One-year outcome following biological or mechanical valve replacement for infective endocarditis☆
Introduction
Despite improvements in diagnosis, antibiotic treatment and surgery, infective endocarditis (IE) remains a serious disease, with 50% of patients requiring cardiac surgery during the acute phase of IE and a 20% in-hospital mortality [1], [2], [3]. Cardiac surgery for IE typically involves valve replacement with a mechanical or xenograft biological prosthesis, although valve repair and homograft replacements may be used. The main advantage of mechanical prostheses is their longevity, but they require lifelong treatment with anticoagulants and the subsequent bleeding risks. Bioprostheses do not require long-term anticoagulation, but have a shorter durability, particularly in the mitral position. In its 2009 guidelines on IE, the European Society of Cardiology did not favor any specific valve substitute but recommended a tailored approach for each individual patient and clinical situation [4]. The American College of Cardiology and the American Heart Association Valvular Disease Guidelines have stated that in general, a mechanical prosthesis is reasonable in patients under 65 years of age, while a bioprosthesis is favored in patients 65 years of age or older for both the aortic and the mitral positions, but do not provide specific recommendations for surgery in IE [5].
There are limited data to support the choice of either type of prosthesis in IE [6]. The characteristics of patients receiving biological or mechanical prosthesis and the association between type of valve prosthesis and outcome are not clearly defined. Thus, the objectives of this observational study were to describe the characteristics of patients according to the type of prosthesis and to examine the relationship between prosthesis type and 1-year mortality.
Section snippets
International Collaboration On Endocarditis — Prospective Cohort Study
Data from the International Collaboration on Endocarditis — Prospective Cohort Study (ICE-PCS) were used for this study. Methods of this prospective, multicenter, international registry of IE have been previously reported [7], [8]. Between January 2000 and December 2006, 5668 patients from 64 centers in 28 countries were enrolled. The ICE-PCS database is maintained at the Duke Clinical Research Institute, which serves as the coordinating center for ICE studies, with institutional review board
Results
There were 5668 patients with definite and possible IE enrolled in the ICE-PCS. Based on pre-specified inclusion and exclusion criteria for this study, 1467 patients, including 917 (63%) who received mechanical prostheses only and 550 (37%) who received bioprostheses only, were included in this study (Fig. 1).
The clinical characteristics of patients receiving biological or mechanical prostheses are presented in Table 1. Compared to patients who received mechanical prostheses, those who received
Discussion
In the present study, 1467 patients received valve prostheses during the acute phase of IE with 37% receiving biological valve replacement and 63% a mechanical prosthesis. Both in-hospital mortality and one-year mortality were higher in the bioprosthesis group. The higher mortality associated with bioprosthesis extended beyond the in-hospital acute phase of IE, and was independently associated with 1-year mortality in multivariable analysis. These results have relevance to current clinical
Conflicts of interest
Dr. Wang is supported in part by AHA Mid-Atlantic Grant-in-Aid Award #12GRNT12030071.
Dr Kanj declared honoraria for talks from Pfizer, Merck, Astra Zeneca, Astellas, Biologix and research funds from Astellas.
Other authors declared no conflict of interest.
Acknowledgments
In addition to all of the named ICE investigators at each site, we would like to acknowledge the support given to this project from all of the personnel at each site and at the coordinating center that have allowed this project to move forward.
Study investigators
Argentina: Liliana Clara, MD, Marisa Sanchez, MD (Hospital Italiano). José Casabé, MD, PhD, Claudia Cortes, MD (Hospital Universitario de la Fundaciòn Favaloro). Francisco Nacinovich, MD, Pablo Fernandez Oses, MD, Ricardo Ronderos, MD,
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2016, Medecine et Maladies InfectieusesCitation Excerpt :However, prevention strategies did not manage to reduce the incidence of this life-threatening disease currently reaching 33.8 case patients/million patient-years in France [2]. In-hospital case fatality for patients presenting with IE reaches 20% [3] with a one-year case fatality of 25% [4]. Although aggressive therapy has become essential to saving lives and eradicating infection in many patients, reported rates of surgery remain heterogeneous and the benefit of surgery on mortality is arguable.
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2016, International Journal of CardiologyCitation Excerpt :Given that bioprostheses are often implanted in a higher risk group (older patients, contraindication to anticoagulation) this may not reflect specific issues related to the prostheses and those results must be interpreted cautiously. ICE-PCS investigators [36] recently published the one-year outcomes of 1467 valve replacements for IE (64% mechanical prostheses, 36% bioprostheses), 1134 of which were for native aortic endocarditis. In-hospital and 1-year death rates were higher in the bioprosthesis group 20.5% vs. 14% (p = 0.0009), but patients who received bioprostheses were older (62 vs. 54 years), had more frequent comorbidities (history of cancer: 9% vs. 6%, moderate or severe renal disease: 9% vs. 4%) and intracardiac abscesses (30% vs. 23%).
Acinetobacter baumannii and cardiac impairment. Increasingly important nosocomial pathogen
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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
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Membership of the International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) is provided in the Acknowledgments.