Infective endocarditis in Rio de Janeiro, Brazil: a 5-year experience at two teaching hospitals

INTRODUCTION

Despite the recent advances in diagnosis and treatment, mortality rates due to infective endocarditis (IE) remain high if not aggressively treated with antibiotics, whether or not associated with surgery. Data on the prevalence, epidemiology and etiology of IE from developing countries remain scarce. The aim of this observational, prospective cohort study was to report a 5-year experience of IE at two teaching hospitals in Rio de Janeiro, Brazil.

MATERIAL AND METHODS

Demographical, anamnestic and microbiological characteristics of 71 IE patients were evaluated during the period of January 2009 to March 2013.

RESULTS

The mean age of the IE patients was 49.8 ± 2.4 years, of which 41 (57.7%) were males. The median time between the onset of symptoms and diagnosis of IE was 35.8 ± 4.8 days. A total of 31 (43.6%) cases of community-acquired infective endocarditis (CAIE) and 40 (56.3%) cases of healthcare-acquired infective endocarditis (HAIE) were observed. Staphylococcus aureus (30%) was the predominant cause of IE. Streptococcus spp. (45.1 %) was the predominant cause of the CAIE while S. aureus (32.5%) and Enterococcus spp. (27.2 %) were the main etiological agents of HAIE. For 64 (90.1 %) patients with native valve endocarditis, the mitral valve was the most commonly affected (48.3%). The main source of IE in this cohort was intravascular catheter. The tricuspid valve and renal chronic insufficiency were more frequent in patients with HAIE than CAIE (p = 0.001). The risk factors associated with in-hospital mortality rate (46.4%) in IE patients were: age over 45 (OR 3.4; 95% CI 1.03-11.24; p = 0.04) and chronic renal insufficiency (OR 38.3; 95% CI 3.2-449.4; p = 0.004).

CONCLUSIONS

At two main teaching hospitals in Brazil, Streptococcus spp. was the principal pathogen of CAIE while S. aureus and Enterococcus spp. were the most frequent causes of HAIE. IE remains a serious disease associated with high in-hospital mortality rate (46.6%); especially, in individuals over 45 years of age and with renal failure. Data suggest that early surgery may improve the outcome of IE patients.

The first case report of non-nosocomial healthcare-associated infective endocarditis due to methicillin-resistant Staphylococcus aureus USA400 in Rio de Janeiro, Brazil

Staphylococcus aureus is the main causal pathogen of infective endocarditis (IE), which may have distinct origins, namely, community, nosocomial, or non-nosocomial healthcare-associated (NNHCA). We report the first case of NNHCA-IE caused by methicillin-resistant S. aureus strain USA400/SCCmec IV in which the combination therapy of rifampin and vancomycin had a favorable outcome for the patient.

Cardiac tamponade in systemic lupus erythematosus. Report of four cases

OBJECTIVE

To report and assess the incidence of cardiac tamponade in systemic lupus erythematosus as a cardiac manifestation of the disease.

METHODS

We reviewed the medical records of 325 patients diagnosed with systemic lupus erythematosus according to the American Rheumatism Association and their complementary laboratory tests compatible with cardiac tamponade.

RESULTS

In the 325 medical records reviewed, we found 108 patients with pericardial effusions corresponding to 33.2% of the total and 54% of the patients studied in the active phase of the disease. Clinical assessment and transthoracic echocardiogram allowed the clinical diagnosis of cardiac tamponade in only 4 (1.23%) patients, 3 of whom were females, white, with ages ranging from 25 to 44 years. The pericardial fluid was hemorrhagic or serosanguineous with high levels of FAN and positivity for LE cells. In the treatment, we successfully used pericardiocentesis associated with high doses of corticosteroids. In clinical and laboratory follow-up performed for a period of 3 years, neither recrudescence of the pericardial effusion nor evolution to constriction occurred.

CONCLUSION

Even though rare (1.23%), cardiac tamponade in patients with systemic lupus erythematosus has a benign evolution when properly treated, according to our experience.

[Significance of alcohol abstinence in alcoholic cardiomyopathy with moderate left ventricular dysfunction]

PURPOSE

To evaluate the role of a 12 month alcohol abstinence period in patients with moderate left ventricular dysfunction treated with anticongestive therapy.

METHODS

Prospective observational study with 20 patients with alcoholic cardiomyopathy (ACM), 9 (45%) in functional class (FC) II and 11 (55%) in FC III, 16 (80%) men, mostly black (55%), from 35 to 56 (x = 45) years old, heavy alcohol users (> 80 g ethanol for 51 to 112 (x = 88) months. At the beginning, all agreed to participate with psychotherapy and clinical evaluation. After 12 months, they were divided in G-I, formed by those who remained abstemious and G-II of non-abstemious.

RESULTS

After 12 months, among the 11 (55%) who remained in psychotherapy, 8 were in G-I, among those who did not 9 (45%), only 2 (22.22%) remained abstemious (G-I). At the end of the evaluation period, both groups had the same number of patients. Comparing them, we observed: a) lower mean systolic and diastolic left ventricular diameters in G-I; b) more hospitalizations in G-II (3); c) more patients with stable or better clinical evaluation in G-I.

CONCLUSION

Despite the initial will, only 50% reached abstinence. When it was reached, patients had a better evolution in left ventricular systolic diameter and abstinence should always be tried even in the presence of moderate left ventricular dysfunction.

[Apical hypertrophic cardiomyopathy associated with coronary artery disease]

A fifty-nine year old man, known to have hypertrophic cardiomyopathy, presented worsening of angina. Multivessel coronary artery disease was diagnosed, and he underwent myocardial revascularization (mammary and two safenous grafts were implanted) with good evolution and reduction of left atrium dimension.

[Obstructive ischemic involvement of the anterior descending coronary artery in asymmetrical septal form of hypertrophic cardiomyopathy]

PURPOSE

The significance of necrosis and fibrosis of the interventricular septum in hypertrophic cardiomyopathy (HCM) is controversial. The purpose of this study was then to evaluate the clinical impact of left anterior descending artery (LAD) disease in HCM.

METHODS

Among 158 patients presenting with HCM, 6 (3.79%) had LAD disease. Mean age was 65.16 years (52 to 70), 4 were men and 4 had the obstructive form of HCM. All patients were submitted to complete clinical and laboratory evaluation. Mean time of the diagnosis was 141 months (ranging from 78 to 182) for HCM and 42 months (ranging from one day to 106 months) for LAD disease.

RESULTS

Five patients had unstable angina and one had myocardial infarction. LAD disease (60 to 100% coronary narrowing) was present in all patients; one patient had single vessel disease and 5 multivessel disease. During follow-up, 3 patients had coronary artery bypass grafting (CABG), one with associated septal myectomy; one was submitted to coronary angioplasty and 2 were submitted to medical treatment. During a follow-up period ranging from 76 to 124 months after LAD disease diagnosis, one patient died. At the end of the study, a reduction of the thickness of the interventricular septum from 1.53 to 1.40 cm was observed and left ventricular outflow pressure gradient decreased from 56 to 16 mmHg. Left ventricular diastolic diameter increased from 4.55 to 4.85 cm and systolic diameter from 2.83 to 3.13 cm. Left atrium diameter was unchanged.

CONCLUSION

LAD disease is well tolerated in the asymmetrical form of HCM and may contribute to septal fibrosis, improving cardiac function. It does not represent an adverse factor in the evolution of HCM.

[Is the apical hypertrophic cardiomyopathy seen in one population in Rio de Janeiro city similar to that found in the East?]

PURPOSE

To investigate the differences between clinical aspects and evolution of apical hypertrophic cardiomyopathy (AHCM) seen in Rio de Janeiro and the Oriental form, which was the first described.

METHODS

In 156 patients with AHCM diagnosed in our institution, there were 13 (8.34%) with the apical form of the disease, whose clinical settings, diagnostic procedures and evolution were studied.

RESULTS

There were 8 males and 5 females, between 19 and 75 years old, all white. Electrocardiogram (EKG) showed giant T waves in precordial leads in 10 (76.92%), echocardiogram (ECHO) demonstrated apical hypertrophy in all, 10 (76.92%) had only in the left ventricle, 2 in right ventricle and one involving both. Cineangiography corroborated ECHO findings. Follow-up ranged from 6 to 294 months (x = 95.4). Two deaths occurred in patients with RV involvement, due to large atria, atrial fibrillation, tricuspid or mitral insufficiency and thromboembolism. Among the survivors, the patient with RV disease has diastolic restriction and the ones with LV involvement, 9 are asymptomatic using either propranolol (8) or amiodarone (1), and one uses no medication.

CONCLUSION

A HCM seen in Rio de Janeiro is similar to that found in the Orient (Japan) regarding presentation, diagnosis and evolution; but in 3 patients we have found RV disease, not described in Japan, characterizing a distinct group with a worse evolution.

[Apical hypertrophic cardiomyopathy with right ventricular involvement]

We report right ventricular involvement in apical hypertrophic cardiomyopathy (HCMP) in two women and one man, aged from 19 to 44 years-old, who presented different signs from those with left ventricular disease (who have good clinical evolution), with signs and symptoms of severe diastolic restriction, showing great atrial enlargement and two with atrial fibrillation and death due to thromboembolism. The right ventricular involvement in apical HCMP leads to a worst prognosis than isolated left ventricular disease, does not have the typical electrocardiographic changes and presents with ventricular restriction and tricuspid regurgitation.

[Cardiac involvement in systemic lupus erythematosus. An echocardiographic evaluation]

PURPOSE

To study, by a non-invasive method, patients with systemic lupus erythematosus (SLE), to evaluate possible cardiac involvement.

METHODS

A hundred-eight lupic patients, 60 of them during activity, were studied, independently of cardiovascular signs and symptoms, by M-mode and two-D echocardiography and Doppler. Among the patients in the acute phase, 19 had never used steroid therapy before.

RESULTS

Echocardiographic evaluation showed cardiac involvement in all patients who were in clinical activity. Seven had myocardial involvement with systolic impairment. In 35 patients, pericardial effusion was found, all in the acute phase. Regarding endocardial involvement, there were valve thickening in 54 patients in group I (acute phase), valve vegetations in eight and one with mitral valve prolapse. There were only six with valve thickening in group II (remission). Pulmonary hypertension was observed in 15 patients in the activity group and in two during remission.

CONCLUSION

Echocardiogram has showed how frequent cardiac involvement is in SLE, especially during disease activity and being independent of previous steroid therapy. As it is a non-invasive method, it could be used in a routine protocol in the evaluation and follow-up of these patients.

[Influence of atrial fibrillation in the natural history of hypertrophic cardiomyopathy]

PURPOSE

To evaluate the influence of atrial fibrillation in the natural history of hypertrophic cardiomyopathy.

METHODS

Eighty-eight patients under ambulatory treatment were studied. Most of them presented the asymmetric type of hypertrophic cardiomyopathy (87.5%). Group I (77 cases) was formed by patients who had never had atrial fibrillation and group II (11 cases) by those who had this arrhythmia paroxysmal or established.

RESULTS

In group I, with ages 48.02 +/- 14.82 years, left atrial dimensions 4.21 +/- 0.66 cm, there was one sudden death; 69 were treated by clinical means and 7 by surgery; no patient developed thromboembolism neither cardiac failure. In group II, with ages 58.02 +/- 11.04 years and left atrial dimension 5.32 +/- 0.45 cm, there were 4 deaths, 4 thromboembolisms and 3 with cardiac failure; all received only clinical treatment, having improved in clinical status in 71.42% after amiodarone therapy.

CONCLUSION

Atrial fibrillation was present in 12.5%, mostly in the asymmetric type, and in patients after 5th decade, all of them with enlarged left atrium (> 4.7 cm), with highest morbidity (thromboembolism and cardiac failure) and mortality. Among the survivors, amiodarone therapy improved functional class in 71.42%.

[Aortic insufficiency due to quadricuspid aortic valve]

In a 45 year old patient with clinic diagnosis of aortic regurgitation the two-dimensional echocardiography demonstrated a quadricuspid aortic valve and severe aortic regurgitation by Doppler. The quadricuspid aortic valve is a rare pathology, usually not associated with other cardiovascular pathologies and in which there is evolution with aortic regurgitation due to malposition of the four cusps.

[Familial complete atrioventricular block in patients with hypertrophic cardiomyopathy]

The association of spontaneous complete heart block and hypertrophic cardiomyopathy is rare. We have studied three patients of the same family, two brothers and one nephew, ages 19-41 years, with hypertrophic cardiomyopathy confirmed by hemodynamic and angiographic studies. All patients were treated with permanent cardiac pacemaker implant. They are asymptomatic, aging 33 to 55 years, with follow-up of 157 to 176 months after the onset of the heart block.

[Silent coronary artery-left ventricular fistula and acute myocardial ischemia]

A 65-year-old woman developed severe coronary insufficiency associated with papillary muscle dysfunction. She was submitted to cineangiocoronarography which ruled out obstructive coronary disease. Coronarography revealed a communication between the coronary arteries and the left ventricle, but a coronary arterial fistula was not seen. The possibility of this uncommon form of coronary drainage to the left ventricle, named silent fistula, being the cause of myocardial ischemia related to the coronary steal phenomenon is discussed.

[Intrapericardial lipoma]

A 27 year-old female patient presented with atypical chest pain. 2-D echocardiogram and thorax computed tomography revealed intrapericardial tumor. The patient was operated on for removal of the tumor, which turned out to be two isolated lipomas. The patient had a rapid postoperative recuperation.

[Surgical treatment of high-risk valvar endocarditis]

The authors have studied the immediate and long term outcome of surgical treatment of acute phase infective endocarditis in a group of 33 high risk patients with valvular heart disease. The age varied from 2 to 68 years, 18 patients were male and 22 were of the white race. The aortic valve was the most frequently involved (18/54.5%), followed by mitral valve (13/39.3%), and tricuspid valve (2/6.0%). Twenty-four patients (72.7%) were in functional class III and seven (21.0%) in functional class IV. The noninvasive studies in those patients revealed 13 cases (39.4%) with normal cardiac size. The EKG was abnormal in 27 cases (81.8%) mostly with left atrial and ventricular hypertrophy. The echocardiogram revealed the presence of vegetations in 27 patients (81.8%) and the blood cultures were positive in 24 cases (72.7%). All patients were treated with antibiotics. The pathologic analysis revealed the presence of vegetations in 94% and structural alterations in 16.5%. Twenty-one patients had heart valve replacement with mechanical prosthesis (63.6%), 11 (33.3%) had bioprosthesis and one had tricuspid excision without replacement (3.0%). The hospital mortality was 12% and the late mortality 3%. Three deaths occurred in patients who had prolonged clinical treatment (more than 35 days) and one patient died of severe fungal endocarditis. The follow-up of the remaining 26 patients varied from 1 to 596 weeks (mean 183) demonstrating important clinical improvement and a normally functioning valve prosthesis. All patients remained in functional class I or II. The analysis of our data indicates that surgical treatment is the best option for high risk endocarditis and should be undertaken earlier in all patients in this group.

[Surgical treatment of high-risk valvular endocarditis]

The authors have studied the short and long term results of surgical treatment of acute phase of infectious endocarditis in a group of 33 high risk patients with valvular heart disease. The age varied from 2 to 68 years; 18 patients were male and 22 were of the white race. The aortic valve was most frequently involved (18/54.5%), followed by the mitral valve (13/39.3%) and tricuspid valve (2/6.0%). Twenty four patients (72.7%) were in functional class III and seven (21%) in functional class IV. The noninvasive studies in those patients revealed 13 cases (39.4%) with normal cardiac size. The ECG was abnormal in 27 cases (81.8%) mostly with left atrial and ventricular hypertrophy. The echocardiogram revealed the presence of vegetations in 27 patients (81.8%) and blood cultures were positive in 22 cases (66.6%). All patients were treated with antibiotics. The pathologic analysis revealed the presence of vegetations in 94% and structural alterations in 16.5%. Twenty-one patients had heart valve replacement with mechanical prosthesis (63.6%), 11(33.3%) had bioprosthesis and one had tricuspid excision without replacement (3.0%). The hospital mortality was 12% and the late mortality 3%. Three deaths occurred in patients who had prolonged clinical treatment (more than 65 days) and one patient died of severe fungal endocarditis. The follow-up of the remaining 26 patients varied from 01 to 448 weeks (mean 183) demonstrating important clinical improvement and a normally functioning valve prostheses. All patients are in functional class I and II. The analysis of our data indicates that surgical treatments is the best option for high risk endocarditis and should be undertaken earlier in all patients in this risk group.