Justification: Contemporary risk and prognostic factors related to aortic valve endocarditis complicated with aorto-cavitary fistula (AoCF) remain partially understood.
Objectives: To identify the risk factors for developing AoCF in patients with definite left-sided infective endocarditis (IE) and establish the variables independently associated with in-hospital and one-year mortality.
Methods: The ICE Cohort is a prospective, multicenter and multinational study enrolling patients with definite native- or prosthetic-valve IE from 61 centers in 28 countries between 2000-06 and 2008-11. For the purpose of this study we have only included cases with definite aortic valve IE. Multivariate logistic regression modeling was used to determine variables associated with AoCF and mortality in patients with AoCF.
Results: Of 5,786 patients with definite left-sided IE, 3,730 (64.5%) were aortic IE. Of those aortic IE, 141 developed a AoCF (3.78%). The rates of AoCF in native valve IE (NVE) and prosthetic valve IE (PVE) were 3.2% and 5.2%, respectively (0.007). Patients with AoCF had more new moderate/severe valve regurgitation (72.8% vs. 58.2%, P<.001), had more frequent perivalvular abscess (100% vs. 22%, P<.001) and congenital heart disease (21.1% vs. 11.7, P<.009). AoCF patients had more congestive heart failure (58.7% vs. 39.7%, P<.001) and more frequent Enterobacteriae spp IE (6.3% vs. 1.3%, P=.021). In-hospital surgery was more frequent in AoCF patients (73.8% vs. 57%, P<.001). Independent risk factors for developing AoCF were: Prosthetic valve endocarditis (OR 1.67, 1.15-2.42, P=.007), congenital heart disease (CHD) (OR 2.03, P=.002) and Enterobacteriae spp. IE (OR 5.01, P<.001). AoCF was associated with increased in-hospital (30% vs. 19%, P=.005) and one-year mortality (43.2% vs. 31.8%, P=.012) rates. In-hospital mortality was associated with age (>60y) (OR=2.97, P=.004), chronic pulmonary disease (OR=4.52, P=.04), Enterococcus spp. IE (OR=7.77, P<.001), congestive heart failure (OR=3.07, P=.006), persistent positive blood cultures (OR=6.11, P=.01) and new conduction abnormality (OR=6.00, P=.005). Surgery was associated with mortality reduction (OR=0.32, P=.003). One-year mortality was associated with age (>60y) (OR=2.77, P=.006), coagulase negative IE (OR=3.89, P=.02), Enterococcus spp. IE (OR=3.89, P=.02, congestive heart failure (OR=2.18, P=.04) and new conduction abnormality (OR=4.50, P=.03). Surgery was a protective factor for mortality at 1-year (OR=0.27, P=.002).
Conclusions: Development of AoCF in patients with aortic IE appears to be associated with PVE, congenital heart disease and Enterobacteriae spp. IE. Congestive heart failure, age >60, Enterococcus spp. and new conduction abnormalities were independently associated in-hospital and 1-y mortality. Cardiovascular surgery in the acute phase was associated with a reduction of mortality, both in-hospital and at 1-year follow up.
