Complicated infective endocarditis necessitating ICU admission: clinical course and prognosis

Aim: To study incidence, clinical course and prognostic factors in patients admitted to medical intensive care units (ICUs) because of a complicated course of infective endocarditis. Method: This was a retrospective multicenter observational study of 4106 patients admitted to four medical ICUs in one tertiary hospital and one university hospital between 1994 and 1999. Results: Infective endocarditis was identified in 33 (0.8%) patients. Of these, 26 were male, mean age was 59 +/- 12 and APACH E-III score was 75 +/- 31. Reasons for transfer to the ICU were congestive heart failure in 64%, septic shock in 21%, neurological deterioration in 15% and cardiopulmonary resuscitation in 9%. Inotropes or vasoconstrictors were required in 73% and multiorgan failure developed in 64% of the patients. Prosthetic valve endocarditis was present in 21%. Gram-positive cocci were found in 96% of all positive cultures; cultures were negative in 27% of the patients. Transthoracic echocardiograms were diagnostic in only 33% and transesophageal studies were required in 91% to confirm diagnosis or fully to delineate the extent of disease. Surgical intervention was performed in 60% of the patients, and the remaining 40% were only treated medically. The APACHE-III score on admission did not differ statistically between the two groups (69 30 versus 84 +/- 34, P= 0.17). In-patient mortality was 84% in patients treated medically, and 35% in surgically treated patients. Using multivariate analysis, acute renal failure on admission was identified as the independent single predictor for in-patient death (OR 5, 95% Cl 1.04-24.03, P= 0.04). Conclusion: The prognosis for patients with infective endocarditis requiring admission to a medical ICU is serious. Nevertheless, the data suggest that surgical intervention may be successfully performed in a substantial number of patients despite the presence of severe shock and occurrence of multiorgan failure.