Infective endocarditis in hypertrophic cardiomyopathy: A multicenter, prospective, cohort study

Abstract

Infective endocarditis (IE) complicating hypertrophic cardiomyopathy (HCM) is a poorly known entity. Although current guidelines do not recommend IE antibiotic prophylaxis (IEAP) in HCM, controversy remains.This study sought to describe the clinical course of a large series of IE HCM and to compare IE in HCM patients with IE patients with and without an indication for IEAP.Data from the GAMES IE registry involving 27 Spanish hospitals were analyzed. From January 2008 to December 2013, 2000 consecutive IE patients were prospectively included in the registry. Eleven IE HCM additional cases from before 2008 were also studied. Clinical, microbiological, and echocardiographic characteristics were analyzed in IE HCM patients (n = 34) and in IE HCM reported in literature (n = 84). Patients with nondevice IE (n = 1807) were classified into 3 groups: group 1, HCM with native-valve IE (n = 26); group 2, patients with IEAP indication (n = 696); group 3, patients with no IEAP indication (n = 1085). IE episode and 1-year follow-up data were gathered.One-year mortality in IE HCM was 42% in our study and 22% in the literature. IE was more frequent, although not exclusive, in obstructive HCM (59% and 74%, respectively). Group 1 exhibited more IE predisposing factors than groups 2 and 3 (62% vs 40% vs 50%, P < 0.01), and more previous dental procedures (23% vs 6% vs 8%, P < 0.01). Furthermore, Group 1 experienced a higher incidence of Streptococcus infections than Group 2 (39% vs 22%, P < 0.01) and similar to Group 3 (39% vs 30%, P = 0.34). Overall mortality was similar among groups (42% vs 36% vs 35%, P = 0.64).IE occurs in HCM patients with and without obstruction. Mortality of IE HCM is high but similar to patients with and without IEAP indication. Predisposing factors, previous dental procedures, and streptococcal infection are higher in IE HCM, suggesting that HCM patients could benefit from IEAP.

Figure 1

Study flowchart showing patients’ selection process.

Figure 2

Examples of IE in 2 HCM patients. A and B, Mitral valve endocarditis. A, Transesophageal echocardiogram, 4 chamber view, 0°. An oscillating 16-mm vegetation is observed on the left atrial side of the anterior mitral leaflet (white arrow). Septal hypertrophy of 16 mm (white asterisk). B, Transesophageal echocardiogram, 5 chamber view, 0°. Color Doppler across the mitral valve with evidence of severe mitral regurgitation (white arrow), as well as flow acceleration noted in the left ventricle outflow tract (white asterisk). C and D, Infective endocarditis affecting the basal interventricular septum. C, Transesophageal echocardiogram, 4 chamber view, 0°. An 8- by 4-mm vegetation is evidenced 20 mm below the aortic valve (white arrow). Severe septal hypertrophy with a maximal wall thickness of 27 mm (white asterisk). D, Pulsed wave Doppler at the left ventricular outflow tract. Maximum gradient of 50 mm Hg and peak velocity of 3.5 m/s, with the characteristic dagger-shaped appearance seen in obstructive HCM. HCM = hypertrophic cardiomyopathy, IE = infective endocarditis.