV-infected or non-HIV-infected IVDA with IE is similar. However, mortality among HIV-infected IVDA is higher in IVDA with less than 200 CD4+ cells/µL or with AIDS criteria



4. IVDA with non-complicated MSSA right-sided IE can be succesfully treated with an IV short-course regimen of nafcillin or cloxacillin plus an aminoglycoside during 2 weeks, although the addition of an aminoglycoside may be avoided or reduced to the first 3-7 days

5. Tricuspid valve replacement using mitral homografts can be a safely alternative to tricuspid valvulectomy for those IVDA with endocarditis who need right heart surgery

Infective Endocarditis in IVDAs & HIV InfectionSUMMARY

“Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1)”Mestres CA et al. Eur J Cardio-thorac Surg 2003; 23:1007-1016



Epidemiology 1990 - 2000

Diagnosis of IE 421IV (IVDA) drug abuse 104General population 317Native IE 213PVE 75Pacemaker/AICD 29Admissions/yr >50



“Surgical treatment of pacemaker and defibrillator lead endocarditis. The impact of electrode lead extraction on outcome”A.del Río, I.Anguera, J.M.Miró, L.Mont, Fowler VG Jr, M.Azqueta, C.A.Mestres and the Hospital Clinic Endocarditis Study GroupChest 2003; 124:1451-1459

“Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature”J.E.Losa, J.M.Miró, A. Del Río, A.Moreno-Camacho, F.Gracia, X.Claramonte, F.Marco, C.A.Mestres, M.Azqueta, J.M.Gatell and the Hospital Clinic Endocarditis Study GroupClin Microbiol Infect 2003; 9:45-54

“Infective endocarditis in intravenous drug abusers and HIV-1 infected patients”J.M.Miró, A. del Río, C.A.MestresInfect Dis Clin North Am 2002; 16:273-295



NVE 387 - ADVP 237 - PVE 130 - PM 49 - All 803



PVE 132



S.aureus 274



0

20

40

60

80

100

North America South America Australia/New Zealand Europe/Middle East

Peripheral/other IV; P =0.13 between regions

Central catheter; P = 0.017 between regions

Tunnelled catheter; P < 0.0001 between regions

Any catheter source; P = NS between regions

0

20

40

60

80

100

North America South America Australia/New Zealand Europe/Middle East

Peripheral/other IV; P =0.13 between regions

Central catheter; P = 0.017 between regions

Tunnelled catheter; P < 0.0001 between regions

Any catheter source; P = NS between regions

Presumed intravascular

catheter source by region

ICEICE

International Collaboration on Endocarditis

International Collaboration on Endocarditis



Specific indications

Mechanical valveYoung, “good” ring, cured IE

BioprosthesisElderly (?), “good” ring, cured IE

HomograftComplicated IE, abscess, annular destruction



The complicated root

1. Root abscess2. Aorto-cavitary fistula



Aorto-cavitary fistulae



L770 - AORTO-CAVITARY FISTULIZATION IN COMPLICATED ENDOCARDITIS. CLINICAL AND

ECHOCARDIOGRAPHIC FEATURES OF 76 CASES (1992-2001) AND PROGNOSTIC FACTORS OF MORTALITY

The Spanish Aorto-cavitary Fistula Endocarditis Working Group

42nd ICAAC. San Diego, CA. September 27-30, 2002



No clinical infective endocarditis (IE) series have been performed studying the development of aorto-cavitary fistulas (ACF) as a result of spread of infection from valvular tissue towards perivalvular structures. Our aims were to investigate the clinical, echocardiographic and microbiologic features and prognostic factors of in-hospital mortality in patients with IE and ACF.

Retrospective and multicentre study at 11 Spanish and 1 North-american Hospitals in patients with IE and ACF.



Spread of infection in infective endocarditis (IE) from valvular structures to the surrounding perivalvular tissue results in periannular complications.

Rupture of abscesses and pseudoaneurysms in the sinuses of Valsalva result in the development of aorto-cavitary fistulas and intracardiac shunts.

Aorto-cavitary fistula formation is an unusual complication of IE. An incidence of 1% of all cases of IE has been estimated. Fistulization of perivalvular abscesses occurs in 6-9% of cases.

Basic considerations



* Multicenter, international, retrospective, descriptive study performed between 1992 and 2001* Infective endocarditis diagnosed according to Duke criteria* Aorto-cavitary fistulization documented by TTE/TEE* Univariate analysis of prognostic factors of mortality



General populationNative valve

AorticMitralOther

PVEAorticMitralOther

PacemakerIV Drug abusers

OVERALL

693838----3131------7

76

314721051056 930 119 872 536 326 10 1701534

4681

2.21.83.6------3.55.8---------0.4

1.6

ACF n Cases IE n Incidence %



Mean age (y)Male genderPrevious valve diseaseComorbidityMechanical ventilationIV drug abuseDuration of symptoms (d)Duration to Dx of ACF (d)CHFNeuro eventsRenal failurePeripheral emboliComplete AV block

50.9±18.7*36 (80%)13 (28%)18 (40%) 6 (13%) 7 (16%)24.5±18.736.2±31.631 (69%) 8 (18%)20 (44%) 8 (18%) 5 (11%)

60.2±13.4*20 (65%)31 (100%) 9 (29%) 1 (3%) 029.8±37.744.1±55.516 (52%) 4 (13%) 8 (26%) 7 (23%) 6 (19%)

54.7±17.256 (74%)44 (59%)27 (36%) 7 (9%) 7 (9%)26.7±27.939.4±42.847 (62%)12 (16%)28 (37%)15 (20%)11 (14%)

NVE=45 PVE=31 All=76Clinical characteristics



Staphylococcus sppS.aureusCNS

Streptococcus sppVGSS.bovisOther streptococci

Enterococcus sppCulture negativeOther (HACEK)

17 (38%)*13 (29%)* 4 (9%)*16 (35%)10 (22%) 2 (4%) 4 (9%) 2 (4%) 5 (11%) 7 (15%)

18 (58%)* 3 (10%)*15 (48%)* 9 (29%) 5 (16%) -- 4 (13%) 2 (6%) -- 2 (6%)

35 (46%)16 (21%)19 (25%)25 (33%)15 (20%) 2 (3%) 8 (10%) 4 (5%) 5 (6%) 9 (12%)

NVE=45 PVE=31 All=76

Pathogens

NVE vs PVE groups (p<0.05)



Echocardiography

Diagnostic yield of TTE and TEE

TTE n (%) TEE n (%)

Native valve 26/44 (59%) 31/33 (94%)

PVE 15/31 (48%) 28/28 (100%)

Overall 40/75 (53%) 59/61 (97%)



Patients with vegetations Mean maximal veg. size (mm)Vegetations > 10 mmPatients with abscess Mean maximal abscess

diameterAbscess > 10 mmVentricular septal defect Mean EF (%)

Mean LVEDD (mm) Multivalvular infection

83 %11.7

56 %78 %

12 mm

54 %20 %61.754.9

30 %

96 %*11.5

49 %71 %

10 mm

44 %21 %62.555.2

33 %

65 %*12.170 %87 %

15 mm

67 %19 %60.554.426%

TotalN=76

NativeN=45

ProstheticN=31

*Native vs prosthetic, p < 0.05

Echo findings



Fistulized sinus of Valsalva (SV)

Right SV

Left SV

Non coronary SV

Fistulized cardiac chamber (%)

Right atrium

Right ventricle

Left atrium

Left ventricle

Multiple

Moderate/severe regurgitation

37%38%25%

17%25%26%16%12%49%

44% 35%20%

18%31%22%13%11%

64%*

26%42%32%

16%16%32%19%

13%*26%*

TotalN=76

NativeN=45

ProstheticN=31

* Native vs prosthetic, p < 0.05

Echo findings



Surgical treatmentTime to surgery

< 24 hours2 - 7 days> 7 days

Closure of fistula (%)SimplePericardial patchGore-tex patch

Valve replacementBioprosthesisMechanicalHomograft

87%

24%42%34%

41%48%11%92%24%50%18%

87%

33%36%31%

41%46% 13%95%28%49% 18%

87%

11%52% 37%

41%52% 7%89% 19%52%19%

TotalN=76

NativeN=45

ProstheticN=31



In-hospital mortality- Surgical group (N=66)- Medical group (N=10)

31 (41%)28 (42%)3 (30%)

16 (36%)13/39 (33%)

3/6 (50%)

15 (48%)15/27 (55%)

0/4 (-)

TotalN=76

NativeN=45

ProstheticN=31

Cause of death- Multiorgan failure- Sudden death- Septic shock- Cardiogenic shock- Hemorrhage

MedicalN=3

SurgicalN=28

23%10%26%19%23%

33%33%

-33%

-



Lost for follow-up

Follow-up (mo., mean, range)

Residual fistula

Late CHF

Late valvular replacement

Late death

2 4

Medical *N=7

SurgicalN=38

36 (1-96)*

-

3

0

1

29 (1-144)*

5 (11%)

7 (16%)

5 (11%)

3 ( 7%)

* The 3 patients who died w/o surgery had fatal co-morbid conditions. The remaining 7 patients did not undergo surgery because they did not have cardiac failure,

severe valvular regurgitation and echocardiographical abscess.



Age > 65yearsMale genderProsthetic endocarditisSymtoms duration >30 d.Moderate or severe CHFRenal failureNeurologic symptomsS.aureus infectionVegetation >10 mmPatients with periannular abscessPeriannular abscess > 10 mmModerate or severe ARFistulized sinus of ValsalvaFistulized cardiac chamberEF <65%Urgent or emergency surgery

2.8 (1.0-7.9)0.8 (0.2-2.4)2.5 (0.9-6.8)0.8 (0.2-2.6)2.2 (0.7-5.1)1.8 (0.7-5.1)0.6 (0.1-2.8)1.2 (0.4-3.6)1.2 (0.4-3.6)1.6 (0.5-5.5)2.3 (0.7-7.3)0.8 (0.3-2.1)

--

1.1 (0.4-3.1)2.7 (0.9-7.8)

0.050.6

0.070.7

0.150.20.50.80.70.4

0.140.70.90.20.8

0.06

OR – 95%CI p



Limitations

* Ascertainment bias – multicenter nature* Severity of CHF higher – low-grade shunts underdiagnosed* High-risk profles of surgical candidate* Not comparable to medically treated* Not comparing medical and surgical patients



Abscesses vs fistulae



Kaplan-Meier estimation of survival from time of diagnosis of periannular complication.



Actuarial freedom from death, heart failure requiring hospital admission and repeat surgery in patients with periannular complications surviving the index hospitalization. A. patients referred to surgical therapy



B. patients medically-managed



* Aorto-cavitary fistulization in IE is an unfrequent event and occurs in patients with aortic endocarditis with high grade of local tissue destruction.

* It was associated with staphylococci and streptococci native-valve IE and with coagulase-negative staphylococci prosthetic valve IE.

* In-hospital mortality was high even when most patients were referred to surgical treatment.

* Congestive heart failure identified the subgroup of patients with the worst prognosis.

Conclusions



Prosthetic valve endocarditis

- What?- When?- Who?- Why?



Methods

* International Collaboration on Endocarditis Merged Database* Large, multicenter, international registry of patients with definiteendocarditis by Duke criteria* Clinical, microbiological, echocardiographic variables to determine* Those factors associated with the use of surgery in PVIE* Logistic regression analysis* Propensity score to match surgery vs medical therapy



PVIE – Patient characteristics



Complications and outcomes of patients with PVIE



Propensity analysis of surgical treatment of PVIE



Logistic regression analysis of variables independentlyassociated with in-hospital mortality in patients with PVIE

and matched propensity for surgical treatment



Conclusions

* Despite the frequent use of surgery for the treatment of PVIEthis condition continues to be associated with high in-hospitalmortality* After adjustment for factors related to surgical intervention,brain embolism and S. aureus infection were independentlyassociated with in-hospital mortality and a trend toward asurvival benefit of surgery was evident



Echocardiographic (TTE) Follow-up

Year Patient TTE TTE FU Last TTE NYHABefore After (Yrs)

1991 AMG Veg 28 mm Mild TR 13 Severe TR IILarge RV

1991 RPO Veg 22 mm Severe TR 13 Severe TR IISevere TR Large RV Large RVLarge RV

1992 PER Veg 30 mm Severe TR 5 Severe TR ISevere TR Ruptured Large RV

chordae1994 JLF Veg 22 mm Mild TR 1 Mild TR I

1996 JFG Veg 28 mm Mild TR 1 Severe TR ISevere TR



Echocardiographic (TTE) Follow-up

Year Patient TTE TTE FU Last TTE NYHABefore After (Yrs)

2001 ERA Severe TR Trivial TR pod Po Death

2002 LML Veg 20 mm Trivial TR pod Po DeathSevere TR Large RVLarge RV

2002 JGR Veg 30 mm Mild TR 2.5 Mild TR ISevere TR



Year Patient FU Drug addiction Recurrent HIV Outcome(Yrs) relapse endocarditis stage

1991 AMG 6 Yes 14 mos B3 Alive(Corynebacterium spp) Late Reop

1991 RPO 6 Yes 48, 58, 63 mos B2 Alive(MSSA all cases) No Reop

1992 PER 5 No No A2 AliveLate Reop

1994 JLF 2.5 Yes No A3 DeathOverdose

1996 JFG 8.5 Yes 7, 12 mos A2 Alive(MSSA) No reop

Outcomes



Year Patient FU Drug addiction Recurrent HIV Outcome(Yrs) relapse endocarditis stage

2001 ERA PO N N C3 Death

2002 LML PO N N B2 Death

2002 JGR 2.5 N No A1 Alive



The most complex situation

Fibrous Skeletal destruction



Acute pectoralis major myositis in an otherwise healthy young male



• 25-year-old male

• Smoker ½ pack/day

Occasional recreational drugs. NO iv abuse

• Job: Waiter. Physically fit. Contact sports (judo, full-contact…)

• In the past 2 years 4 episodes of abscess requiring surgical drainage (hand, foot, knee, axilla)

• No other personal nor familiar medical history of interest

• 5-day left upper limb and upper left chest pain accompanied by high-degree fever (39°C), chills and malaise



• Aortic root replacement with a 20-22 mm cryopreserved aortic homograft

• Intraoperative findings: Massive AR due to perforation of the right coronary cusp on a morphologically normal aortic valve. Full root subaortic abscess extending towards the left atrial roof

• Aortic cross-clamp 73 min – CPB 189 min• Left ventricular failure and myocardial edema

after CPB. Sternum open. Intraaortic ballon pump support



Outcome - I

• Postop unstable hemodynamics. Urgent TTE showed anterior-septoapical hypokinesia

• Urgent coronary angiogram showed 70% LMCA stenosis with remaining normal coronaries

• August 12, 2004: Off-pump LIMA-LAD bypass graft and delayed sternal closure

• August 12, 2004 2/2 + blood cultures (ORSA)



Outcome - II

• Early favourable postop. Improved condition, no congestive heart failure

• August 14, 2004, 2/2 negative blood cultures. Trasnsferred to ward August 22, 2004. Good condition with low-degree fever (37°C)

• August 24, 2004 new control TTE



Surgery - II

• September 1, 2004 – Homograft replacement with a 21 mm SJM Toronto-Root porcine heterograft

• Surgical findings: Subaortic circumferential detachment of the normal functioning homograft. Extensive lesions of the entire fibrous body. Left atrial fistula

• Post-repair severe mitral regurgitation• Profound left ventricular failure. LVAD Abiomed BVS-

5000 implanted• All samples to Microbiology



Outcome - IV

• September 2, 2004 – Unstable under maximal intropic support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation

• September 3, 2004 – Orthotopic heart transplantation



Final diagnosis

1. Community-acquired ORSA myositis

2. Acute aortic root ORSA infective endocarditis

3. Heart transplantation



Endocarditis and Heart Transplantation• 1: Galbraith AJ et al. Cardiac transplantation for

prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999; 18:805-806

• 2: Blanche C et al. Heart transplantation for Q fever endocarditis. Ann Thorac Surg. 1994; 58:1768-1769

• 3: Pulpon LA et al. Recalcitrant endocarditis successfully treated by heart transplantation. Am Heart J 1994; 127:958-960

• 4: Park SJ et al. Heart transplantation for complicated and recurrent early prosthetic valve endocarditis. J Heart Lung Transplant. 1993; 12:802-803.

• 5: DiSesa VJ et al. Heart transplantation for intractable prosthetic valve endocarditis. J Heart Transplant. 1990; 9:142-143



Endocarditis and Heart Transplantation

• “Heart transplantation could be an alternative, not a contraindication, when in Infective Endocarditis all other measures have failed” (1)

Galbraith AJ Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999 Aug;18(8):805-6



Case Age Pathogen Valve Position Timing for HTx Conditions

1 25 M. hominis Tissue Aortic 2 months SLE

2 30 S viridans Mechanical Aortic 1 month PreTX + cultures

3 58 S viridans Native Mitral 2 years 3 VR’s

4 32 C burnetti Native Mi + Ao 14 months Persistent fever

5 54 MRSA Mechanical Mitral 17 days Previous HTx



Conclusions

* IE is a very serious pathology* It is not popular* Highly demanding* Suboptimal results* Team approach* Risk takers



Parsonnet score

Single centre – Subjective factors – Overestimates risk

Cleveland score

Single centre – Excludes non CABG – Leads to gaming

EuroScore

Large multicentre database – Fit for all adult cardiacsurgical patients – Even correlates with STS



EuroSCORE

0 – 23 – 56 – 89 – 1112>

0.88 – 1.512.62 – 3.516.51 – 8.3714.02 – 19.1231.00 – 42.32

Additive

Score % mortality



EuroSCORE

Its predictive accuracy has been establishedOnly the additive model has been validated

Inconsistencies among the additive and logisticmodels when applied to the high-risk patients



Cross-over point



Reasons to predict mortality in Cardiac Surgery

1. Helping to determine indications for surgery2. Quality monitoring

Additive EuroScore works well for most purposes



Considerations

The relationship between risk factors is not additive

Combined impact of two or more factors on operativerisk may be more than simple sum

Logistic score more realistic



The reality

* Infective endocarditis is a high-risk situation

* There is lack of data regarding risk assessment before valve surgery



Aim of the study

To validate the EuroSCORE preoperative stratification risk model in infective endocarditis



Population

Period Jan 95 – Jan 04Patients 147Mean age 56.33 ± 15.95Male gender 69.4%



Native valve IE

N %

Aortic 64 43.5

Mitral 25 17

Tricuspid 2 1.4

Pulmonary 1 0.7

A + M 12 8.2

M + T 1 0.7



Prosthetic valve IE

N %

PVE Aortic 17 11.6

Homograft Ao 2 1.4

PVE Mitral 11 7.5

PVE Ao + M 1 0.7

PVE Ao + PVE Mi 2 1.4

A + PVE Mi 1 0.7



Intravascular leads

N %

DDD 3 2

AICD 1 0.7

VVI R 1 0.7

VVI 2 1.4

Mitral + DDD 2 1.4



Characteristics

Active endocarditis 91.2%IV Drug addicts 10.9%HIV+ 5.4%ESR – HD 3.4%Reoperation 27.2%



Pathogens

N %

Culture negative 10 6.8

Staphylococcus 55 37.4

Streptococcus 43 29.3

Enterococcus 14 9.5

Polimicrobial 8 5.4

Candida 1 0.7

Other 14 9.5



Type of operation

Emergency 29.9%Urgent 21.8%Elective 46.9%



EuroSCORE

Additive

RangeMeanMedian

2 – 1910.15 ±3.8110



EuroSCORE

Logistic

RangeMeanMedian

1.51 – 94.17% EM25.59 ± 20.8118.95



Results

Overall in-hospital mortality 32.7%

- Intraoperative death- 30 days po- Regardless the length of stay



Results

Area SE Lower bound

Upper bound

Sig.

All patients .826 .036 .756 .896 .000

Asymptotic 95% confidence interval

Receiver operating characteristics (ROC) curves

Area > 0.7 Good correlationArea > 0.8 Very good correlationArea > 0.9 Excellent correlation



Results

Area SE Lower Bound

Upper Bound

Sig.

Native valve IE .814 .045 .727 .902 .000

Prosthetic IE .779 .088 .607 .952 .000



Results

Area SE Lower Bound

Upper Bound

Sig.

Aortic position .778 .064 .652 .904 .001

Mitral position .937 .051 .836 1.037 .001



Results

Area SE Lower Bound

Upper Bound

Sig.

Aortic prostheses .729 .125 .484 .980 .112

Mitral prostheses .833 .152 .535 1.132 .068



Results

Area SE Lower Bound

Upper Bound

Sig.

Gram + .819 .041 .739 .899 .000

Gram - .833 .204 .433 1.233 .248



Results

Area SE Lower Bound

Upper Bound

Sig.

Staphylococci .834 .054 .727 .940 .000

Streptococci .856 .087 .686 1.026 .002

Enterococci .500 .163 .181 .829 1.000

Polymicrobial .800 .165 .476 1.124 .180



ROC Curve

VÁLVULA: A

Diagonal segments are produced by ties.

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

ROC Curve

VÁLVULA: A


1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00Case Processing Summaryb

16

46

2

Exitus poPositivea

Negative

Missing

Valid N(listwise)

Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.

The positive actual state is S.a.

VÁLVULA = Ab.

Area Under the Curvec

Test Result Variable(s): Logístico (%)

,778 ,064 ,001 ,652 ,904Area Std. Error

aAsymptotic

Sig.b

Lower Bound Upper Bound

Asymptotic 95% ConfidenceInterval

The test result variable(s): Logístico (%) has at least one tie between thepositive actual state group and the negative actual state group. Statisticsmay be biased.

Under the nonparametric assumptiona.

Null hypothesis: true area = 0.5b.

VÁLVULA = Ac.

Aortic valve



ROC Curve

VÁLVULA: HA

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

ROC Curve

VÁLVULA: HA

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25


1

1

Exitus poPositivea

Negative

Valid N(listwise)



VÁLVULA = HAb.



1,000 ,000 ,317 1,000 1,000Area Std. Error

aAsymptotic

Sig.b





VÁLVULA = HAc.

Homograft aortic



ROC Curve

VÁLVULA: M

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

ROC Curve

VÁLVULA: M

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25


7

18

Exitus poPositivea

Negative

Valid N(listwise)



VÁLVULA = Mb.



,937 ,051 ,001 ,836 1,037Area Std. Error

aAsymptotic

Sig.b





VÁLVULA = Mc.

Mitral valve



ROC Curve

VÁLVULA: PA


1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

ROC Curve

VÁLVULA: PA


1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

Case Processing Summaryb

9

8

Exitus poPositivea

Negative

Valid N(listwise)



VÁLVULA = PAb.



,729 ,125 ,112 ,484 ,975Area Std. Error

aAsymptotic

Sig.b



The test result variable(s): Logístico (%) has at least one tie between thepositive actual state group and the negative actual state group. Statisticsmay be biased.



VÁLVULA = PAc.

Aortic prosthesis



ROC Curve

VÁLVULA: PM

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00

ROC Curve

VÁLVULA: PM

1 - Specificity

1,00,75,50,250,00

Se

nsi

tivity

1,00

,75

,50

,25

0,00Case Processing Summaryc

6

5

Exitus pob

Positivea

Negative

Valid N(listwise)



The test result variable(s): Logístico (%) has atleast one tie between the positive actual stategroup and the negative actual state group.

b.

VÁLVULA = PMc.



,833 ,152 ,068 ,535 1,132Area Std. Error

aAsymptotic

Sig.b





VÁLVULA = PMc.

Mitral prosthesis



Comments

There is a very good correlation between logisticEuroSCORE and mortality for the entire group

Division in subgroups yields a decrease in statisticalpower but correlation is almost the same in all subgroups

The area is good in the prosthetic valve IE although nonsignificant by position



Comments

The area is very good for Gram – and polymicrobialalthough with low statistical power

There is statistical power for significance in theStaphylococci and Streptococci groups



Limitations

Small sample size

Statistical power decreases when analyzing subgroups

Just preliminary results



When to use Logistic EuroScore?

-To calculate a precise and realistic risk prediction for a very high-risk patient, particularly when the indication for surgery may not be clear

- To monitor quality of care in institutions where a substantial proportion of patients are of very high-risk

- To help in the further study of risk modelling by groups and institutions with a scientific interest in the subject

- To carry out normal stratification in institutions with easy availability of accesible information technology, especially where high-risk surgery forms a substantial part of the workload



The Future of risk stratification

* Larger sample size

* More institutions involved

* Subgroup analysis (Pathogens, abscess…)

* Team approach

* The role of ICE

* Changing our approach to patients?

* Quality assurance



Conclusions

* IE is a very serious pathology* It is not popular* Highly demanding* Suboptimal results* Team approach* Risk takers

carlos-a. mestres, md, phd, fetcs consultant cardiovascular surgery

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