Endocarditis - Surgery / Valve Replacement - HIV

8/17/2005

Question:  Is HIV-positive status alone a contraindications for surgery for infective endocarditis?

8261150.ui or 12874891.ui or 12691542.ui or 12092473.ui or 11198308.ui or 1510525.ui or 2627466.ui

http://endocarditis.org/iscvid/ISCVID_2001_Final_Program.pdf

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8261150.ui or 12874891.ui or 12691542.ui or 12092473.ui or 11198308.ui or 1510525.ui or 2627466.ui

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8261150[PMID] OR 12874891[PMID] OR 12691542[PMID] OR 12092473[PMID] OR 11198308[PMID] OR 1510525[PMID] OR 2627466[PMID]-------------------------------------------------------

<1>

Unique Identifier [PMID]: 8261150

Authors: Carrel T. Schaffner A. Vogt P. Laske A. Niederhauser U. Schneider J. Turina M.

Institution: Department of Medicine, University Hospital, Zurich, Switzerland.

Title: Endocarditis in intravenous drug addicts and HIV infected patients: possibilities and limitations of surgical treatment.

Source: Journal of Heart Valve Disease. 2(2):140-7, 1993 Mar.

Abstract: The incidence of infective endocarditis in drug addicts is increasing with the spread of intravenous drug abuse. The tricuspid valve is involved most commonly, followed by the mitral. We evaluated 22 patients prospectively with a mean age of 23 years, presenting with addiction-associated endocarditis and referred to our institution during a three-year period. The tricuspid valve was involved in 13 instances, the mitral in four, mitral plus tricuspid valves in five patients and the aortic valve in one. Staphylococcus aureus was the most frequent infective organism (15 cases), followed by streptococci (4 cases), corynebacteria (2 cases) and one case with a mixed infection. Six patients were HIV positive and 17 had evidence of chronic viral hepatitis. Ten patients (three of them HIV positive) were treated surgically. Resection of the tricuspid valve with (one case) or without replacement (four cases), resection of vegetations and tricuspid repair (two cases), mitral valve replacement (2 cases) and aortic valve replacement (one case) were performed. Operative mortality (< 30 days) was high (2/10, 20%); one patient died from cerebral hemorrhage and another from multi-organ failure. Another three patients died after a mean follow up of 10 months. In 12 patients, surgery was not attempted because of still existing intravenous drug abuse or renal and liver failure. Five of these patients died after a mean follow up of 13 months, two from septicemia, two from AIDS-related complications and one from drug overdose. The prognosis of drug-associated endocarditis treated with antibiotics is generally good.(ABSTRACT TRUNCATED AT 250 WORDS)

Publication Type: Journal Article.

<2>

Unique Identifier [PMID]: 12874891

Authors: Miro JM. del Rio A. Mestres CA.

Institution: Infectious Diseases Service, Institut Clinic Infeccions i Immunologia, Institut d'Investigacions Biomediques August Pi i Sunyer-Hospital Clinic, University of Barcelona, Barcelona, Spain. miro@medicina.ub.es

Title: Infective endocarditis and cardiac surgery in intravenous drug abusers and HIV-1 infected patients. [Review] [135 refs]

Source: Cardiology Clinics. 21(2):167-84, v-vi, 2003 May.

Abstract: Infective endocarditis (IE) is one of the most severe complications of parenteral drug abuse. The incidence of IE in intravenous drug abusers (IVDAs) is 2% to 5% per year, being responsible for 5% to 10% of the overall death rate. The prevalence of HIV infection among IVDAs with IE ranges between 30% and 70% in developed countries and HIV-infection by itself increases the risk of IE in IVDAs. The incidence of IE in IVDAs is currently decreasing in some areas, probably due to changes in drug administration habits by addicts to avoid HIV transmission. Overall, Staphylococcus aureus is the most common etiological agent, being usually sensitive to methicillin (MSSA). The tricuspid valve is the most frequently affected (60% to 70%), followed by the mitral and aortic valves (20% to 30%). HIV-positive IVDAs have a higher ratio of right-sided IE and S aureus IE than HIV-negative IVDAs. Response to antibiotic therapy is similar. Drug addicts with non-complicated MSSA right-sided IE can be treated with an i.v. short-course regimen of nafcillin or cloxacillin for 2 weeks, with or without addition of an aminoglycoside during the first 3 to 7 days. The prognosis of right-sided endocarditis is generally good; overall mortality is less than 5%, and with surgery is less than 2%. In contrast, the prognosis of left-sided IE is less favorable; mortality is 20% to 30%, and even with surgery is 15% to 25%. IE caused by GNB or fungi has the worst prognosis. Mortality between HIV-infected or non-HIV-infected IVDAs with IE is similar. However, among HIV-infected IVDAs, mortality is significantly higher in those who are most severely immunosuppressed, with CD4+ cell count < 200/microL or with AIDS criteria. Conversely, IE in HIV-infected patients who are not drug abusers is rare. The epidemiology of cardiac surgery in IVDAs and/or HIV-infected patients has changed in recent years. There is a decrease in IE and an increase of patients undergoing surgery (CABS) for coronary artery disease secondary to the hyperlipidemia and lipodystrophy induced by highly active antiretroviral therapy (HAART). Cardiac surgery in HIV-infected patients with or without IE does not worsen the prognosis because extracorporeal circulation did not affect the immune status after surgery. Morbidity and mortality seems to stay within the same range as the non-infected patients. In our experience, in the IE in HIV-infected IVDA group, the 1-year survival is 65% and the 5 and 10-year actuarial survival is 35%. For patients operated on for coronary artery disease, the 5-year survival is 100%. [References: 135]

Publication Type: Journal Article. Review.

<3>

Unique Identifier [PMID]: 12691542

Authors: Losa JE. Miro JM. Del Rio A. Moreno-Camacho A. Garcia F. Claramonte X. Marco F. Mestres CA. Azqueta M. Gatell JM. Hospital Clinic Endocarditis Study Group.

Institution: Fundacion Hospital de Alcorcon, Madrid, Spain.

Title: Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature. [Review] [33 refs]

Source: Clinical Microbiology & Infection. 9(1):45-54, 2003 Jan.

Abstract: OBJECTIVES: To add to the limited information on infective endocarditis (IE) not related to intravenous drug abuse (IVDA) in HIV-1-infected patients. METHODS: We have reviewed the characteristics of eight cases of IE in non-IVDA HIV-1 infected patients diagnosed in our institution between 1979 and 1999 as well as cases in the literature. RESULTS: All our patients were male, and the mean age was 44 years (range 29-64). HIV-1 risk factors were: homosexuality in five, heterosexuality in two, and the use of blood products in one. HIV stage C was found in six cases, and the median (range) CD4 cell count was 22/microL (4-274 cells/microL). IE was caused by Enterococcus faecalis in three cases, staphylococci in two cases, and Salmonella enteritidis, viridans group streptococci and Coxiella burnetii in one case each. Three patients acquired IE while in the hospital. All IE cases involved a native valve, and underlying valve disease was found in three patients. The aortic valve was the most frequently affected (five cases). Two patients underwent surgery, with a good outcome, and one patient died. Fourteen cases of IE not related to IVDA in HIV-1-infected patients were found in the literature review. The most common causative agents were Salmonella spp. and fungi (four cases each). Two patients had prosthetic valve IE, and the mitral valve was the most frequently affected (10 cases). The remaining clinical characteristics and the outcome were similar to those in the present series. CONCLUSIONS: IE not related to IVDA is rare in HIV-1-infected patients. In more than half of the cases, IE develops in patients with advanced HIV-1 disease. A wide etiologic range is found, reflecting different clinical and environmental conditions. None of the patients who underwent surgery died, and the overall mortality rate was not higher than in non-HIV-1-infected patients with IE. [References: 33]

Publication Type: Journal Article. Review.

<4>

Unique Identifier [PMID]: 12092473

Authors: Miro JM. del Rio A. Mestres CA.

Institution: Infectious Diseases Service, Institut Clinic Infeccions i Immunologia, Institut d'Investigacions Biomediques August Pi i Sunyer-Hospital Clinic, University of Barcelona, Barcelona, Spain. miro@medicina.ub.es

Title: Infective endocarditis in intravenous drug abusers and HIV-1 infected patients. [Review] [123 refs]

Source: Infectious Disease Clinics of North America. 16(2):273-95, vii-viii, 2002 Jun.

Abstract: Infective endocarditis (IE) is one of the most severe complications of parenteral drug abuse. The incidence of IE in intravenous drug abusers (IVDAs) is 2% to 5% per year, being responsible for 5% to 20% of hospital admissions and 5% to 10% of the overall death rate. IVDAs often develop recurrent IE. The prevalence of HIV infection among IVDAs with IE ranges between 30% and 70% in urban areas in developed countries. The incidence of IE in IVDAs is currently decreasing in some geographical areas, probably due to changes in drug administration habits undertaken by addicts in order to avoid HIV transmission. Overall, Staphylococcus aureus is the most common etiological agent, being in most geographical areas sensitive to methicillin (MSSA). The remainder of cases is caused by streptocococci, enterococci, GNR, Candida spp, and other less common organisms. Polymicrobial infection occurs in 2% to 5% of cases. The tricuspid valve is the most frequently affected (60% to 70%), followed by the mitral and aortic valves (20% to 30%); pulmonic valve infection is rare (< 1%). More than one valve is infected in 5% to 10% of cases. HIV-positive IVDAs have a higher ratio of right-sided IE and S. aureus IE than HIV-negative IVDAs. Response to antibiotic therapy is similar among HIV-infected or non-HIV-infected IVDAs. Drug addicts with non-complicated MSSA right-sided IE can be treated successfully with an i.v. short-course regimen of nafcillin or cloxacillin for 2 weeks, with or without addition of an aminoglycoside during the first 3 to 7 days. Surgery in HIV-infected IVDAs with IE does not worsen the prognosis. The prognosis of right-sided endocarditis is generally good; overall mortality is less than 5%, and with surgery less than 2%. In contrast, the prognosis of left-sided IE is less favorable; mortality is 20% to 30%, and even with surgery is 15% to 25%. IE caused by GNB or fungi has the worst prognosis. Mortality between HIV-infected or non-HIV-infected IVDAs with IE is similar. However, among HIV-infected IVDAs, mortality is significantly higher in those who are most severely immunosuppressed, with CD4+ cell count < 200/microL or with AIDS criteria. Finally, IE in HIV-infected patients who are not drug abusers is rare. [References: 123]

Publication Type: Journal Article. Review.

<5>

Unique Identifier [PMID]: 00000000

http://endocarditis.org/iscvid/ISCVID_2001_Final_Program.pdf

Authors: Miró, J.M.1, Singh, R.2, Engemann, J.2, Cabell, C.H.2,3, Marco, F.1, Olaison, L.4, Raoult, D.5, Abrutyn, E.6, Eykyn, S.7, Hoen, B.8, Chen, A.2, Sexton, D.J.1, and the ICE Study Group 1Infectious Disease Unit.

Institution: Infectious Disease Unit. Hospital Clinic i Provincial. Barcelona, Spain; Duke Univ. School of Medicine. Durham NC, USA.; Duke Clinical Research Institute. Durham NC, USA.; Sahlgrenska University Hosp. Göteborg, Sweden.; Unite des Rickettsies. Faculte de Medecine. Marseille, France.; MCP/Hahnemann School of Medicine. Philadelphia PA, USA.; St. Thomas’ Hosp. London, United Kingdom.; Hôpital Saint-Jacques. Besançon, France.

Title: Infective Endocarditis In Non-Intravenous Drug Users: A Comparison Of Hiv-Positive And Hiv-Negative Patients A Report From The Ice Investigators.

Source: Sixth International Symposium On Modern Concepts In Endocarditis And Cardiovascular Infections 6 Joia De La Mediterrània June 27 - 29, 2001 Meliá Gran Sitges Hotel Sitges (Barcelona), Spain.  Abstract P 045

Abstract: Infective endocarditis (IE) in HIV-positive patients has been shown to be associated predominately with intravenous drug use (IVDU). No previous study of HIV-positive patients with IE has attempted to characterize the non-IVDU population.

Objecte: This study of non-IVDU patients was designed to determine the differences between HIV-positive and HIVnegative patients with IE in a large multinational cohort.

Methods: A multi-national consortium, The International Collaboration on Endocarditis (ICE), has been formed to study IE. Of the 25 ICE centers, 7 have large existing IE databases representing more than 3000 cases of IE. These databases were selectively combined to establish a single large database for analytic purposes. Each database was mapped to a core set of variables with standard definitions. Non-IVDU, HIV-positive IE patients were compared with non-IVDU, HIV-negative IE patients.

Results: The databases included 647 non-IVDU patients with definite IE and documented HIV status from 3 sites in 3 countries (France, Spain, USA). 14 (2.2%) IE patients were HIVpositive while 633 IE patients were HIV-negative. The predominant organism isolated from both groups was Staphylococcus aureus, which occurred in 36% of HIV-positive patients and 24% of HIV-negative patients. Prosthetic valves were more common in HIV-negative IE patients compared to HIV-positive IE patients (22% vs 7%). HIV-positive IE patients were less likely to go to surgery during the episode (7.2% vs 38.6%, p = 0.022). The occurrence of left-sided IE was comparable between both groups. Recorded in-hospital mortality for HIV-positive and HIV-negative patients was similar (14.3 vs 14.5%). However, HIV-positive IE patients had a higher follow-up mortality (78.6% vs 40.1%, p = 0.005).

Conclusions: There are significant differences between HIVpositive and HIV-negative patients with IE when examining the non-IVDU population. Most importantly, HIV-positive patients had the same in-hospital mortality, even though they were more likely to be treated conservatively. Further studies are needed with larger populations of non-IDVU, HIV-positive IE patients to determine the reasons for these differences.

Publication Type: Conference Publication.

<6>

Unique Identifier [PMID]: 11198308

Authors: Abad C. Cardenes MA. Jimenez PC. Armas MV. Betancor P.

Institution: Department of Cardio-Vascular Surgery, University Hospital de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain.

Title: Cardiac surgery in patients infected with human immunodeficiency virus.

Source: Texas Heart Institute Journal. 27(4):356-60, 2000.

Abstract: From January 1991 through December 1999, 5 consecutive patients who were infected with human immunodeficiency virus presented in need of cardiac surgery. All were men; the median age was 44 years. Two of them presented with mitral and aortic infectious valve endocarditis, 1 with tricuspid endocarditis, 1 with prosthetic valve endocarditis, and 1 with pericarditis and pericardial tamponade. Under cardiopulmonary bypass, the 4 patients with endocarditis underwent these procedures: mitral and aortic valve replacement (2), tricuspid valve replacement (1), and aortic valve replacement (reoperation) and concomitant repair of a mycotic ascending aortic aneurysm (1). In the patient who had pericardial effusion, subxifoid pericardiostomy and drainage were performed, and a pericardial window was created. There was no intraoperative mortality. The patient with pericardial effusion died 8 days after surgery; he was in septic shock and had multiple organ failure. Two deaths occurred at 2 and 63 months, due to hemoptysis and sudden death, respectively. The 2 patients who underwent double valve replacement are alive and in good condition after a median follow-up of 71 months. Cardiac surgery is indicated in selected patients infected by the human immunodeficiency virus. These patients are frequently drug abusers or homosexual. Valvular endocarditis is the most common finding. Hospital morbidity and mortality rates are higher than usual in this group of patients.

Publication Type: Journal Article.

<7>

Unique Identifier [PMID]: 1510525

Authors: Brau N. Esposito RA. Simberkoff MS.

Institution: Infectious Diseases Section, Department of Veterans Affairs Medical Center, New York, New York 10010.

Title: Cardiac valve replacement in patients infected with the human immunodeficiency virus.

Source: Annals of Thoracic Surgery. 54(3):552-4, 1992 Sep.

Abstract: Major surgical procedures, especially when performed under general anesthesia, can depress immunological parameters measured in vitro. Therefore concern has been expressed that operation might have an adverse effect on the immune status of individuals infected with the human immunodeficiency virus (HIV). Four HIV-positive patients without symptoms of HIV disease underwent cardiac valve replacement in consequence of infective endocarditis. After up to 15 months postoperatively, 3 patients are alive and well without signs of progressive immunodeficiency or recurrent endocarditis. One patient died of recurrent endocarditis without evidence of HIV-related disease on autopsy. Cardiac operation does not seem to accelerate HIV-related immunodeficiency.

Publication Type: Case Reports. Journal Article.

<8>

Unique Identifier [PMID]: 2627466

Authors: Frater RW. Sisto D. Condit D.

Institution: Department of Cardiothoracic Surgery, Albert Einstein College of Medicine, Bronx, NY.

Title: Cardiac surgery in human immunodeficiency virus (HIV) carriers.

Source: European Journal of Cardio-Thoracic Surgery. 3(2):146-50; discussion 150-1, 1989.

Abstract: Intravenous drug addicts have always been at risk for acquiring infective endocarditis. In the United States in recent years, as many as 50% of addicts have become infected also with the human immunodeficiency virus (HIV). Since testing became available in late 1984, we have knowingly performed open cardiac surgery for endocarditis 11 times in HIV-positive patients. In 7, signs of infection were still presented at the time of surgery. Four died within 2 months of continued or recurrent sepsis. The others are alive, although 1 has returned to IV drug abuse. Open heart surgery was performed 4 times in patients whose endocarditis had been cured by antibiotics but who were left with destroyed valves and severe congestive cardiac failure. All these patients left hospital alive and well. One has since died of AIDS. Ten addicts with endocarditis coming to surgery in the pre-AIDS era had similar valvular pathology but only 2 with uncontrolled infection. All were cured by the combination of antibiotics and surgery. Conclusions: in HIV-positive patients with endocarditis, continued sepsis despite appropriate antibiotic therapy signals a potentially very serious prognosis which may be due to an already seriously impaired immune state. By contrast, in the absence of uncontrolled infection, HIV-positive patients appear to have a normal response to open cardiac surgery. Data on the risk to the patient of progressing to AIDS and the risk to the surgical team of acquiring HIV infection are unknown. Testing is vital for answering these questions.

Publication Type: Journal Article.