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PubMed1978

Experimental endocarditis in rabbits. 2. Course of untreated Streptococcus faecalis infection.

Insertion of a polyethylene catheter in the left side of the heart was used to induce sterile endocarditis in 34 rabbits. Bacterial endocarditis was established by injection of approximately 10(8) Streptococcus faecalis into the blood stream simultaneous with the removal of the catheter which had been in place for 3 days. The course of the bacterial endocarditis was examined by autopsy of rabbits sacrificed at regular intervals after the infection. The results showed that the presence of the catheter was not essential for the induction or maintenance of the infection. Growth of the bacteria took place in the preformed vegetations in the aorta, on the aortic valves and in the left ventricle. However, increases in the size of the vegetations, a high density of bacteria in the vegetations and secondary spreading were found only on the aortic valves. The extracardial manifestations of left-sided S. faecalis endocarditis included constant bacteriaemia, a high frequency of septic kidney infarcts and enlargement of the spleen. This form of experimentally provoked bacterial endocarditis in rabbits provides a good imitation of human subacute endocarditis, and would thus seem to be suitable for further study of the pathophysiology of endocarditis and evaluation of the effect of treatment with antibiotics.

Animals↗

PubMed1979

Fate of circulating immune complexes in infective endocarditis.

To examine the role of circulating immune complexes (CIC) in infective endocarditis, we studied 64 patients with infective endocarditis for the presence of CIC by the polyethylene-glycol (PEG)-precipitation test and the Clq binding test. This study was repeated during the course of the disease in 23 patients. CIC were found in 84 per cent of patients (66 per cent with acute infective endocarditis, 89 per cent with subacute infective endocarditis) during the active phase of the disease. Higer PEG precipitates were associated with typical cutaneous signs, cryoglobulins and nonstreptococcic culture-positive infective endocarditis. Under appropriate antibiotic treatment, the PEG precipitate levels of 17 patients fell within 1 month to the normal range, with a concomitant drop in cryoglobulinemia and rheumatoid factor. Conversely, uncontrolled sepsis always (six of six) yielded a rising level of CIC. These findings support the hypothesis that CIC may be important in the pathogenesis of peripheral lesions in infective endocarditis.

Adolescent↗

PubMed1976

Circulating immune complexes in infective endocarditis.

To examine further the role of immune-complex deposition in infective endocarditis, we studied 29 patients with infective endocarditis for presence of complement-containing circulating immune complexes. Ninety-seven per cent (28 of 29) had serum levels of immune complexes greater than 12 mug per milliliter. Mean levels in these patients were significantly higher than in patients with sepsis without endocarditis or in normal controls (P less than 0.05). Circulating immune-complex levels were correlated with longer duration of illness (P less than 0.025), extravalvular manifestations of endocarditis (P less than 0.025) and hypocomplementemia (P less than 0.05). Patients with right-sided endocarditis had significantly higher circulating immune-complex levels than patients with left-sided involvement (P less than 0.025). In general, levels fell to zero with successful antimicrobial or surgical therapy. This drop was concurrent with disappearance of extravalvular signs, blood cultures becoming sterile, and rise in serum complement levels. These findings support the concept that immune complexes may be important in the pathogenesis of infective endocarditis.

Anti-Bacterial Agents↗

PubMed1979

Endocarditis caused by coagulase-negative staphylococci.

Sixteen patients with coagulase-negative staphylococcal endocarditis were treated at the University of Minnesota Hospitals between January 1970 and September 1977. In six patients, endocarditis developed after prosthetic valve surgery; among the other ten patients (the medical group), eight had known antecedent valvular disease. The skin was thought to be the source of infection in eight patients, suggesting that prompt treatment of skin infections and avoidance of injections in patients with valvular disease are important measures in the prevention of this disease. Patients with prosthetic valve endocarditis were infected with antibiotic-resistant organisms and had a higher mortality than those in the medical group (83% versus 20%). Bacterial isolates from three patients with prosthetic valve endocarditis were resistant to methicillin, and two of these three isolates also were resistant to cephalothin by quantitative susceptibility testing. The only patient with prosthetic valve endocarditis to survive was operated upon early in the course of his illness. These observation, coupled with the high mortality in this series and in others, has prompted us to advocate early surgery in prosthetic valve endocarditis.

Adolescent↗

PubMed1979

Circulating immune complexes in experimental streptococcal endocarditis: a monitor of therapeutic efficacy.

An important problem in the management of infective endocarditis has been the delineation of laboratory procedures that are sensitive, reliable indicators of therapeutic efficacy. Because circulating, complement-containing immune complexes of the IgG type (CICs) have been demonstrated in most humans with infective endocarditis, serum CIC levels during the natural course of the infection and in response to penicillin therapy were studied in 42 rabbits with right-sided endocarditis due to Streptococcus salivarius. A significant rise in the level of CICs in both 21 control rabbits and 21 treated rabbits was observed after induction but before treatment of infective endocarditis (P less than 0.01). In the 17 successfully treated rabbits, CIC levels fell sharply during the first week of therapy and remained at preinduction levels thereafter (P less than 0.005). In contrast, CIC values did not change significantly either in control animals or in the four treated animals with refractory endocarditis, although in the latter animals, serum bactericidal titers remained less than or equal to 1:32. These findings suggest that serial measurements of CIC levels during antimicrobial therapy of infective endocarditis may aid in monitoring therapeutic efficacy.

Animals↗

PubMed1978

Treatment of infective endocarditis: a 10-year comparative analysis.

The results of surgical and non-surgical treatment of active infective endocarditis in 182 patients over a 10-year period were analyzed. Heart failure, annular and myocardial abscesses, heart block, and coronary embolism, seen most frequently with staphylococcal and fungal endocarditis, were the primary causes of death in both native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). In NVE, surgery significantly improved the survival in patients with moderate or severe heart failure (P less than 0.05) and in all patients with staphylococcal endocarditis (P less than 0.03). In PVE, surgery significantly influenced survival in patients with moderate or severe heart failure (P less than 0.05) and in the entire group with late PVE (P less than 0.01). Early surgery is recommended for patients with native valve endocarditis and moderate or severe heart failure; those patients with staphylococcal NVE, regardless of hemodynamic state, should undergo early valve replacement. Early surgery is recommended for PVE patients with moderate or severe heart failure. We also recommend early valve replacement for early and late staphylococcal PVE.

Adolescent↗

PubMedDate not supplied

The "incubation period" of subacute bacterial endocarditis.

In an attempt to gain information about the "incubation period" of subacute bacterial endocarditis, the literature was searched for case reports stating a specific interval between an event likely to cause bacteremia and the onset of symptoms. In 76 cases of streptococcal endocarditis for which this information was given, the median "incubation period" was one week. Symptoms began within two weeks in 64 of these cases (84%). Although there may be a bias toward reporting short incubation periods, it is concluded that the incubation period of subacute bacterial endocarditis is often shorter than is generally realized, and that procedures carried out more than two weeks before onset of symptoms are less likely to be causally related. In postcardiotomy cases, where timing of the bacteremia causing endocarditis is less easy to define, 27% of 122 cases of staphylococcal endocarditis developed within two weeks of surgery. This information is relevant to the planning and evaluation of prophylactic chemotherapy against bacterial endocarditis.

Cardiac Surgical Procedures↗

PubMed1976

A comparative study of 48 host valve and 24 prosthetic valve endocarditis cases.

Forty-eight cases of host valve endocarditis and 24 cases of prosthetic valve endocarditis occurring during a concurrent period of time were analyzed to assess differences between the two groups. The over-all incidence of prosthetic valve endocarditis during this 40 month period was 4.4%. The symptoms and signs in both groups were similar, except that PVE patients had more frequent occurrences of changing heart murmurs and splenic and cerebral emboli. Spleen scans may be helpful in the diagnosis of selected cases of culture-negative prosthetic valve endocarditis. There was no significant difference between the two groups for the various infecting microorganisms. However, the culture-negative prosthetic valve group had a mortality rate of 77.7% compared to 46.2% for the host valve group. In the HVE patients the oral cavity or urinary tract was the probable source of infection in 50.0% of the patients. In about one third of HVE cases, there was strong evidence that the infection was related to a therapeutic procedure, whereas nearly half of the PVE patients had clinical evidence of an extracardiac infection at the time of open-heart surgery. We emphasize the need for good pre- and postoperative surveillance to eliminate possible predisposing infections and appropriate antibiotic prophylaxis in all patients with valvular disease at times of risk. The survival rate in patients with prosthetic valve endocarditis was highest in those patients who received "appropriate" antibiotics and, if significant congestive heart failure was present, surgical intervention was necessary.

Adolescent↗

PubMed1977

[Bacterial endocarditis: clinical and bacteriological aspects and prognostic factors].

The microbiological, clinical and therapeutic aspects of all (71) cases of bacterial endocarditis admitted to the Hôpital cantonal, Geneva, between August 1970 and October 1974 were reviewed: there was a definite trend towards higher prevalence of acute cases compared to subacute cases. The pathogenic role of S. epidermidis, mostly in cases of prosthetic valve endocarditis, could be demonstrated in several cases. When defined initially by microbiological criteria only, acute endocarditis were characterized by rapid evolution, destruction of the valvular structures (especially aortic valve), and by further evolution under adequate antibiotic therapy: thus, 10/25 patients with acute endocarditis died, whereas the mortality rate in the subacute cases was only 10/46. Many cases in our series showed one or more often frequent embolic phenomena: 70% of the cured cases and 80% of the patients with a fatal outcome. An unfavorable evolution could be correlated with neurologic involvement, cardiac rhythm or conduction disturbances, and/or heart failure; indeed, heart failure due to various mechanisms was the single most frequent cause of death and is presently the main therapeutic problem. Thus, acute infection leading to destruction of the aortic valve and to heart failure still carries a bad prognosis, even if emergency valve replacement is attempted. Finally, 22/30 patients who developed a bacterial endocarditis after oral or urological procedures knew about a heart murmur, but did not receive antibiotic prophylaxis. This clearly shows that emphasis should be put on the elaboration and diffusion of adequate prophylactic regimens.

Adult↗

PubMed1976

Enterococcal endocarditis in heroin addicts.

Enterococci caused eleven of 20 cases (55%) of narcotic-associated endocarditis in Cleveland over a 54-month period. Acute staphylococcal endocarditis seen concurrently in this addict population displayed tricuspid valve involvement and septic pulmonary emboli, but enterococcal endocarditis was subacute, affected only aortic or mitral valves, and was not associated with septic pulmonary emboli. In contrast to enterococcal endocarditis in a nonaddict population, patients were younger and rarely had antecedent valvular disease or genitourinary abnormality. Staphylococcal tricuspid valve endocarditis was managed with relatively little difficulty in this addict population. Enterococcal infection, however, was complicated by severe cardiac failure that often required valvular prostheses, relapses due to continued use of narcotics, Candida superinfection, and nervous system complications, including cerebral emboli and mycotic aneurysms.

Acute Disease↗

PubMed1975

Bacterial endocarditis in idiopathic hypertrophic subaortic stenosis.

Bacterial endocarditis complicating idiopathic hypertrophic subaortic stenosis (IHSS) is uncommon but endocarditis may be the first clinical manifestation of IHSS. In this report of such a case, the aortic and the mitral valves were the sites of the bacterial infection. Many chordae tendineae to the mitral valve were ruptured from the extension of the infectious process. The endothelial lesions, which served as the seat for the bacterial infection on the anterior mitral leaflet, likely resulted from its abutting action against the septal prominence. Damage to the aortic valve leaflet may have resulted from abnormal valve motion caused by IHSS and created an environment conducive to endocarditis. This patient developed aortic insufficiency during the course of bacterial endocarditis, suggesting that the occasional association of aortic insufficiency in patients with IHSS may be secondary to healed endocarditis of the aortic valve.

Adult↗

PubMed1978

Infective endocarditis in heroin addicts: epidemiological observations and some unusual cases.

The total number of cases of heroin-induced endocarditis occurring over a four-year period were reviewed in order to explain an increase in the number of cases in the last year studied (1975). Brown heroin was noted to be used more frequently by addicts during the period of increased incidence. Cultures of "street samples" of brown and white heroin as well as cocaine were obtained in order to elucidate a possible relationship between the increased use of brown heroin and the increased number of endocarditis cases. Despite frequent contamination of both white and brown heroin, none of the common endocarditis-causing pathogens were isolated from the samples. Staphylococcus aureus, the most common etiological agent, frequently resulted in tricuspid endocarditis. That the accepted criteria for tricuspid endocarditis may be present without actual cardiac valve involvement is demonstrated by a most unusual case of hepatic vasculature infection.

Adolescent↗

PubMed1977

[Pathogenesis of endocarditis verrucosa simplex in the newborn (author's transl)].

Verrucous endocarditis in the newborn is not only a rare but also a problematic disease as concerns its etiology and pathogenesis. In the older literature septic infections of mother and child were said to be the causative factors. Recent experiences with the pathophysiology and pathomorphology of shock have also shown new aspects of the origin of this kind of endocarditis. Two cases from our own experience are compared with 7 cases from the literature. In the maternal history of gestation there was no infectious disease which could explain the endocarditis of the newborn. A short time after delivery the children showed a respiratory distress syndrome and died between 1.5 hours and 3 days after birth. At autopsy verrucous vegetations up to 8 X 5 X 4 mm in diameter were found on the tricuspid valve in 8 cases, once on the mitral valve and twice on both mitral and tricuspid valve. Malformations of the hearts were not noted. Histologically the fresh vegetations consist of clotted platelets and a fibrin network. At the base of the verruca the valvular leaflets show an edema, occasional fibroblastic changes and tiny lympho-histiocytic infiltrates in the subendothelial layer. Extracardial findings are hyaline membranes of the lungs and microthrombi in small vessels of lung, heart, liver and kidney due to shock and consumption-coagulopathy. According to Mittermayer et al. (1971a, b) who studied endocarditis verrucosa simplex in adults and animal-experiments endocarditis verrucosa simplex of the newborn is probably caused by intrauterine or perinatal shock.

Autopsy↗

PubMed1977

Protective role of complement in experimental Escherichia coli endocarditis.

Fourteen strains of Escherichia coli were tested for ability to cause infective endocarditis in rabbits prepared by prior placement of an intracardiac catheter. Strains that were resistant to the bactericidal action of serum caused E. coli endocarditis in 91.4% of rabbits, whereas serum-sensitive strains usually failed to cause persisting infection (11.3% infected, P less than 0.001). Although serum-sensitive E. coli lodged on heart valves within 1 h after intravenous injection, they survived less than 24 h in most normal rabbits. In contrast to normals, all five C6-deficient rabbits injected with a serum-sensitive strain of E. coli developed infective endocarditis (P less than 0.005). No correlation was found between the presence of K1 antigen and the incidence of experimental E. coli endocarditis. Thus, the ability of strains of E. coli to establish persisting endocardial infection in rabbits appears to be directly associated with resistance to the complement-mediated serum bactericidal system. These findings may explain in part the rarity of gram-negative bacillary endocarditis in patients; they also indicate that in certain special circumstances the serum bactericidal system can play a decisive role in host defense.

Animals↗

PubMed1979

Effect of type-specific active immunization on the development and progression of experimental Pseudomonas aeruginosa endocarditis.

Rabbits with intracardiac catheters were immunized with heat-killed Pseudomonas aeruginosa or saline and challenged with either 10(9) (high inoculum) or 10(7) (low inoculum) pseudomonas. Immunization did not decrease the incidence of endocarditis when compared with controls, but it did significantly prolong survival. The longer survival of immunized rabbits after high-inoculum challenge was not due to prolongation of the course of endocarditis but to type-specific protection from early, overwhelming bacteremia. However, after low-inoculum challenge there were no early deaths and there was a significantly (P < 0.01) longer survival of immunized (17.4 days) than unimmunized (10.6 days) animals dying of endocarditis. Increased survival was associated with higher total and 2-mercaptoethanol-resistant hemagglutinating antibody titers 1 week after challenge in immunized as compared with unimmunized rabbits. Early (48 h after challenge) vegetation colonization was also significantly (P < 0.05) greater after type-specific as opposed to non-type-specific or saline immunization and low-inoculum challenge. However, whereas 67% of type-specifically immunized rabbits had colonized vegetations at 48 h, only 38.9% died with bacteremic endocarditis. Another 19.2% of immunized rabbits had vegetations colonized with > 10(5) colony-forming units of pseudomonas at elective sacrifice 2 weeks after challenge but no bacteremia; no unimmunized rabbit exhibited similar late colonization. Preexisting antibody may be important in the pathogenesis of pseudomonas endocarditis in drug addicts, and its presence may explain the subacute and often protracted course of the disease.

Animals↗

PubMed1979

A collaborative study of infective endocarditis in the 1970s. Emphasis on infections in patients who have undergone cardiovascular surgery.

Twenty-six major cardiovascular centers participated in a cooperative study of all cases of infective endocarditis occurring during a single calendar year to obtain an overview of infective endocarditis. The study was designed to learn which patients appear to be at highest risk to develop this infection after palliative or reparative cardiovascular surgery. Of 278 patients developing infective endocarditis during the year at these medical centers, 63 (23%) had had previous cardiovascular surgery and 215 had not. Seventy percent of the 278 patients had recognized congenital or acquired heart disease before developing the infection. Rheumatic heart disease accounted for over half of the patients with underlying structural heart disease. A majority (55%) of the 63 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of those who did not require prosthetic valves, the majority had congenital heart disease with systemic artery-to-pulmonary artery shunts. Although these data were obtained from a selected group of patients, they confirm a significant risk of endocarditis in patients with prosthetic valves and suggest that in postoperative patients with non-valvular congenital heart disease, the highest risk appears to be in cyanotic patients with palliative pulmonary artery-to-systemic artery shunts.

Adolescent↗

PubMed1979

Imaging experimental infective endocarditis with indium-111-labeled blood cellular components.

The capability of radionuclide imaging to detect experimental aortic valve infective endocarditis was assessed with indium-111 (111In)-labeled blood cells. Sequential cardiac imaging and tissue distribution studies were obtained in 17 rabbits with infective endocarditis after administration of 111In-platelets and in five after 111In-polymorphonuclear leukocytes. Forty-eight to 72 hours after platelet administration, in vivo imaging demonstrated abnormal 111In uptake in all animals in the region of the aortic valve in an anatomically distinct pattern. Images of the excised heart showed discrete cardiac uptake conforming to the in vivo image and gross pathological examination. 111In platelet uptake in vegetations from the 17 animals averaged 240 +/- 41 times greater than that in normal myocardium and 99 +/- 15 times greater uptake in blood. In contrast, 111In-leukocyte cardiac imaging showed no abnormal aortic valve uptake 24 hours after tracer administration and the lesion myocardium activity ratio was only 5 +/- 2 (3 +/- 1 for lesion/blood activity). Four normal rabbits demonstrated neither positive 111In platelet scintigraphs nor abnormal cardiac tissue uptake. Likewise, noncellular 111In was not concentrated to any significant extent in three animals with infective endocarditis. This study demonstrates that 111In platelet, but not leukocyte cardiac imaging, is a sensitive technique for detecting experimental infective endocarditis. The imaging data conform to the cellular pathology of the infective endocarditis vegetation.

Animals↗

PubMed1979

Surgery for mitral valve endocarditis.

The records of 20 patients who underwent mitral valve replacement for complications of bacterial endocarditis were reviewed. Although the indications for surgery were the same as those for patients with aortic endocarditis, major emboli (cerebral, coronary or retinal) prompted surgery in 8 of 20 patients, a much higher incidence than reported for surgery in aortic valve endocarditis. Eighteen of the patients had mitral regurgitation; 14 of these had severe congestive heart failure, but the development of congestive failure tended to be more insidious than in patients with aortic endocarditis. Continued septicemia despite appropriate antibiotics was the least common indication for surgery. Sixteen of the 20 patients were salvaged by surgery, although some had major residual deficits, related mainly to preoperative emboli. These results are a marked improvement in the expected 90-100 percent mortality rate for patients with these complications of endocarditis. The main reason for a poor result following surgery was temporization leading to continued deterioration of vital functions preoperatively. Reinfection of the prosthesis did not occur, and we do not consider duration of preoperative antibiotic therapy an important factor in the decision to perform surgery.

Adult↗