Braz J Cardiovasc Surg 2022;37(6):829-835

ORIGINAL ARTICLE

Early Mortality Predictors in İnfective Endocarditis

Patients: A Single-Center Surgical Experience
Çiğdem Tel Üstünışık1, MD; Zihni Mert Duman2, MD; Barış Timur3, MD; Timuçin Aksu4, MD; Taner İyigün4, MD; Safa Göde4,
MD; Muhammed Bayram4, MD; Vedat Erentuğ4, MD

DOI: 10.21470/1678-9741-2021-0621

ABSTRACT

Introduction: Infective endocarditis is a disease that progresses with Emergency surgery was performed in nine (7.3%) patients. In-hospital
morbidity and mortality, affecting 3-10 out of 100,000 people per mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients
year. We conducted this study to review the early outcomes of surgical were discharged. In-hospital mortality was related with older age,
treatment of infective endocarditis. presence of periannular abscess, New York Heart Association class 3 or 4
Methods: In this retrospective study, 122 patients who underwent symptoms, low albumin level, high alanine aminotransferase level, and
cardiac surgery for infective endocarditis in our clinic between November longer cross-clamping time (P<0.05 for all).
2009 and December 2020 were evaluated. Patients were divided Conclusion: The presence of paravalvular abscess was the most
into two groups according to in-hospital mortality. Demographic, important prognostic factor in patients operated for infective
echocardiographic, laboratory, operative, and postoperative data of the endocarditis.
groups were compared. Keywords: Endocarditis. Thoracic Surgery. Mortality. Abscess. Alanine
Results: Between November 3, 2009, and December 7, 2020, 122 Transaminase. Hospital Mortality.
patients were operated for infective endocarditis in our hospital.

Abbreviations, Acronyms & Symbols

ALT = Alanine aminotransferase MRCNS = Methicillin-resistant coagulase-negative staphylococci
AST = Aspartate aminotransferase MRSA = Methicillin-resistant Staphylococcus aureus
BUN = Blood urea nitrogen MSCNS = Methicillin-sensitive coagulase-negative staphylococci
CI = Confidence interval MSSA = Methicillin-sensitive Staphylococcus aureus
CRP = C-reactive protein NYHA = New York Heart Association
HGB = Haemoglobin OR = Odds ratio
IABP = Intra-aortic balloon pump PLT = Platelet
ICU = Intensive care unit SD = Standard deviation
IE = Infective endocarditis WBC = White blood cell

1Department of Cardiovascular Surgery, Istanbul University Cerrahpasa Faculty of Correspondence Address:

Medicine, Istanbul, Turkey. Zihni Mert Duman
2Department of Cardiovascular Surgery, Cizre State Hospital, Şırnak, Turkey. https://orcid.org/0000-0002-3628-8080
3Department of Cardiovascular Surgery, Istanbul Dr. Siyami Ersek Thoracic and Cizre State Hospital
Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey. Sur District, Banecırf Locality, Devlet hastanesi garaj, Cizre, Şırnak, Turkey
4Department of Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Zip Code: 73200
Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey. E-mail: [email protected]

This study was carried out at the Department of Cardiovascular Surgery, Istanbul
Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Article received on December 21st, 2021.
Hospital, Istanbul, Turkey. Article accepted on March 20th, 2022.

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INTRODUCTION RESULTS

Infective endocarditis (IE) is a disease that progresses with Between November 3, 2009, and December 7, 2020, 175 patients
morbidity and mortality, affecting 3-10 out of 100,000 people per were hospitalized for IE in our clinic, and 122 (69.7%) patients
year[1]. Despite early diagnosis and surgical interventions, hospital were operated. Of the operated patients, 84 were male (68.9%)
mortality was 17.1% in the European Infective Endocarditis (or and their mean age was 52.53±15.10 years. There were seven
EUROENDO) study published in 2019[2]. Surgical intervention in (5.4) patients with a history of IE. Clinical features of the patients
patients with IE is required because of heart failure, uncontrollable were as follows: New York Heart Association (NYHA) Functional
infection, and prevention of embolism. Almost half of IE patients Classification class 3 or 4 dyspnea (33.6%), fever exceeding
undergo heart surgery during hospitalization[3]. 38°C (49.2%), and history of arterial embolism or stroke (17.2%).
We conducted this study to review the early outcomes of surgical Emergency surgery was performed in nine (7.3%) patients.
treatment of IE and to explain the impact of demographic, clinical, Coagulase-negative staphylococci were the most common
echocardiographic, and intraoperative parameters on in-hospital pathogens causing IE in 25 patients — methicillin-resistant
mortality and morbidity of IE patients after surgical treatment. coagulase-negative staphylococci in 18 (14.75%), methicillin-
sensitive coagulase-negative staphylococci in seven (5,74%) —,
METHODS followed by streptococci in 11 (9.01%), Staphylococcus aureus in
10 (methicillin-sensitive S. aureus in seven [5.74%], methicillin-
In this retrospective case-control study, patients who underwent resistant S. aureus in three [2.46%]), Enterococcus faecalis in
cardiac surgery for IE in our clinic between November 2009 and nine (7.38%), Candida in three (2.46%), Escherichia coli and
December 2020 were evaluated. During this period, a total of Stenotrophomonas in two (1.64%), and Brucella in one (0.82%)
122 patients were operated for IE in our clinic. Their baseline patient. Blood cultures were negative in 73 patients (48.4%) (Table 1).
demographic data, echocardiographic data, performance status, In-hospital mortality occurred in 23 (18.9%) patients, and 99
laboratory data, operative data, and postoperative status were (81.1%) patients were discharged. Demographic, preoperative
comprehensively collected. Blood cultures were taken from all laboratory, and clinical characteristics of patients with and
patients at the time of admission. Empirical broad-spectrum without in-hospital mortality were compared (Table 2).
antibiotics were administered to patients with no known In-hospital mortality was related with older age, presence of
recent blood culture results. Then, specific treatment was periannular abscess, NYHA class 3 or 4 symptoms, low albumin
arranged according to hemoculture and antibiogram results. level, high alanine aminotransferase (ALT) level, and longer cross-
Routine laboratory tests and blood, valves, and vegetations clamping time (P<0.05 for all).
cultures were performed during hospitalization and treatment. Except for wound complication and focal neurological deficit,
Transesophageal echocardiography was performed after other complications were higher in the group of patients with
transthoracic echocardiography in all patients to determine in-hospital mortality. But there was no statistically significant
surgical strategy. Surgical procedures for IE were performed difference between the two groups in terms of intensive care unit
using conventional cardiopulmonary bypass. All infected stay (Table 3). Postoperative mesenteric hemorrhage was seen in
tissue was resected, and a physiological or anatomical surgical one patient. Tracheostomy was performed in one patient due to
reconstruction was performed. prolonged hospitalization. Nine patients were rehospitalized due
We defined emergency surgery as an operation with a refractory to pleural or wound complications.
cardiac problem, which will not respond to any treatment other Univariate and multivariate analyses were performed to
than cardiac surgery, and where there should be no delay identify independent risk factors related to in-hospital mortality.
in operative intervention. Hospital mortality was defined as Univariate variables with P<0.05 were included in the multivariate
mortality occurring within 30 days postoperatively or without analysis. Table 4 shows that older age, NYHA class 3-4 symptoms,
discharge. This study was approved by the local ethics committee and presence of periannular abscess were independently
of our hospital (2018-23) and complies with the standards of the associated with in-hospital mortality after IE surgery in the
Declaration of Helsinki and current ethical guidelines. multivariate analysis.

Statistical Analysis DISCUSSION

Statistical analyses were performed using the IBM Corp. Released The epidemiology of IE has changed significantly over the past
2015, IBM SPSS Statistics for Windows, version 23.0, Armonk, NY: three decades[4]. Mean age of the patients in our study was 52.53
IBM Corp. Continuous variables are expressed as mean ± standard years; compared to developed countries, patients with IE were
deviation and categorical data as proportions throughout the mostly young[5,6]. The male rate was found to be 68.9%, which is
manuscript. Categorical variables were compared using the χ2 consistent with male prevailing in the literature[7]. In our study,
test or Fisher’s exact test, and independent continuous variables 7.3% of the patients were operated under emergency conditions.
were compared by the unpaired Student’s t-test or Kruskal-Wallis The duration of antibiotic use before the operation was 17.18
test as appropriate. Logistic regression analysis was performed to days in all patients.
determine the predictors of in-hospital mortality. P-value < 0.05 In our cohort, 67.3% of the patients were operated for native
was considered statistically significant. valve endocarditis and 32.7% for prosthetic valve or cardiac

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Table 1. Demographics and clinical characteristics of all infective endocarditis patients.

Patients’ Characteristics n (%)/mean±SD
Demographic feature
Age, years 52.53±15.10
Male, n (%) 84 (68.9)
History of infective endocarditis 7 (5.7)
Preoperative clinical feature
NYHA class 3 or 4 symptoms 41 (33.6)
Body temperature > 38°C, n (%) 60 (49.2)
Previous emboli or stroke, n (%) 21 (17.2)
Emergency surgery, n (%) 9 (7.3)
Duration of antibiotic use, days 17.18±15.56
Preoperative echocardiographic data
Right heart endocarditis 8 (6.6)
Ejection fraction 55.49±10.28
Pulmonary arterial pressure, mmHg 43.07±13.11
Vegetation > 1 cm, n (%) 49 (40.2)
Presence of periannular abscess, n (%) 16 (13.1)
Vegetation site
Native aortic valve, n (%) 34 (27.9)
Native mitral valve, n (%) 32 (26.2)
Native tricuspid valve, n (%) 3 (2.5)
Multiple native valve, n (%) 13 (10.6)
Prosthetic aortic valve, n (%) 12 (9.8)
Prosthetic mitral valve, n (%) 20 (16.4)
Multiple prosthetic valve, n (%) 3 (2.5)
Device, n (%) 5 (4.1)
Identified microorganism
Coagulase-negative staphylococci
MRCNS 18 (14.75)
MSCNSA 7 (5.74)
Staphylococcus aureus
MSSA 7 (5.74)
MRSA 3 (2.46)
Streptococcus 11 (9.01)
Enterococcus faecalis 9 (7.38)
Candida 3 (2.46)
Stenotrophomonas 2 (1.64)
Escherichia coli 2 (1.64)
Brucella 1 (0.82)
Negative blood culture 57 (46.7)

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Operational data
Mitral valve replacement, n (%) 46 (37.7)
Mitral valve repair, n (%) 12 (9.8)
Mitral valve repair and tricuspid annuloplasty, n (%) 6 (4.9)
Aortic valve replacement, n (%) 25 (20.5)
Aortic and mitral valve replacement, n (%) 19 (15.6)
Bentall procedure, n (%) 7 (5.7)
Right heart or device surgery, n (%) 7 (5.7)
Cardiopulmonary bypass time, min 152.76±84.31
Cross-clamping time, min 112.20±73.51
MRCNS=methicillin-resistant coagulase-negative staphylococci; MRSA=methicillin-resistant Staphylococcus aureus;
MSCNS=methicillin-sensitive coagulase-negative staphylococci; MSSA=methicillin-sensitive Staphylococcus aureus; NYHA=New
York Heart Association; SD=standard deviation

Table 2. Comparison of demographic, preoperative laboratory, and clinical characteristics between patients with in-hospital
mortality and patients without in-hospital mortality.
Patients without in-hospital Patients with in-hospital
P-value
mortality (n=99) mortality (n=23)
Patients’ Characteristics n (%)/mean±SD n (%)/mean±SD
Demographic feature
Age, years 49.83±14.53 64.13±11.81 0.001*
Male, n (%) 69 (82.1) 15 (17.9) 0.676
History of infective endocarditis 6 (6.1) 1 (4.3) 0.750
Preoperative clinical feature
NYHA class 3 or 4 symptoms 28 (28.3) 13 (56.5) 0.01*
Body temperature > 38°C, n (%) 47 (47.5) 13 (56.5) 0.434
Previous emboli or stroke, n (%) 14 (14.1) 7 (30.4) 0.062
Emergency surgery, n (%) 8 (8.1) 1 (4.3) 0,537
Duration of antibiotic use, days 17.49±16.05 15.82±3.45 0.645
Preoperative echocardiographic data
Right heart endocarditis 8 (8.1) 0 (0) 0.158
Ejection fraction 57.49±16.05 55.82±13.45 0.645
Pulmonary arterial pressure, mmHg 43.12±13.32 42.87±12.42 0.937
Vegetation > 1 cm, n (%) 39 (39.4) 13 (56.5) 0.135
Presence of periannular abscess, n (%) 9 (9.1) 7 (30.4) 0.006*
Preoperative laboratory value
WBC (109/L) 10.43±6.28 10.08±4.36 0.799
PLT (109/L) 278.31±130.96 253.13±104.02 0.391
HGB (g/dL) 10.83±3.7 9.61±1.72 0.127
Creatinine 1.25±1.28 1.47±1.11 0.443
BUN 21.85±12.23 26.91±16.88 0.101

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Albumin (g/L) 37.84±8.56 31.78±7.91 0.020*

ALT (U/L) 24.87±40.42 48.78±75.44 0.036*
AST (U/L) 30.57±41.70 48.81±55.18 0.082
CRP 55.49±67.89 65.01±45.36 0.525
Procalcitonin 4.55±11.17 0.94±1.35 0.373
Sedimentation rate 62.84±33.65 81.5±40.71 0.132
Operative data
Cardiopulmonary bypass time, min 146.63±82.70 179.13±87.94 0.096
Cross-clamping time, min 104.07±66.36 147.21±92.34 0.011*
Cardiac reoperation 37 (37.4) 11 (47.8) 0,355
*P<0.05 is considered as significant.
ALT=alanine aminotransferase; AST=aspartate aminotransferase; BUN=blood urea nitrogen; CRP=C-reactive protein;
HGB=haemoglobin; NYHA=New York Heart Association; PLT=platelet; SD=standard deviation; WBC=white blood cell

Table 3. Comparison of postoperative complications between patients with in-hospital mortality and those without in-hospital
mortality.
Patients without in- hospital Patients with in-hospital
P-value
mortality (n=99) mortality (n=23)
Low cardiac output syndrome, n (%) 4 (4) 14 (60.9) < 0.0001*
Inotrope requirement, n (%) 24 (24.2) 22 (95.7) < 0.0001*
Global neurological deficit, n (%) 7 (7.1) 13 (56.5) < 0.0001*
Focal neurological deficit, n (%) 4 (4) 2 (8.7) 0.352
Arrhythmia, n (%) 21 (21.2) 14 (60.9) < 0.0001*
Temporary pacemaker requirement, n (%) 7 (7.1) 5 (21.7) 0.033*
Lung parenchyma complications
12 (12.1) 7 (30.4) 0.029*
(atelectasis, pneumonia, etc.), n (%)
Pleural complications, n (%) 17 (17.2) 12 (52.2) < 0.0001*
Acute kidney injury, n (%) 15 (15.2) 14 (60.9) < 0.0001*
Hemodialysis requirement, n (%) 4 (4) 12 (52.2) < 0.0001*
Acute liver injury, n (%) 4 (4) 5 (21.7) 0.003*
Re-exploration for bleeding, n (%) 8 (8.1) 14 (60.9) < 0.0001*
Wound complication, n (%) 10 (10.1) 3 (13) 0.680
Blood transfusion > 3 units, n (%) 23 (23.2) 15 (65.2) < 0.0001*
IABP, n (%) 1 (1) 5 (21.7) < 0.0001*
ICU stay, days 4.32±9.687 7.26±7.910 0.179
*P<0.05 is considered as significant. IABP=intra-aortic balloon pump; ICU=intensive care unit

device endocarditis. These data are similar to the International In-hospital mortality rate was 18.9%, close to the two large
Collaboration on Endocarditis (or ICE) data published in 2009[8]. international registries[2,8].
The most common pathogen in our study was staphylococci, As shown in our study, mortality was higher in elderly patients
similar to the literature[9]. The reason for the high culture with IE. The high incidences of IE in the elderly and its clinical
negativity in our study may be the patients referred to our and echocardiographic features have been emphasized in many
hospital. It can be explained by the negative blood culture taken studies[11-13].
from patients diagnosed with IE in another hospital and started No significant relationship was found between vegetation
on antibiotic therapy[10]. length > 1 cm and in-hospital mortality. However, there are

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Table 4. Univariate and multivariate analyses for risk factors related to in-hospital mortality.
Univariate analysis Multivariate analysis
OR 95% CI P-value OR 95% CI P-value
Age, years 1.093 1.043-1.146 < 0.000 1.074 1.024-1.127 0.003*
Previous emboli or stroke 2.656 0.927-7.612 0.069
NYHA class 3 or 4 symptoms 3.296 1.296-8.382 0.012 3.152 1.006-9.873 0.049*
Body temperature > 38°C 1.438 0.577-3.587 0.436
Presence of periannular
4.375 1.425-13.433 0.010 4.823 1.066-21.816 0.041*
abscess
Ejection fraction 0.992 0.951-1.036 0.726
Cross-clamping time 1.007 1.001-1.013 0.020 1.004 0.997–1.011 0.224
Cardiopulmonary bypass
1.004 0.999-1.009 0.108
time
*P<0.05 is considered as significant. CI=confidence interval; NYHA=New York Heart Association; OR=odds ratio

many studies in the literature showing a relationship between Authors’ Roles & Responsibilities
vegetation size, in-hospital mortality, and embolic events[14].
In our study, we found a relationship between periannular ÇTÜ Substantial contributions to the acquisition, analysis,
and interpretation of data for the work; agreement to be
abscess and in-hospital mortality. The presence of periannular accountable for all aspects of the work; final approval of the
abscess increased four times in-hospital mortality. Radical version to be published
debridement of abscess cavities is an essential procedure
ZMD Substantial contributions to the acquisition, analysis, and
in cardiac surgery and is important in active IE. In most interpretation of data for the work; drafting the work; final
cases, reconstruction using a pericardial patch is required approval of the version to be published
to close the abscess cavity[15]. Necessary aggressive surgical BT Substantial contributions to the acquisition, analysis, and
treatment results in high complication and mortality rates. interpretation of data for the work; final approval of the
In the in-hospital mortality group, the serum albumin level was version to be published
found to be low in the preoperative period. Hypoalbuminemia TA Substantial contributions to the acquisition, analysis, and
increases mortality as it is associated with malnutrition and interpretation of data for the work; final approval of the
frailty[16]. version to be published
Tİ Substantial contributions to the acquisition, analysis and
Limitations interpretation of data for the work; final approval of the
version to be published
The limitations of this study were the small number of SG Substantial contributions to the acquisition, analysis, and
patients, the review of short-term results, and the fact that it interpretation of data for the work; final approval of the
was a retrospective study. The study offered the opportunity version to be published
to evaluate surgically treated IE patients from a single referral MB Substantial contributions to the acquisition, analysis, and
tertiary care center. interpretation of data for the work; final approval of the
version to be published
CONCLUSION VE Substantial contributions to the acquisition, analysis, and
interpretation of data for the work; final approval of the
Although in-hospital mortality was related with older age, version to be published
presence of periannular abscess, NYHA class 3 or 4 symptoms,
low albumin level, high ALT level, and longer cross-clamping
time in univariate analysis, multivariate analysis showed that
the presence of paravalvular abscess was the most important REFERENCES
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