CHAPTER 8
Prognosis
The determinants of early and late survival in patients with IE have been identified [1]. Several factors worsen the prognosis of IE and early surgical intervention may be necessary [2].
Clinical factors include old age, the presence of heart failure, renal failure, neurological symptoms, systemic em- boli, and delay in diagnosis. Persistent fever beyond the first week of treatment often indicates the development of complications such as progressive valve destruction, extension of infection to the valve’s annulus, develop- ment of perivalvular abscess, or the presence of septic emboli.
Bacteriological factors include the causative organism, with a worse prognosis in the case of Staphylococcus aureus, certain Gram-negative aerobic bacilli, and fungi. These of- ten present as acute IE and produce severe intracardiac de- struction and major embolic complications. Early surgical intervention is frequently required and the mortality rate is>20% [3].
Echocardiographic factors include aortic valve endo- carditis, PVE, and ring abscesses when persisting infection is more likely and surgery often inevitable [4]. The presence of recent, large (>10 mm), very mobile, pedunculated veg- etations increases the risk of systemic embolization, which may significantly affect prognosis.
The cure rate for NVE is>90% for streptococci, 75–
90% for enterococci, and 60–75% for S. aureus [5–8].The usual causes of death are heart failure, emboli, rupture of mycotic aneurysms, postoperative complications, re- nal failure, and overwhelming infection. The prognosis is worse in PVE than in NVE, and on rare occasions only heart transplantation can resolve intractable infection on
prosthetic valves [9]. Late prosthetic valve endocarditis has a better prognosis than early prosthetic valve endocarditis, with mortality rates of 19–50% and 41–80% respectively [10–15]. Valvular dysfunction, dehiscence, and intracar- diac abscesses are commoner in early infection and the antibiotic-resistant organisms associated with early dis- ease contribute to the higher mortality.
In 1995, Delahaye et al reported on the long-term prog- nosis of IE [16].In their series (1970–1986), global survival was 75% at 6 months and 57% at 5 years, with the annual instantaneous risk of death being 0.55 at 6 months, 0.18 at 1 year, then 0.03. After 1 year, the only factor influencing prognosis was age. The risk of recurrence appears to be 0.3–2.5/100 patient-years [16,17].
Castillo et al (1987–1997) reported a 5-year survival of 71% [18].In NVE, 5-year survival has been reported to be 88–96%, in contrast to PVE where 5-year survival rate is 60–82% [18–20]. Late PVE may have 5-year survival rates of 80–82% [18,21].
Netzer et al [22] reported that long-term survival fol- lowing IE is 50% after 10 years and is predicted by early surgical treatment, age<55 years, lack of congestive heart failure, and the initial presence of more symptoms of IE.
The long-term results of multivalvular surgery for IE have been recently reported [23].
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