ABC | Volume 114, Nº1, January 2019

Original Article Marques et al. In-hospital mortality in infective endocarditis Arq Bras Cardiol. 2020; 114(1):1-8 Valve obstruction was diagnosed in 8 cases (5 cases of prosthetic IE and 3 cases in native valves) and was related to degenerated prosthesis in 4 patients, to large vegetations causing valve obstruction in 3 patients and in 1 case due to severe valvular aortic stenosis. 18F-fluorodeoxyglucose positron emission tomography/ computer tomography ( 18 F-FDG PET/CT) was performed in 1 patient, detecting signs of abnormal activity around the site of the prosthetic valve implantation (surgery performed more than 1 year before). None of the diagnosis was made by radiolabeled WBC single-photon emission computed tomography/Computed Tomography (SPECT/CT). The median length of hospital stay was 41 ± 23 days (range 1-112 days). Forty-four (32.8%) patients underwent cardiac surgery. The main indication for surgery was heart failure (n = 33; 75%), followed by uncontrolled infection (n = 11; 27.3%) and prevention of embolism (n = 6; 13.6%). One patient was referred to surgery for pacemaker lead extraction. The mean time between the first day of hospitalization and surgical procedure was 26 ± 18 days, the mean time between IE diagnosis and the surgical procedure was 21 ± 16 days and the mean time between the indication for surgery and surgical procedure was 14 ± 12 days. Adverse outcomes during hospitalization The in-hospital mortality rate was 31.3% (42 patients). Septic shock was the cause of death for one third of the patients (n = 14), 10 (23.8%) patients died due to heart failure, 9 (21.4%) due to embolic complications and 1 (2.4%) patient died due to cardiac tamponade. The cause of death was uncertain in 8 patients (19%). Most of these patients (73.8%, 31 patients) were not candidates for cardiac surgery. The reasons for these patients not being candidates for cardiac surgery are described in table 2. Eleven patients (26.2%) were candidates for surgery but 4 died before the intervention (2 patients due to embolic events occurrence, 1 due to septic shock and 1 patient due to heart failure); 3 patients were refused for surgery by the surgical team (2 patients due to the presence of an ischemic Continuation Microbiology – n°. (%) Blood culture-negative infective endocarditis 16 (17.4) 13 (31) 29 (21.6) 0.077 Staphylococcal species 25 (27.2) 17 (40.5) 42 (31.3) 0.124 Staphylococcus aureus 15 (16.3) 15 (35.4) 30 (22.4) 0.012* Staphylococcus epidermidis 5 (5.4) 1 (2.4) 6 (4.5) 0.665 Other coagulase-negative Staphylococci 4 (4.3) 1 (2.4) 5 (3.7) 1.000 Streptococcal Species 34 (37) 7 (16.7) 41 (30,6) 0.018* Viridans Group Streptococci 14 (15.2) 3 (7.1) 17 (12.7) 0.193 Streptococcus gallolyticus 12 (13) 1 (2.4) 13 (9.7) 0.063 Streptococcus milleri 2 (2.2) 1 (2.4) 3(2.2) 1.000 Enterococcal species 12 (13) 4 (9.5) 16 (11.9) 0.560 Gram-negative bacteria 2 (2.2) 3 (7.1) 5 (3.7) 0.177 Fungi 2 (2.2) 1 (2.4) 3 (2.2) 1.000 HACEK group 1 (1) 0 (0) 1 (0.7) 1.000 Echocardiographic Findings – n°. (%) Vegetation 74 (80.4) 32 (76.2) 106 (79.1) 0.776 Valve regurgitation 50 (54.3) 19 (45.2) 69 (51.5) 0.539 Valve destruction 19 (20.7) 7 (16.7) 26 (19.4) 0.722 Valve obstruction 3 (3.3) 5 (11.9) 8 (6) 0.05* Abscess 8 (8.7) 10 (23.8) 18 (13.4) 0.009* Pseudoaneurysm 5 (5.4) 0 (0) 5 (3.7) 0.320 Valve Aneurysm 3 (3.3) 0 (0) 3 (2.2) 0.554 Intracardiac Fistula 4 (4.3) 2 (4.8) 6 (4.5) 1.000 Treatment – n°. (%) Only medical treatment 52 (56.5) 38 (90.5) 90 (67.2) < 0.001* Cardiac Surgery 40 (43.5) 4 (9.5) 44 (32.8) * Statistically significant variable. IE: infective endocarditis; SD: standard deviation. 4