CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 AFRICA 197 The main indications for surgery were intractable heart failure (n = 35, 47.9%), large vegetations with increased risk for embolisation (n = 21, 28.8%) and ongoing sepsis despite appropriate antibiotic therapy (n = 11, 15.1%). Surgery was also performed for complications such as valve dehiscence, root abscess/aneurysm rupture or fistula, and/or a large perivalvular abscess. During surgery, IE was confirmed in 60 of the 73 subjects (HIV positive, n = 8; HIV negative, n = 65) who underwent surgery. In 10 subjects, features of chronic RHD were observed with no findings in keeping with IE, and in the remaining three, the surgery notes were not found. In the 60 subjects with confirmed IE, vegetations were observed in 41 cases (HIV positive, n = 6; HIV negative, n = 35) and chordal rupture/leaflet perforation was present in 36 cases (HIV positive, n = 5; HIV negative, n = 31). There was no difference in the prevalence of vegetations (p = 0.932) or chordal rupture/leaflet perforation (p = 0.715) present at surgery between the HIV-positive and -negative groups. However, an aortic root abscess was noted to be more common in the HIV-negative group. All seven cases documented at surgery were from this group (Table 5). There was no difference in the surgical outcomes between the HIV-positive and HIV-negative groups. There were six surgeryrelated deaths (HIV positive, 12.5%; HIV negative, 7.7%, p = 0.402). The HIV-positive patients who underwent surgery had a good CD4 count with a mean range of 471.4 × 106 cells/l, with only one such patient presenting with an AIDS-defining CD4 count of less than 200 × 106 cells/l. This patient negotiated surgery well with no postoperative complications. The total number of deaths (17 pre-operative and six postoperative) yielded an overall mortality rate of 23.7%. Eight (8.2%) patients were too ill on presentation to hospital for surgery and died shortly after admission. A further seven (7.2%) patients died while awaiting surgery. One patient was elderly with multiple co-morbidities and a poor pre-morbid condition precluding surgery, and in one patient surgical intervention was declined. Correcting for the 10 cases in whom IE was excluded at surgery yielded an adjusted overall mortality rate of 26.4% and surgical mortality rate of 9.5%. The majority of those who died (n = 20, 87.0%) had left-sided infection and 10 (43.5%) cases had an acute onset of presentation. Staphylococcus aureus (n = 4, 17.4%) and Streptococcus viridans (n = 3, 13.0%) were the most frequent pathogens, and negative blood cultures were noted in six (26.1%) cases. The mean EF was 55 ± 7.5% and the vegetation size was more than 10 mm in nine cases (39.1%). The mortality rate was similarly high in the HIV-positive and HIV-negative groups (n = 4, 33.3 vs n = 19, 22.4%, p = 0.402). One of the HIV-positive patients who died had an AIDS-defining CD4 count of 87 × 106 cells/l. Regression analyses were performed on the total IE cohort (HIV-positive and HIV-negative patients) to identify predictors of mortality. Univariate analysis showed that fever (OR 3.45, 95% CI 1.31–9.11, p = 0.012), haematuria (OR 3.76, 95% CI 1.42–9.98, p = 0.008), a low haemoglobin level (< 10 g/dl) (OR 1.30, 95% CI 1.03–164, p = 0.012) and vegetation size of > 15 mm (OR 2.12, 95% CI 0.72–6.73, p = 0.009) were predictive of death. On multivariate analysis, acute-onset IE (OR 251.46, 95% CI 1.18–5343.63, p = 0.043), vegetation size of > 15 mm (OR 222.60, 95% CI 1.04–4730.34, p = 0.043) and medical management only (OR 20.89, 95% CI 2.12–200.65, p = 0.037) were associated with increased in-hospital mortality rates (Table 6). Discussion This study shows that IE is a disease that affects young subjects and is associated with a high mortality rate in a Third-World setting. Over two-thirds of our subjects were under the age of 30 years, reflecting the predisposing valve lesion that was underlying RHD in 85% of cases. These findings are identical to previous studies undertaken in the Western Cape where RHD was observed in 76.6–84% of the study population.9,10 In our study, congenital heart disease, indwelling catheters and IV drug use featured in less than 15% of cases, quite different from Western series, which report a higher incidence of IE in IV drug users, and in subjects with degenerative valve disease, congenital heart disease, previous valve surgery and intravenous procedures.4,6 Table 4. Echocardiographic findings stratified by HIV status Parameters HIV (+) n = 12(%) HIV (–) n = 85(%) Total n = 97(%) EF% mean (SD) 57.8 ± 6.7 55.6 ± 6.4 55.9 ± 6.6 Infection site Mitral 5 (41.7) 34 (40.0) 39 (40.2) Aortic 4 (33.3) 15 (17.7) 19 (19.6) Mitral and aortic 3 (25.0) 24 (28.2) 27 (27.8) Tricuspid valve 0 (0.0) 8 (9.4) 8 (8.3) Pulmonary 0 (0.0) 3 (3.5) 3 (3.1) Other * 0 (0.0) 1 (1.2) 1 (1.0) Vegetations Present** 11 (91.7) 74 (87.1) 85 (87.6) Size in mm (range) 4–24 4–34 4–34 Size > 15 mm 3 (25.0) 13 (15.3) 16 (16.5) Complications** Chordal rupture 8 (66.7) 33 (38.8) 41 (42.3) Pericardial effusion 6 (50.0) 33 (38.8) 39 (40.2) Aortic root abscess 1 (8.3) 9 (10.6) 10 (10.3) Dehiscence of prosthetic valve 0 (0.0) 4 (4.7) 4 (4.1) Annular abscess 0 (0.0) 1 (1.2) 1 (1.0) Aneurysm*** 1 (8.3) 2 (2.4) 3 (3.1) *Pacemaker lead sepsis. **There was no difference in the prevalence of vegetations (p = 0.654) and transthoracic echocardiogram complications (p = 0.536) between the HIV-positive and -negative groups. ***Aneurysm = septal, n = 1, sinus of Valsalva, n = 1 and posterior mitral valve leaflet, n = 1. Table 5. Surgical findings in IE stratified by HIV status Parameters HIV (–) n = 65 (%) HIV (+) n = 8 (%) Total n = 73 (%) Vegetations* 35 (53.8) 6 (75.0) 41 (56.2) Vegetations only 11 (16.9) 2 (25.0) 13 (17.8) Vegetation + leaflet perforation/chordal rupture 22 (33.8) 3 (37.5) 25 (34.2) Vegetation + AR abscess 2 (3.1) 0 (0.0) 2 (2.7) Vegetation + aneurysm 0 (0.0) 1 (12.5) 1 (1.4) Valve destruction** 15 (23.1) 1 (12.5) 16 (21.9) Leaflet perforation/chordal rupture only 10 (15.4) 1 (12.5)*** 11 (15.1) Root abscess/fistula 5 (7.7) 0 (0.0) 5 (6.8) Prosthetic valve dehiscence 2 (3.1) 0 (0.0) 2 (2.7) Pacemaker sepsis 1 (1.5) 0 (0.0) 1 (1.4) Not in keeping with IE 9 (13.8) 1 (12.5) 10 (13.7) Surgical records not found 3 (4.6) 0 (0.0) 3 (4.1) *There was no difference in the prevalence of vegetations between the HIVpositive and -negative groups (p = 0.932). **Valve destruction was also similar in both groups. ***Tear in the non-coronary cusp.
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