Valvular heart disease
Impact of a Multidisciplinary Management Strategy on the Outcome of Patients With Native Valve Infective Endocarditis

https://doi.org/10.1016/j.amjcard.2013.05.060Get rights and content

Strategies to improve management of patients with native valve endocarditis (NVE) are needed because of persistently high morbidity and mortality. We sought to assess the impact of an operative protocol of multidisciplinary approach on the outcome of patients with NVE. A formal policy for the care of infective endocarditis was introduced at our hospital in 2003 in which patients were referred to and managed by a preexisting team involving a cardiologist, a specialist in infectious diseases, and a cardiac surgeon. The initial multidisciplinary evaluation was performed within 12 hours of admission. Whenever conditions associated with impending hemodynamic impairment, high-risk for systemic embolization, or unsuccessful medical therapy were found, patients were operated on within 48 hours. Stable patients were evaluated weekly by the multidisciplinary team, and on-treatment surgery was performed whenever the above high-risk conditions had developed. Comparing the period 2003 through 2009 with 1996 through 2002 (when a multidisciplinary policy was not followed), patients were more numerous (190 vs 102), older (mean age 59.1 vs 54.2, p = 0.01), and had more co-morbidities (mean Charlson index 3.01 vs 2.31, p = 0.02). The pattern of infection did not change in terms of valve infected or paravalvular complications. In the second period, fewer patients had culture-negative NVE (8% vs 21%, p = 0.01) and worsened renal function (37% vs 58%, p = 0.001). A significant reduction in overall in-hospital mortality (28% to 13%, p = 0.02), mortality for surgery during the active phase (47% to 13%, p ≤0.001), and 3-year mortality (34% vs 16%, p = 0.0007) was observed. In conclusion, formalized, collaborative management led to significant improvement in NVE-related mortality, notwithstanding the less favorable patients' baseline characteristics.

Section snippets

Methods

From 1996 through 2009, 292 consecutive patients with definite NVE according to modified Duke criteria14 were identified at Ca' Foncello Hospital, Treviso, Italy. Clinical, microbiological, and imaging data were collected prospectively in a computerized database. Comorbidity was assessed by using the Charlson co-morbidity index.15 Each patient underwent ≥1 transthoracic and ≥transesophageal echocardiography (TEE) study. Three or more blood cultures were obtained from each patient. Delayed

Results

During the whole study period, 307 patients had NVE. After review of each case by 2 expert investigators, 15 cases were excluded for the following reasons: possible or rejected NVE (10) and incomplete case report form (5).The final sample was made up of 292 patients with definite NVE. One hundred two cases of NVE were included during period 1 (1996 through 2002), and 190 cases were included in period 2 (2003 through 2008), following the implementation of the management protocol. Comparing

Discussion

The present study demonstrates a significant reduction in NVE-related mortality since the inception of a formalized policy regarding the establishment of a multidisciplinary and coordinated approach to management, suggesting a beneficial impact of this strategy. Although it remains difficult to definitively demonstrate a direct relationship between the reduction in mortality and the use of our protocol, it seems unlikely that an intrinsic difference between the 2 patient populations can be

Disclosures

The authors have no conflicts of interest to disclose.

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