Early clinical course and long-term outcome of patients with infective endocarditis complicated by perivalvular abscess

Abstract

Background: Perivalvular abscess is an ominous development in patients with infective endocarditis. There is little information concerning the long-term outcome of these patients.

Methods: Patients admitted to a tertiary care centre in Ottawa between November 1987 and December 1995 because of infective endocarditis complicated by perivalvular abscess were identified by chart audit and by review of the transesophageal echocardiography database. The patients were followed for at least 4 years to determine cardiac complications, late cardiac surgery, long-term outcome and functional status.

Results: Forty-three consecutive patients with infective endocarditis and perivalvular abscess (32 men and 11 women; mean age 56 [standard deviation 16] years) were identified; 17 had native valve endocarditis and 26 had prosthetic valve endocarditis. Of the 43 patients, 31 had cardiac surgery during the hospital stay; 6 died in hospital, and 10 died during follow-up. Twelve patients received medical treatment alone; none died in hospital, and 8 died during follow-up. The medically treated patients had less severe heart failure than the surgically treated patients (p = 0.12), but the 2 groups were similar in age and infective organisms. After a mean of 4.5 years of follow-up, the cumulative death rate was 57%; survival was similar among the medically and surgically treated patients. The survivors were younger than the nonsurvivors (p = 0.04). Complications of perivalvular abscess, including pseudoaneurysms and fistulae, were common, occurring in all medically treated patients and in 10 of the 24 surgically treated patients who had follow-up transesophageal echocardiography.

Interpretation: Patients with infective endocarditis and perivalvular abscess had a high rate of death after hospital discharge and a high incidence of complications of perivalvular abscess, despite early surgical intervention in most patients. Lower age was the only predictor of long-term survival.

Fig. 1: Kaplan–Meier survival curves from time of diagnosis for patients with endocarditis complicated by perivalvular abscess. Survival was similar for patients who received early surgical therapy (broken line) and those who received medical treatment alone (solid line).

Fig. 2: Transesophageal echocardiograms of aortic root in short axis, showing evolution of perivalvular abscess in patient with bioprosthetic aortic valve. Top: The abscess (arrows) was located in the posterior aortic root. Bottom: The abscess became a pseudoaneurysm (arrows) communicating with the aortic root on follow-up study.