131.右侧心内膜炎

右侧心内膜炎的流行病学及诊治

Int J Clin Exp Med 2014;7(1):199-218 /ISSN:1940-5901/IJCEM1311033

Original ArticleRight-sided infective endocarditis: recent epidemiologic changes

Shi-Min Yuan

Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, China

Received November 17, 2013; Accepted December 26, 2013; Epub January 15, 2014; Published January 30, 2014

Abstract: Background: Infective endocarditis (IE) has been increasingly reported, however, little is available regard-ing recent development of right-sided IE. Methods: Right-sided IE was comprehensively analyzed based on recent 5?-year literature. Results: Portal of entry, implanted foreign material, and repaired congenital heart defects were the main predisposing risk factors. Vegetation size on the right-sided valves was much smaller than those beyond the valves. Multiple logistic regression analysis revealed that predisposing risk factors, and vegetation size and locations were independent predictive risks of patients’ survival. Conclusions: Changes of right-sided IE in the past 5? years included younger patient age, and increased vegetation size, but still prominent Staphylococcus aureus infections. Complication spectrum has changed into more valve insufficiency, more embolic events, reduced ab-scess formation, and considerably decreased valve perforations. With effective antibiotic regimens, prognoses of the patients seemed to be better than before.

Keywords: Anti-bacterial agents, blood-borne pathogens, cardiac surgical procedures, complications, embolismIntroduction

Infective endocarditis (IE) involves the aortic valve the most common, the mitral valve more common, and tricuspid and pulmonary valve the least common. Multiple valve involvements were seen in 17-22% of the patients: aortic plus mitral valves the most common, mitral plus tri-cuspid valves more common, and aortic plus tricuspid and aortic plus pulmonary valves the least common [1, 2]. Right-sided IE occupied 5-10% of all IE [3]. In the patients with congeni-tal heart defects, left-, right- and both-sided IE accounted for 46.4%, 32.7% and 2.3%, respec-tively [4]. The prevalence of isolated tricuspid and pulmonary valve IE was 2.5-3.1% [5] and 2% [6], respectively.

It is notable that continuous changes have taken place with regard to epidemiology and prophylactic strategies of IE in the past decades [7]. Indwelling catheter, foreign medical device implants, and intravenous drug abusers have become the increasing risk factors for bacterial colonization, thus being a source of bacteremia [7, 8]. Staphylococcus aureus has become the most common microorganism of IE, while Streptococcus viridans infections reduced. The novel trends of IE resulted in significant increas-es in mortality and morbidity irrespective of advanced modern diagnostic and therapeutic strategies [9]. However, little information is available regarding for the recent development of right-sided IE. This study aims at presenting the changing trends of epidemiology, predis-posing risk factors, microbiology, and prognosis of right-sided IE under current antimicrobial treatments based on recent 5?-year literature.Materials and methodsRecent 5?-year literature retrieval from January 1, 2008 to April 30, 2013 was made in PubMED database and Google search engine. The search terms included “right heart endocardi-tis”, “right-sided endocarditis”, “pulmonary valve endocarditis”, “tricuspid valve endocardi-tis”, “pacemaker lead endocarditis”, “atrial sep-tal defect endocarditis”, “ventricular septal defect endocarditis”, “Chiari network endocar-ditis”, “Eustachian valve endocarditis”, “pulmo-nary artery endarteritis”, and “multiple valve

右侧心内膜炎的流行病学及诊治

Right-sided infective endocarditis

Table 1. Clinical manifestations of 166 patients

Clinical manifestationn (%)Fever

152 (91.6)Lethargy/fatigue/malaise/weakness53 (31.9)Dyspnea37 (22.3)Cough

29 (17.5)Weight loss17 (10.2)Chest pain18 (10.8)Night sweats12 (7.2)Back pain

6 (3.6)Abdominal pain

4 (2.4)Congestive heart failure10 (6.0)Pleural effusions12 (7.2)Pericardial effusions9 (5.4)Hepatomegaly11 (6.6)Splenomegaly5 (3.0)Ascites

2 (1.2)Skin lesions11 (6.6) Rash

2 (1.2) Erythema nodosum migrans1 (0.6) Erythematous painful nodules1 (0.6) Janeway lesion1 (0.6) Macules extremity1 (0.6) Osler nodes1 (0.6) Petechiae1 (0.6) Petechial rash1 (0.6) Purpura

1 (0.6) Purpuric rash

1 (0.6)

endocarditis”. Libman-Sacks nonbacterial endocarditis caused by antiphospholipid syn-drome, Loeffler’s endocarditis, and patent ductus arteriosus endarteritis was not included. -Patients with IE described as a long-term mor-bidity of current admission, with a history of right-sided IE, but current admission was for a left-sided one, or patients with non-active (healed) IE, were excluded.

Quantitative data were presented in mean ± standard deviation with range and median. Comparisons of frequencies were made by Fisher’s exact test. One-way ANOVA was taken for the univariant analysis. Multiple logistic regressions were used for predictive evaluation of patient survival/mortality. sidered statistically significant.p<0.05 was con-Results

Literature retrieval yielded 401 publications. Following the exclusion criteria, totally 168 pub-200

lications (14 original articles, 8 case series, and 146 case reports) [5, 10-176] including 299 patients were obtained. Gender was not reported for 37 patients. The remaining 262 patients included 182 males and 80 females with a male-to-female ratio of 2.3:1. The patients were at the age of 40.2 ± 21.3 (range, 0.04-88; median 41) years (n=195).

On admission, 76 patients had their cardiac murmurs recorded: 68 (89.5%) patients had a cardiac murmur (60 were systolic, 5 were dia-stolic, 2 were continuous, and 1 was both dia-stolic and diastolic), and 8 (10.5%) did not have a cardiac murmur. Locations of the cardiac murmurs were described in 50 patients: 25 (50%) at the left parasternal boarder, 11 (22%) at the tricuspid area, 5 (10%) at the right para-sternal boarder, 4 (8%) at the mitral area, 3 (6%) at the pulmonary area, 1 (2%) at the mitral and tricuspid areas and 1 (2%) at the pulmo-nary and tricuspid areas.

Fourteen (4.7%) patients were afebrile, while 285 (95.3%) patients were febrile with a body temperature of 38.8 ± 0.7 (range, 37.5-40.3; median, 38.9) °C (tions were depicted in n=56). Clinical manifesta-was 102.8 ± 23.5 (40-152; median, 105) /min Table 1. Their heart rate ((60-167; 120) mmHg (n=50), systolic blood pressure 116.9 ± 22.7 pressure 70.2 ± 13.4 (38-97; 70) mmHg n=47), diastolic blood (22.5) /min (n=45), and respiratory rate 25.1 ± 6.5 (18-38; ration with room air was 93.7 ± 6.3 (range, n=18). Arterial oxyhemoglobin satu-78-100; median, 97) % (hemoglobin n=18), and arterial oxy-mask was 95-98% and 91% in 2 patients, saturation with low-flow oxygen respectively. Pulmonary artery hypertension was present in 21 (7.0%) patients with a sys-tolic pulmonary arterial pressure of 54.4 ± 14.9 (40-90; 48) mmHg (hypertension was moderate in 17 (81.0%), n=15). Pulmonary arterial severe monary arterial hypertension was unknown in 1 in 3 (14.3%), and classification of pul-(4.8%) patient, respectively.

Predisposing risk factors for the occurrence of IE could be summarized into: portal of entry (36.1%), implanted foreign material (27.0%), underlying heart disease (22.8%), invasive den-tal, medical or surgical procedure (12.4%), dis-tant infections (6.6%), a history of IE (2.5%), miscellaneous risk factors (23.2%), and no risk factor at all (1.7%). Intravenous drug user, pace-Int J Clin Exp Med 2014;7(1):199-218

右侧心内膜炎的流行病学及诊治

Right-sided infective endocarditis

Table 2. Predisposing risk factors in 241 patients with infective endocarditis

Predisposing risk factor

Portal of entry

Intravenous drug user Hemodialysis

Central venous catheter

Maintenance of blood transfusion for anemiaImplanted foreign material Pacemaker implantation

Congenital heart defect surgery with a conduit, shunt or patch

Prosthetic valve prosthesis (1 was percutaneous pulmonary valve implantation) Superior vena cava filter deployment

Peritoneovenous (LeVeen) shunt after hepatic lobectomyUnderlying heart disease

Congenital heart disease, unrepaired Coronary artery disease Valvular heart disease

Invasive dental, medical or surgical procedure Dental problem

Previous surgical operation (other than heart operation)

Previous heart valve repair (probably with no implanted foreign material) Coronary artery bypass grafting Induced abortion

Invasive diagnostic means (catheterization, prostate biopsy) Percutaneous transluminal coronary angioplasty Balloon dilation of pulmonary stenosis AcupunctureDistant infections Abscess formation Infectious disease Gangrene of the footHistory of infective endocarditisMiscellaneous risk factors

System disease (diabetes mellitus 2, sclerosis and systemic lupus erythematosus) Pregnancy

Alcoholic consumption and alcoholic disease Cancer (including leukemia) Trauma and traumatic complication Postpartum Sporadic marihuana Parasite infection Animal bite/scratch Skin disease

Necrotizing enterocolitis ArthritisNil

*

n (%)

87 (36.1)71 (29.5)8 (3.3)7 (2.9)1 (0.4)65 (27.0)38 (15.8)16 (6.6)9 (3.7)1 (0.4)1 (0.4)55 (22.8)51 (21.2)*3 (1.2)1 (0.4)30 (12.4)7 (2.9)6 (2.5)4 (1.7)4 (1.7)4 (1.7)2 (0.8)1 (0.4)1 (0.4)1 (0.4)16 (6.6)13 (5.4)2 (0.8)1 (0.4)6 (2.5)56 (23.2)20 (8.3)7 (2.9)6 (2.5)5 (2.1)5 (2.1)3 (1.2)2 (0.8)2 (0.8)2 (0.8)2 (0.8)1 (0.8)1 (0.4)4 (1.7)

p value (Fisher’s exact test)

<0.0001

<0.0001

<0.0001

0.7870 (by excluding the variables with n≤2)

<0.0001

--<0.0001 (by excluding the variables with n≤2)

--

p<0.0001 comparing with “congenital heart defect surgery with a conduit, shunt or patch”.

maker implantation and unrepaired congenital heart disease represented the first three pre-dominant risk factors, respectively (Table 2). Unrepaired congenital heart disease account-ed for 92.7% (51/55) of the underlying heart disease, while congenital heart defect surgery with a conduit, shunt or patch accounted for 24.6% (16/65) of implanted foreign material (χ2=56.05, p<0.0001). Right-sided IE was due to cardiac surgical operations in 33 (11.0%) patients, including congenital heart defect sur-gery with a conduit, shunt or patch in 16

201 Int J Clin Exp Med 2014;7(1):199-218

右侧心内膜炎的流行病学及诊治

右侧心内膜炎的流行病学及诊治

Right-sided infective endocarditis

(48.5%), heart valve replacement in 9 (27.3%), heart valve repair in 4 (12.1%), and coronary artery bypass grafting in 4 (12.1%), respectively (χ2=16.84, p=0.000762).

Hemoglobin was 9.6 ± 2.5 (range, 4.2-17; medi-an, 9.8) g/dl ((80%) patients: 18 (45%) were mild, 20 (40%) n=50). Anemia was noted in 40 were moderate, and 2 (4%) were severe ane-mia, respectively. Leukocyte count was report-ed in 97 (32.4%) patients with a value of 19.2 ± 19.4 (range, 2.9-16.7; median, 16.5) × 109(/L white count, 82 (84.5%) patients had leukocy-n=73). Fourteen (14.4%) patients had a normal tosis, and 1 (1.0%) patient had leukopenia. The platelet count was reported in 19 patients, which was 114.1 ± 120.5 (range, 7-404; medi-an, 67) × 109cases of thrombocytopenia: 5 (41.7%) were /L (n=19). There were 12 (63.2%) mild, 3 (25%) were moderate, 1 was (8.3%) severe, and 3 (25%) were extremely severe thrombocytopenia. Erythrocyte sedimentation rate was reported in 46 (15.4%) patients: 44 (95.7%) patients were positive, and 2 (4.3%) were normal. The quantitative value of the abnormal erythrocyte sedimentation rate was 80.2 ± 38.0 (range, 8-140; median, 77) mm/h (reported C-reactive protein, 89 (98.9%) were n=26). Of the 90 (30.1%) patients with a positive, and 1 (1.1%) was normal. The quanti-tative C-reactive protein value was 21.3 ± 42.3 (0.15-297; median, 10.9) mg/dl (creatinine was reported in 17 (5.7%) patients: 6 n=66). Serum (35.3%) patients had a normal value 0.9 ± 0.2 (range, 0.6-1.2; median, 0.98) mg/dl (11 (64.7%) patients had an elevated value 2.0 n=6), and ± 0.6 (range, 1.45-3.3; median, 1.9) mg/dl ((range, 0.6-3.3; median, 1.6) mg/dl (n=11). The overall creatinine was 1.6 ± 0.7 aspartate aminotransferase 126 ± 171.9 (33-n=17), 573; 48) IU/L (normal reference, 7-56 IU/L) ((range 27-268; median, 59) IU/L (normal refer-n=9), and alanine transaminase 76.7 ± 67.2 ence, 5-40 IU/L) (ferase and alanine transaminase were elevat-n=11). Aspartate aminotrans-ed in 6 patients each.

Both transthoracic and transesophageal echo-cardiographic studies were carried out for the diagnosis of intracardiac vegetations in 33 patients: identical results were obtained in 18 (54.5%) patients (however, the origin of the veg-etation was not clearly visualized by transtho-racic, but clearly visualized by transesophageal echocardiography); at least one vegetation was missed by transthoracic but supplemented 203

information was obtained by transesophageal echocardiography in 15 (45.5%) patients. In 51 (79.7%) of the surgical patients, echocardio-graphic vegetations conformed to the surgical exploration, however, transthoracic or trans-esophageal echocardiographic misdiagnoses of vegetations were disclosed by open heart surgery in 13 (20.3%) patients.

The locations of the vegetations were not given in 63 patients. Four (1.7%) patients did not have a vegetation. The managements of the four patients with no vegetation varied accord-ing to patient’s age, predisposing risk factor (previous surgical maneuvers), and cardiac sit-uations, etations were found involving the right heart in etc. (Table 3). A single or multiple veg-232 (98.3%) patients. Most of the vegetations were single on a single valve/site of the right heart. Multiple vegetations on a single right heart valve, multiple vegetations on multiple sites of the right heart and multiple vegetations on both sides of the heart totally amounted to one-third of the whole presentation (The size of the right-sided vegetations was 1.96 Table 4). ± 1.16 (range, 0.14-7; median, 1.75) mm (ed IE, no significant difference was found in the n=114). For the single vegetations of right-sid-vegetation sizes between tricuspid and pulmo-nary valve IE (1.84 ± 0.76 mm p=vs. 1.77 ± 1.33, sided valves (both tricuspid and pulmonary 0.8420). Vegetations developed on the right-valves) were much smaller than those occurred beyond the valves on the right atrial or right ventricular free walls, superior vena cava, supe-rior vena cava-right atrium junction, ventricular septal defect patch, or the pacemaker lead (1.82 ± 0.88 mm p(site) of the right heart were smaller than those <0.0001). Multiple vegetations on one valve vs. 3.33 ± 1.45 mm, of the single vegetation on one valve (site), but did not reaching a significant difference (1.63 ± 0.78 mm Multiple vegetations on multiple sites of the vs. 2.08 ± 1.14 mm, p=0.0755). right heart measured 2.00 ± 1.85 mm, and multiple vegetations on multiple sites of both the left and right heart measured 1.75 ± 1.29 mm.

Complications amounted to 251, which devel-oped in 161 patients with a mean of 1.6/patient. and abscess formation were the most common Valvular insufficiency, embolic events complications of right-sided IE, representing 49.1% (79/161), 52.8% (85/161) and 15.5% (25/161), respectively. Leaflet perforation only

Int J Clin Exp Med 2014;7(1):199-218