A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE

doi:10.1016/j.ijcard.2017.03.148

International Journal of Cardiology

Volume 241, 15 August 2017, Pages 97-102

https://doi.org/10.1016/j.ijcard.2017.03.148 Get rights and content

Abstract

Background

The aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE).

Methods

From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers).

Results

Early mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2 mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC = 0.851).

Conclusions

The following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called “The EndoSCORE”.

Introduction

Surgical treatment of heart valve and prosthesis infective endocarditis (IE) is account for 25–50% of cases in active IE and 20–40% in treated IE [1], [2], [3], [4]. The mortality rate is very heterogeneous, ranging from 6 to 36% [5], [6], [7], [8], [9], [10], [11], [12], [13], [14].

The European System for Cardiac Operative Risk Evaluation (Euroscore), either I or II [15], [16], have been developed for risk assessment in general population undergoing cardiac surgery. Recently, these models were demonstrated to underestimate mortality in patients within lower risk strata and to overestimate mortality among patients at higher risk [17], [18], [19]. In a recent study [19], the Euroscore II was applied in a cohort of 149 cases with IE undergoing surgery, demonstrating as Euroscore II underestimates mortality by 5–10% when predicted mortality was higher than 10%.

Some studies have already addressed the issue to provide a specific risk score for early outcome according to pre- and operative data [20], [21], [22], [23]. De Feo et al. [20] compared Euroscore with their specific score in a subset of 252 patients undergoing surgery for IE; Area under curve of their score was significantly higher than Euroscore for the more specific model (0.91 versus 0.84). However, the role of Euroscore in this specific field remains still debated, since other studies showed good discrimination [24], [25].

Given the recent callout to report logistic models for the assessment of risk for surgery in case of valve or prosthesis IE [26], we reviewed the experience of 26 Italian Cardiac Surgery Centers to provide a logistic risk model for predicting early mortality of patients with heart valve and prosthesis IE undergoing surgery.

Section snippets

Study population

From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers (Appendix A) with a mean prevalence of 2.0% (1.4%–2.5%) of overall surgical population in the same Centers across the same period. Pre- and Operative characteristics are listed in the Table 1.

Definition of terms and end-points

All the variables collected in the dataset were defined according to Euroscore [15]. The primary end-point was early mortality, defined as

Results

Early mortality was 11.0% (298/2715). The following variables were found to be related to higher early mortality at univariate analysis (Table 1): age classes; female gender; lower left ventricular ejection fraction (LVEF); site of IE; aortic regurgitation; prosthesis involvement, preoperative shock or heart failure, severe pulmonary hypertension, diabetes, chronic obstructive pulmonary disease (COPD), creatinine value equal or higher 2 mg/dl, reoperation, presence of abscess, number of treated

Discussion

The possible reason for discrepancy between Euroscore and more specific scores is very likely due to the low prevalence of IE among cohorts used to develop both versions of Euroscore (1.1% in Euroscore I and 2.2% in Euroscore II). Hence, the contribution of IE related features might have been diluted in the final models. In fact, Euroscore does not sufficiently take into account surgical difficulties due to extent of locally infected tissue (i.e. abscess), sepsis-related disorders (i.e.

Limitations

The main limitation of this study is the retrospective nature so that we were unable to investigate the prognostic role of some variables as the interval time from IE onset and surgery, recurrent embolization, persistent positive cultures. Concerning the timing of surgery, no significant difference was found for active versus treated endocarditis at univariate; however, we are unable to define the exact timing of surgery for any patient.

In conclusion, although these limitations, GIROC provides

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Cited by (46)

Infective Endocarditis—Update for the Perioperative Clinician
2023, Journal of Cardiothoracic and Vascular Anesthesia
Infective endocarditis is a common pathology routinely encountered by perioperative physicians. There has been a need for a comprehensive review of this important topic. In this expert review, the authors discuss in detail the incidence, etiology, definition, microbiology, and trends of infective endocarditis. The authors discuss the clinical and imaging criteria for diagnosing infective endocarditis and the perioperative considerations for the same. Other imaging modalities to evaluate infective endocarditis also are discussed. Furthermore, the authors describe in detail the clinical risk scores that are used for determining clinical prognostic criteria and how they are tied to the current societal guidelines. Knowledge about native and prosthetic valve endocarditis, with emphasis on the timing of surgical intervention-focused surgical approaches and analysis of current outcomes, are critical to managing such patients, especially high-risk patients like those with heart failure, patients with intravenous drug abuse, and with internal pacemakers and defibrillators in situ. And lastly, with the advancement of percutaneous transcatheter valves becoming a norm for the management of various valvular pathologies, the authors discuss an in-depth review of transcatheter valve endocarditis with a focus on its incidence, the timing of surgical interventions, outcome data, and management of high-risk patients.
Future directions in infective endocarditis
2022, Infective Endocarditis: A Multidisciplinary Approach
Descriptions of infective endocarditis (IE) date back to the 1600s and despite significant advances in medicine, the diagnosis and management of the disease continue to perplex physicians in the current era. In this chapter, we will explore recent advances in the care of patients with IE as well as areas currently under investigation and opportunities for improvement in the future. The utilization of prosthetic devices, such as heart valves and pacemakers, along with the recent surge in injection drug use has significantly changed the profile of patients with IE as well as the characteristics of the disease. Concurrent advances in laboratory testing, imaging, and surgical care have permitted acceptable outcomes though challenges remain. Improved understanding of the disease process combined with individualized patient management hold promise in addressing the high morbidity and mortality of IE.
Prognostic models for mortality after cardiac surgery in patients with infective endocarditis: a systematic review and aggregation of prediction models
2021, Clinical Microbiology and Infection
Citation Excerpt :
Participants were recruited between 1980 and 2015 (see Supplementary material, Table S3). Three models were developed to predict any death occurring before discharge or within 30 days of surgery [24,26,30], five models to predict any death occurring before discharge [25,29,31,32], and the remaining three as death within 30 days of surgery [27,28]. The incidence of deaths varied between 8.2% and 29.2% (Table 1).
There are several prognostic models to estimate the risk of mortality after surgery for active infective endocarditis (IE). However, these models incorporate different predictors and their performance is uncertain.
We systematically reviewed and critically appraised all available prediction models of postoperative mortality in patients undergoing surgery for IE, and aggregated them into a meta-model.
We searched Medline and EMBASE databases from inception to June 2020.
We included studies that developed or updated a prognostic model of postoperative mortality in patient with IE.
We assessed the risk of bias of the models using PROBAST (Prediction model Risk Of Bias ASsessment Tool) and we aggregated them into an aggregate meta-model based on stacked regressions and optimized it for a nationwide registry of IE patients. The meta-model performance was assessed using bootstrap validation methods and adjusted for optimism.
We identified 11 prognostic models for postoperative mortality. Eight models had a high risk of bias. The meta-model included weighted predictors from the remaining three models (EndoSCORE, specific ES-I and specific ES-II), which were not rated as high risk of bias and provided full model equations. Additionally, two variables (age and infectious agent) that had been modelled differently across studies, were estimated based on the nationwide registry. The performance of the meta-model was better than the original three models, with the corresponding performance measures: C-statistics 0.79 (95% CI 0.76–0.82), calibration slope 0.98 (95% CI 0.86–1.13) and calibration-in-the-large –0.05 (95% CI –0.20 to 0.11).
The meta-model outperformed published models and showed a robust predictive capacity for predicting the individualized risk of postoperative mortality in patients with IE.
PROSPERO (registration number CRD42020192602).
Infective endocarditis: Time for new diagnostic criteria and management strategies?
2020, Hellenic Journal of Cardiology
Using surgical risk scores in nonsurgically treated infective endocarditis patients
2020, Hellenic Journal of Cardiology
Citation Excerpt :
The authors of the present study speculated whether commonly used risk scores, structured to predict in-hospital mortality following an operation for IE, could be informative for the medically only treated cohort of patients from an extensive national registry. It is known from the literature [3,7–16] that further validation studies are required to adopt the most promising risk score, from the available ones, regarding the prognostic accuracy of surgical mortality for IE. The task will be even more difficult if similar scores are applied to the solely medically treated IE patients, as it would refer to an heterogeneous group of patients that includes (1) those without a need for surgery, (2) those reluctant to undergo surgical treatment despite the fact that the operation is indicated, and (3) patients with severe comorbidities that make the surgery a futile option.
The accuracy of surgical scores in predicting in-hospital mortality for nonsurgically treated patients with infective endocarditis (IE) has not yet been explored.
Patients with definite IE who did not undergo valve surgery were selected from the database of seven French administrative areas (Association pour l'Étude et la Prévention de l'Endocardite Infectieuse [AEPEI] Registry, 2008). The patients were scored using (a) six systems specifically devised to predict in-hospital mortality after surgery for IE, (b) three commonly used risk scores for heart surgery, and (c) a risk score for predicting six-month mortality in IE after either surgery or medical therapy. Calibration (Hosmer–Lemeshow test) and discriminatory power (receiver operating characteristic [ROC] analysis) were assessed for each score. Areas under ROC curves were compared one-to-one (Hanley-McNeil method).
A total of 192 patients (mean age, 65.2±15.2 years) were considered for analysis. There were 38 (19.8%) in-hospital deaths. Age >70 years (p=0.001), Staphylococcus aureus as causal agent (p=0.05), and severe sepsis (p=0.027) were independent predictors of in-hospital mortality. Despite many differences in the number and type of variables, all but two of the investigated scores showed good calibration (p>0.66). However, discriminatory power was satisfactory (area under ROC curve >0.70) only for three of the scores specific for IE and two of the scores used to predict mortality after cardiac surgery.
Among the 10 surgical scores evaluated in this study, five could be adopted to predict in-hospital mortality even for IE patients receiving medical treatment only.
Effect of lung protective ventilation on perioperative pulmonary infection in elderly patients with mild to moderate COPD under general anesthesia
2020, Journal of Infection and Public Health
The research aims to explore the effects of different ventilation time on postoperative pulmonary infection in elderly patients with the mild and moderate chronic pulmonary obstructive disease (COPD), so as to provide evidence for reducing postoperative pulmonary infection complications in patients with COPD.
120 elderly patients with mild and moderate COPD were selected as the research objects. First, the general information of patients with COPD before surgery and the difference between healthy population and lung forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC and maximum midexpiratory flow (MMEF) functional indexes were analyzed and detected. Patients with COPD were operated on with single lung ventilation and general anesthesia. Patients with mild and moderate COPD were divided into two groups according to lung ventilation time (ventilation time 1.0–2.0 h group, ventilation time >2.0 h group). The inflammatory factors of IL-6, IL-21, TNF-α, and CXCL13 as well as inflammatory indicators of polycaprolactam (PCT), C-reactive protein (CRP) and white blood cell (WBC) in serum of all patients were detected after the operation. The probability of pulmonary infection after COPD was diagnosed and analyzed. Finally, the regression analysis of postoperative pulmonary infection in COPD patients was analyzed.
(1) The results showed that the smoking rate of mild and COPD patients was significantly higher than that of healthy people (P < 0.05). (2) The lung function indexes of the mild and moderate groups were significantly lower than those of the control group (P < 0.01), while the lung function indexes of the moderate group were significantly lower than those of the mild group (P < 0.05). (3) All the inflammatory indicators of moderate COPD patients were significantly higher than those of mild COPD patients (P < 0.05). (4) All inflammation-related indicators in patients with mild and moderate COPD with ventilation time of >2.0 h were significantly higher than those in the 1.0–2.0 h group (P < 0.05). (5) The probability of postoperative pulmonary infection in moderate patients was significantly higher than that in mild patients (P < 0.01). The probability of postoperative pulmonary infection in >2.0 h group was significantly higher than that in the 1.0–2.0 h group (P < 0.01). (6) Multivariate Logistic regression analysis results showed that lung function, duration of lung ventilation and smoking were independent risk factors for postoperative pulmonary infection in COPD patients.
It is important to detect pulmonary function before surgery, maintain single lung ventilation protection for no more than 2.0 h during surgery, and quit smoking to improve pulmonary infection in patients with COPD after surgery. In addition, the incidence of postoperative pulmonary infection in patients with moderate COPD was higher than that in patients with mild COPD, suggesting that early treatment in patients with COPD was also of great significance in reducing the incidence of postoperative pulmonary infection.

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^☆: No potential conflicts exist; No funding was provided.

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A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Definition of terms and end-points

Results

Discussion

Limitations

Ann. Thorac. Surg.

Ann. Thorac. Surg.

Am. J. Med.

Ann. Thorac. Surg.

Int. J. Cardiol.

Int. J. Cardiol.

Am. J. Cardiol.

Long term outcome of infective endocarditis in patients who were not drug addicts: a 10 year study

Heart

Contemporary clinical profile and outcome of prosthetic valve endocarditis

JAMA

Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the international collaboration on endocarditis-prospective cohort study

Arch. Intern. Med.

Mortality from infective endocarditis: clinical predictors of outcome

Heart

Complicated left-sided native valve endocarditis in adults: risk classification for mortality

JAMA

Impact of valve surgery on 6-month mortality in adults with complicated left sided native valve infective endocarditis: a propensity analysis

JAMA

Prosthetic valve endocarditis: who needs surgery? A multicenter study of 104 cases

Heart

In-hospital mortality of infective endocarditis: prognostic factors and evolution over an 8 year period

Scand. J. Infect. Dis.