Analysis of uncontrolled infection in infective endocarditis: prevalence, prognostic significance, and role of cardiac surgery
P Landin, D Gomez Ramirez, C Olmos, D Perez Camargo, M Carnero, J Lopez, C Saez Bejar, J Perez Serrano, M de Miguel, A Lozano, I Vilacosta, J A San RomanAbstract
Background
The aim of the study was to describe the prevalence of uncontrolled infection in infective endocarditis (IE), to analyse the main prognostic determinants of in-hospital mortality, and to evaluate the role of cardiac surgery in these patients.
Methods
A total of 1,799 patients with IE were prospectively recruited from three tertiary hospitals between 1996 and 2023. Of the total sample, patients who showed signs of uncontrolled infection at any point during the episode were analysed, followed by those in this group who underwent cardiac surgery.
Results
A total of 524 patients (29.1%) presented signs of uncontrolled infection. In-hospital mortality was significantly higher than in the remaining patients (49% vs 18.6%; p<0.001), both in patients who underwent cardiac surgery (34.5% vs 16.6%; p<0.001) and in those who did not (67.1% vs 22%; p<0.001).
In patients with uncontrolled infection, the variables significantly associated with in-hospital mortality were age, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD), S. aureus infection, prosthetic IE, and preoperative complications such as heart failure, septic shock, and acute kidney injury (Table). Cardiac surgery was significantly associated with lower in-hospital mortality (OR: 0.25; 95% CI: 0.18-0.37).
In patients who underwent cardiac surgery (n=290), the main prognostic determinants of mortality were age (OR: 1.01; 95% CI: 1.01-1.03), diabetes mellitus (OR: 2.38; 95% CI: 1.37-4.13), prosthetic IE (OR: 1.76; 95% CI: 1.08-2.88), preoperative acute kidney injury (OR: 3.66; 95% CI: 2.20-6.09), and preoperative septic shock (OR: 4.03; 95% CI: 2.27-7.18).
Conclusions
Uncontrolled infection occurs in one in three episodes of IE, and nearly half of the patients die during hospitalisation. Age, comorbidities such as diabetes mellitus and chronic kidney disease, S. aureus infection, and the development of preoperative septic shock and acute kidney injury were predictive factors for mortality in these patients. The odds of survival are 4 times higher in patients who undergo surgery. Therefore, despite the high mortality, surgery is essential for improving prognosis in this group of patients.TableForrest plot