Endocarditis infecciosa diagnosticada a hospitals sense cirurgia cardíaca a Catalunya. Anàlisi de l'epidemiologia, maneig i pronòstic

Abstract

Infective endocarditis (IE) is a serious disease with an estimated incidence of 3. 4 cases per 100,000 people/year in Spain. The current knowledge of its characteristics comes from descriptions in large international cohorts, the most significant being the International Collaboration on Endocarditis cohort (ICE), which included 2,781 episodes diagnosed between 2000 and 2005, and more recently, the European Infective Endocarditis Registry (EURO-ENDO), which included 3,116 episodes diagnosed between 2016 and 2018. The main limitation of international IE registries is the lack of representation of episodes diagnosed in non-surgical centers. In this thesis, we aim to address this information gap by analyzing 501 consecutive patients from community hospitals diagnosed with IE. We demonstrate the existence of three patient cohorts: (a) transferred for surgical indication (SI), (b) not transferred despite having SI, and (c) not transferred due to the absence of SI; each group has clearly distinct demographic, clinical, and prognostic characteristics. Additionally, the prevalence of prosthetic valve infective endocarditis (PVIE) has significantly increased, potentially attributed to the rise in surgical indications, the higher frequency of interventions, longer overall life expectancy among patients, and improved diagnostic capabilities. When patients with PVIE are diagnosed in community hospitals, according to clinical guidelines, they should be promptly referred to a surgical center for evaluation and to plan the most appropriate treatment. However, this recommendation is based on expert opinion, as no comparative studies have been conducted on the different strategies for managing PVIE diagnosed in non-surgical centers. To address this issue, 201 episodes of PVIE were analyzed (118 diagnosed in community hospitals and 83 at the cardiac surgery referral center). When analyzing the patient cohorts based on their center of origin, we observed significant differences in demographic characteristics and severity at presentation, which was associated with a higher rate of surgical indication in PVIE episodes from the referral center. Conversely, there were no significant differences in hospital mortality rates (21% vs 30%) or one-year mortality rates (29% vs 37%) between patients diagnosed in both settings. This thesis demonstrates that the population diagnosed with IE in community hospitals without cardiac surgery has clearly distinct characteristics compared to those represented in large international cohorts from centers with cardiac surgery. Nearly 20% of patients with IE diagnosed in community hospitals meet the criteria for transfer due to surgical indication, but they are not transferred for various reasons, and their prognosis is poor. Finally, while PVIE cases are complex, if there is a good relationship with the referral surgical center, management in community hospitals does not negatively impact survival. Cardiac surgery is the most important protective prognostic factor in the short and medium term for patients diagnosed with IE in general, making it essential to establish appropriate protocols to ensure optimal and equitable management of these patients.

Date of Award	18 Dec 2024
Original language	Catalan
Supervisor	Oriol Gasch Blasi (Director) & Josep Maria Miro Meda (Director)