Poster No. 2075Poster No. 2075Hospital General Universitario Gregorio MaraHospital General Universitario Gregorio Marañóñónn

Doctor Esquerdo 46, 28007Doctor Esquerdo 46, 28007Madrid, Spain. pmunoz@micro.hggm.esMadrid, Spain. pmunoz@micro.hggm.es

Valve surgery in infective endocarditis: determinants of in-hospital prognosisMM. MartinezMM. Martinez--Selles , A. Arnaiz , P. MuSelles , A. Arnaiz , P. Muññoz , J. Ruiz , M. Moreno , J. Reguera , J. Galvez , J. Portu , Joz , J. Ruiz , M. Moreno , J. Reguera , J. Galvez , J. Portu , J. Oteo , J. de la Torre , E. Bouza, on behalf . Oteo , J. de la Torre , E. Bouza, on behalf

of Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en Espof Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en Espaañña a -- Spanish Collaboration on Endocarditis (GAMES)* Spanish Collaboration on Endocarditis (GAMES)*

Infective endocarditis (IE) is a relatively uncommon disease; Infective endocarditis (IE) is a relatively uncommon disease; therefore, collaborative multicenter groups are desirable in ordtherefore, collaborative multicenter groups are desirable in order to er to obtain significant data over a short period. obtain significant data over a short period. In 2007, in collaboration with ICE, we created in Spain a nationIn 2007, in collaboration with ICE, we created in Spain a national al collaborative study group called GAMES, with the objectives of collaborative study group called GAMES, with the objectives of improving the care of IE patients and conducting research.improving the care of IE patients and conducting research. IEIE--related morbidity and mortality remain high. Surgical related morbidity and mortality remain high. Surgical intervention is necessary in about half the cases and it is assointervention is necessary in about half the cases and it is associated ciated with a mortality rate varying from 6 to 36%. with a mortality rate varying from 6 to 36%. Predictive factors for operative mortality are not well knownPredictive factors for operative mortality are not well known

MATERIAL AND METHODSMATERIAL AND METHODS

* Members of GAMES: Hospital Costa del Sol, (Marbella): Fernando Fernández Sánchez, Marian Noureddine, Gabriel Rosas, Javier de la Torre Lima; Hospital de Cruces, (Bilbao): José Aramendi, María Victoria Boado, Josune Goikoetxea, Susana Gómez, José Luis Hernández, José Ramón Iruretagoyena, Josu Irurzun Zuazabal, Inés Martínez, Miguel Montejo, Pedro María Pérez, , Roberto Voces; Hospital Clínico Virgen de la Victoria, (Málaga): Mª Victoria García López, Radka Ivanova Georgieva, Manuel Márquez Solero, Isabel Rodríguez Bailón, Josefa Ruiz Morales; Hospital Donostia-Policlínica Gipuzkoa, (San Sebastián): Ana María Cuende, Miguel Ángel Goenaga, Pedro Idígoras, José Antonio Iribarren, Alberto Izaguirre Yarza, Carlos Reviejo, Francisco Rodríguez; Hospital General Yagüe, (Burgos): Carlos Dueñas Gutiérrez, Luis Iglesias, Marian Mantecón, , M. A. Moran; Hospital General Universitario de Alicante, (Alicante): Rafael Carrasco, Vicente Climent, Patricio Llamas, Esperanza Merino, Joaquín Plazas, Sergio Reus; Hospital Juan Canalejo, (Coruña): Nemesio Álvarez, María del Mar Carmona, Laura Castelo, José Cuenca, Pedro Llinares, Enrique Miguez Rey, Dolores Sousa, Mª Carmen Zúñiga; Hospital Juan Ramón Jiménez, (Huelva): José Manuel Lomas, Francisco Javier Martínez; Hospital Universitario de Canarias, (Canarias): Mª del Mar Alonso, Beatriz Castro, Mª del Carmen Durán, Mª Miguel Gómez, Juan La Calzada, Ibrahim Nassar; Hospital Regional Universitario Carlos Haya, (Málaga): Antonio Plata Ciezar, José Mª Reguera Iglesias; Hospital Universitario Central Asturias, (Oviedo): Carlos Costas, Jesús de la Hera, Carlos Morales, Alfonso Moreno Torrico, Carmen Palomo, Francisco Pérez, Ángeles Rodríguez, Mauricio Telenti; Hospital Universitario Clínic de Barcelona, (Barcelona): Manuel Almela, Yolanda Armero, Manuel Azqueta, Ximena Castañeda, Carlos Cervera, Carlos Falces, Cristina García-de-la- Maria, José M. Gatell, Elisa De Lazzari, Magda Heras, Francesc Marco, Carlos A. Mestres, José Mª Miró, Asunción Moreno, Salvador Ninot, José Ramírez, Ana del Río, Marta Sitges, Carlos Paré; Hospital General Universitario Gregorio Marañón, (Madrid): Javier Bermejo, Emilio Bouza, Alia Eworo, Ana Fernández Cruz, Víctor González Ramallo, Mercedes Marín, Manuel Martínez-Sellés, Mª Cruz Menárguez, Patricia Muñoz, Hugo Rodríguez-Abella, Marta Rodríguez-Créixems, Jorge Rodríguez Roda, Antonio Segado, Jorge Solis, Blanca Pinilla, Ángel Pinto, Maricela Valerio, Eduardo Verde; Hospital Universitario La Paz, (Madrid): Isabel Antorrena, José Mª Fraile Vicente, Carlos García Cerrada, Luis García Guereta, Alicia Lorenao Hernández, Alejandro Martín Quirós, Mar Moreno, José Ramón Paño, Mª Angustias Quesada Simón, Mª Ángeles Rodríguez Dávila, , Alicia Rico Nieto; Hospital Universitario Marqués de Valdecilla, (Santander): Ana Arnaiz, Sara Bellisco, José Berrazueta, Manuel Cobo Belaustegui, MªCarmen Fariñas, Carlos Fernández, José García, Rubén Gómez, José Gutiérrez, Rafael Martín, Marcos Pajarón, Ramón Teira, Jesús Zarauza; Hospital Universitario Miguel Servet, (Zaragoza): Piedad Arazo Garces, Eduardo Cay, Juan Manuel García Lechuz, , Mª José Revillo, Dr.Vallejo; Hospital Universitario Puerta de Hierro, (Madrid): Pablo García Pavía, Jesús González, Beatriz Orden Antonio Ramos; Hospital Universitario Ramón y Cajal, (Madrid): Tomasa Centella, José Hermida, José Moya, Pilar Martínez, Enrique Navas, Enrique Oliva, Alejandro del Río, Soledad Ruiz; Complexo Hospitalario Universitario de Vigo, (Pontevedra): César Martínez, Andrés Nodar, Roberto Pérez, , Francisco José Vasallo; Hospital Universitario Virgen de las Nieves, (Granada): Carmen Hidalgo Tenorio; Hospital Universitario Virgen Macarena, (Sevilla): Antonio de Castro, Marina de Cueto, Pastora Gallego, Juan Gálvez Acebal, Jesús Rodríguez Baño; Hospital Universitario Virgen del Rocío, (Sevilla): Arístides de Alarcón, Emilio García, Juan Luis Haro, José Antonio Lepe, Francisco López, Rafael Luque; Hospital San Pedro, (Logroño): Luis Javier Alonso, José Ramón Blanco, Lara García, Inés Olarte, , Carmen Martínez, José Antonio Oteo, Laura Pérez; Hospital de la Santa Creu i Sant Pau, (Barcelona): Natividad de Benito, Mercé Gurguí, Cristina Pacho, Roser Pericas, Guillem Pons; Hospital Santiago de Compostela, (A Coruña): M. Álvarez, A. L. Fernández, Amparo Martínez, A. Prieto, Benito Regueiro, E. Tijera, Marino Vega; Hospital Santiago Apóstol, (Vitoria): Andrés Canut Blasco, José Cordo Mollar, Juan Carlos Gainzarain Arana, Oscar García Uriarte, Alejandro Martín López, José Antonio Urturi Matos; Hospital SAS Línea, (Cádiz): Mª Belén Nacle, Antonio Sánchez, Luis Vallejo; Hospital de Pontevedra, (Pontevedra): Nicolás Bayón, Mª Dolores Díaz, Darío Durán, Juan Carlos Rodríguez, Antonio Moreno; Hospital de Txagorritxu, (Vitoria): Ángel Alonso, Lourdes Michaus, Joseba Portu, Paola Tarabini-Castellani.

Describe the current practice of IE-surgery in Spain and identify predictive factors of operative mortalityOBJECTIVESOBJECTIVES

INTRODUCTIONINTRODUCTIONProspective consecutive IE collected by multidisciplinary teams Prospective consecutive IE collected by multidisciplinary teams (150 HCW) (150 HCW) Ethics committee approval and informed consentEthics committee approval and informed consentPrePre--established protocol. Standard diagnostic criteria and established protocol. Standard diagnostic criteria and definitions. definitions. Data collection started in Jan 2008Data collection started in Jan 2008Reports centralized in the coordinating center (Hospital GeneralReports centralized in the coordinating center (Hospital GeneralUniversitario Gregorio MaraUniversitario Gregorio Marañóñón)n) Operative mortality: within the hospitalization when surgery waOperative mortality: within the hospitalization when surgery was s performedperformedUnivariate and multivariate statistical analysisUnivariate and multivariate statistical analysis

Study period: January 2008 – December 2010. First 1000 cases of IE registered in our databaseMean age was 68.3 (IQR 55.8-76.4); Men: 699 cases Mean Charlson-Age Comorbidity Index was 4.31±2.6. Underlying conditions: 410 heart failure, 330 previous cardiac surgery,

265 diabetes mellitus, 249 renal insufficiency, 229 atrial fibrillation, 178 lung disease, 162 neoplasia Nosocomial: 29.3% Other characteristics of the series: see poster 2115

EPIDEMIOLOGICAL CHARACTERISTICS of 1000 CASES OF IEEPIDEMIOLOGICAL CHARACTERISTICS of 1000 CASES OF IEHospital Cases %

Gregorio Marañón 146 14.6

Marques de Valdecilla 108 10.8

Virgen del Rocío 96 9.6

Juan Canalejo 83 8.3

Clinic i Provincia 81 8.1

Ramón y Cajal 51 5.1

Hospital Central de Asturias 50 5.0

La Paz 50 5.0

Virgen de la Victoria 50 5.0

Cruces 49 4.9

Donostia-Gipuzcua 42 4.2

Virgen Macarena 40 4.0

Carlos Haya 40 4.0

Costa del Sol 28 2.8

Virgen de las Nieves 24 2.4

Txagorritxu 16 1.6

San Pedro 14 1.4

Juan Ramón Jiménez 11 1.1

Apóstol Santiago 9 .9

Hospital Universitario de Canarias 8 .8

Hospital General de Alicante 4 .4

Total 1000 100.0Fig 1. 21 hospitals recruiting

Surgery perfomed: 43.7 %, although initially indicated in 63%

93% definitive and 7% possible endocarditis

Type of endocarditis: native valve 61%, prosthetic valve 28%, intracardiac device related 11%

Affected valve: aortic 53%, mitral 42%

Etiology: Staphylococcus spp. 43%, Streptococcus spp. 22%, Enterococcus 11%

Urgent/emergent surgery: 29%

CHARACTERISTICS of OPERATED INFECTIVE ENDOCARDITISCHARACTERISTICS of OPERATED INFECTIVE ENDOCARDITIS

Table 1. Surgery in different types of IETable 1. Surgery in different types of IETOTAL Native

IVDUN=36

NativeN=625

ProstheticN=261

DeviceN=78

P

SurgeryIndicatedOperated on

633437

47.2%22.2%

59.0%41.4%

70.1%44.4%

82.0%69.2%

<0.01

Reasons for surgeryCardiac insufficiencyEarly prosthetic IELate prosthetic IEValvular insufficiency

2054734

170

8.3%--

13.8%

24.1%0.96%0.16%19.7%

19.1%15.3%11.9%15.7%

1.3%1.3%2.5%1.3%

<0.01

COMPARISON OF OPERATED VS NONCOMPARISON OF OPERATED VS NON--OPERATED PATIENTSOPERATED PATIENTS

Operated patients

younger (61.4± 5.5 vs 65.9±6.4 years, p <0,001)

less frequently women (25 vs. 34%, p=0.001)

less comorbidity (Charlson index 1.9±2.0 vs 2.6±2.2, p=0.03)

more negative blood cultures (19 vs 9%, p <0.001)

more cardiac insufficiency (52 vs 32%, p<0.001)

LESS IN HOSPITAL MORTALITY: 24% vs 31%, p = 0.02

Median Euroscore: 10 Surgery was significantly more frequent in patients with device-related or prosthetic endocarditis (Table 1) Indications for surgery included: heart failure 45%, valve insufficiency 36%, clinical failure of antimicrobial

therapy 18%, valve destruction 14%, early prosthetic endocarditis 10% (Table 2) Median hospital stay: 35 days Complications: 190 (44%) Shock (44%), renal insufficiency(25%), pneumonia (18%), hemorrhage (17%), AVB (10%)

N (%)Heart failure 196 (44.9)Severe valve regurgitation 159 (36.4)Low likelihood of cure with medical therapy 79 (18.1)Substantial intra-cardiac destruction 63 (14.4)Early Prosthetic Valve IE 44 (10.1)Sepsis 33 (7.6)Embolization 32 (7.3)Late Prosthetic Valve IE 30 (6.9)IE recurrence 9 (2.1)

Table 2. Reasons to perform surgery

CONCLUSIONSCONCLUSIONS

Table 4. Independent predictors of inTable 4. Independent predictors of in--hospital mortalityhospital mortality

Risk factors for in-hospital mortality after infective endocarditis surgery are not easily amenable for intervention.

Aged women with advanced prosthetic staphylococcal endocarditis who require urgent surgery have the highest risk of dying. EuroScore seems to be a good predictor of outcome.

OR (95% CI) P valueAge (increase per year) 1.03 (1.003-1.047) 0.03Prosthetic valve IE 2.2 (1.2-4.0) 0.008Substantial intra-cardiac destruction 1.9 (1.1-3.4) 0.02Female sex 2.1 (1.1-3.6) 0.03Urgent surgery 2.0 (1.2-3.1) 0.004Staphylococcus spp 2.3 (1.3-4.1) 0.004EuroSCORE (per point) 1.02 (1.01-1.03) 0.006

Multivariate analysis of risk factors for in-hospital mortality (Table 4): Age and female sex

Urgent surgery and high Euroscore

Prosthetic valve IE and substantial intracardiac destruction

Staphylococcal spp. etiology

RISK FACTORS FOR MORTALITY IN OPERATED PATIENTSRISK FACTORS FOR MORTALITY IN OPERATED PATIENTS

Medical therapy (N=563) Surgery (N=437) P valueAge (years) 65.9±16.4 61.4±15.5 <0.001Female sex 193 (34.3) 108 (24.7) 0.001Charlson index 2.6±2.2 1.9±2.0 0.03COPD 104 (18.5) 74 (16.9) 0.01Atrial fibrillation 151 (26.8) 78 (17.8) 0.003Diabetes 159 (18.2) 106 (24.3) 0.09Cancer 108 (19.2) 54 (12.4) 0.01Prosthetic Valve IE 155 (27.5) 122 (27.9) 0.89Culture-negative IE 49 (8.7) 81 (19.0) <0.001Heart failure 182 (32.4) 228 (52.3) <0.001Inhospital Mortality 173 (30.7) 106 (24.3) 0.02

Table 3. Comparison of operated and non-operated

patients