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European Heart Journal Advance Access originally published online on November 30, 2004
European Heart Journal 2005 26(3):288-297; doi:10.1093/eurheartj/ehi034
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European Heart Journal vol. 26 no. 3 © The European Society of Cardiology 2004; all rights reserved.

Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality

Ignasi Anguera1, Jose M. Miro2,*, Isidre Vilacosta3, Benito Almirante4, Manuel Anguita5, Patricia Muñoz6, Jose Alberto San Roman7, Aristides de Alarcon8, Tomas Ripoll9, Enrique Navas10, Carlos Gonzalez-Juanatey11, Christopher H. Cabell12, Cristina Sarria13, Ignacio Garcia-Bolao14, M. Carmen Fariñas15, Ruben Leta16, Gabriel Rufi17, Francisco Miralles18, Carles Pare2, Artur Evangelista4, Vance G. Fowler, Jr12, Carlos A. Mestres2, Elisa de Lazzari2, Joan R. Guma1 and Aorto-cavitary Fistula in Endocarditis Working Group{dagger}

1Corporacio Sanitaria Parc Tauli-Hospital de Sabadell, Sabadell, Spain
2H. Clinic, IDIBAPS (Institut d'Investigacions Biomediques August Pi i Sunyer), University of Barcelona, Barcelona, Spain
3Hospital Clinico San Carlos, Madrid, Spain
4Hospital Vall d'Hebron, Barcelona, Spain
5Hospital Reina Sofia, Cordoba, Spain
6Hospital Gregorio Marañon, Madrid, Spain
7Hospital Universitario, Valladolid, Spain
8Hospital Universitario Virgen del Rocio, Sevilla, Spain
9Hospital Son Llatzer, Palma de Mallorca, Spain
10Hospital Ramon y Cajal, Madrid, Spain
11Hospital Xeral, Lugo, Spain
12Duke University Medical Center, Durham, NC, USA
13Hospital de la Princesa, Madrid, Spain
14Clínica Universitaria de Navarra, Pamplona, Spain
15Hospital Marques de Valdecilla Facultad de Medicina, Santander, Spain
16Hospital de Sant Pau, Barcelona, Spain
17Hospital de Bellvitge, Barcelona, Spain
18Hospital Carlos Haya, Malaga, Spain

Received 22 April 2004; revised 1 September 2004; accepted 1 October 2004; online publish-ahead-of-print 30 November 2004.

* Corresponding author: Infectious Diseases Service, Hospital Clinic - IDIBAPS, University of Barcelona, Helios-Villarroel Building, Desk no. 26, Villarroel, 170, 08036-Barcelona, Spain. Tel: +34 93 227 55 86; fax: +34 93 451 44 38/54 24. E-mail address: jmmiro{at}ub.edu or miro97{at}fundsoriano.es

See page 213 for the editorial comment on this article (doi:10.1093/eurheartj/ehi076)

Aims To investigate the clinical features, echocardiographic characteristics, management, and prognostic factors of mortality of aorto-cavitary fistulization (ACF) in infective endocarditis (IE). Extension of infection in aortic valve IE beyond valvular structures may result in peri-annular complications with resulting necrosis and rupture, and subsequent development of ACF. Aorto-cavitary communications create intra-cardiac shunts, which may result in further clinical deterioration and haemodynamic instability.

Methods and results In a retrospective multi-centre study over 4681 episodes of IE, a total of 76 patients with ACF [1.6%, confidence interval (CI) 95%: 1.2–2.0%] diagnosed by echocardiography or during surgery were identified. Fistulae were found in 1.8% of cases of native valve IE and in 3.5% of cases of prosthetic valve IE from the general population and in 0.4% of drug abusers. PVE was present in 31 (41%) cases of ACF. Transthoracic and transoesophageal echocardiography detected the fistulous tracts in 53 and 97% of cases, respectively. Peri-annular abscesses were detected in 78% of cases, fistulae originated in similar rates from the three sinuses of Valsalva, and the four cardiac chambers were equally involved in the fistulous tracts. Heart failure (HF) developed in 62% of cases and surgery was performed in 66 (87% CI 95% 77–93%) patients with a mortality of 41% (95% CI 30–53%) in the overall population. Multivariate analysis identified HF (OR 3.4, CI 95% 1.0–11.5), prosthetic IE (OR 4.6, CI 95% 1.4–15.4) and urgent or emergency surgical treatment (OR 4.3, CI 95% 1.3–16.6) as variables significantly associated with an increased risk of death. Major complications during follow-up (death, re-operation, or re-admission for HF) among the five operative survivors with residual fistulae occurred in 20 and 100% of patients at 1 and 2 years, respectively.

Conclusion Aorto-cavitary fistulous tract formation is an uncommon but extremely serious complication of IE. In-hospital mortality was exceptionally high despite aggressive management with surgical intervention in the majority of patients. Prosthetic IE, urgent surgery, and the development of HF identify the subgroup of patients with IE and ACF that have significantly increased risk of in-hospital death.

Key Words: Infective endocarditis • Aorto-cavitary fistula • Heart failure • Surgery


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