Pediatric Infective Endocarditis Over the Last 30 Years: Thromboembolic Complications and Associations of Valve Vegetation and Heart Failure with Increased Mortality
Bibliographic record
Abstract
Abstract Abstract 4223 Background: Pediatric infective endocarditis (IE) continues to be a condition associated with high morbidity and mortality. Contributing factors for IE-related morbidity include thromboembolic complications (TEC) (cerebrovascular events (CVE): acute ischemic stroke (AIS); non-CVEs: arterial/venous TEC outside of the central nervous system). Conversely, reported mortality risk factors include age, gender, vegetation size, and TEC. Objectives: To describe the experience of a single center tertiary pediatric hospital including patients diagnosed and treated with IE over the last three decades. Methods: A retrospective chart review of pediatric patients with definite IE by the Dukes Criteria admitted to the Hospital for Sick Children between January 1978 and January 2008 was conducted. Data distribution was divided into periods I (PI) (1978-1989), PII (1990-1999), and PIII (2000-2008). Thrombotic events were included only if radiologically proven, concomitantly and/or after IE confirmation; infectious etiology was accepted only by positive blood cultures; and heart failure was defined by clinical criteria. Descriptive statistics including percentages and means were calculated; categorical correlations used Chi-square statistics; survival analysis included Kaplan Meier analysis; p values<0.05 was considered statistically significant. Results: 113 patients (pts) aged 0 to 18 years were included [mean: 3.6 yrs; females: 46 pts (41%)]. Congenital heart defects (CHD) were present in 95 pts (84%); cyanotic CHD in 33/95 (35%). In 64 pts (57%), 67 cardiac vegetations were found by echocardiogram [mitral (19%), aortic (18%), tricuspid valve (16%); multiple vegetations: 24/67 (36%)]; aneurysms occurred in 6 pts (5%). Large vegetations (≥1 cm) developed in 32 pts (27%). Only CHD (p=0.04), but not age, gender, or organism correlated with vegetation development. Overall, community acquired IE (CA-IE) was seen in 69/113 pts (61%), caused mostly by S. viridans; nosocomial and postoperative IE was caused mostly by S. aureus (54% vs. 27%; p<0.05), showing significantly higher mortality (27% vs. 7%; p<0.05). Period III showed the highest rate of older pts (p<0.001), CA-IE (p=0.04), vegetations (p=0.01), and TEC (p=0.01), but not of surgical interventions; yet, mortality was comparable in all periods (p=0.98). Fourty-one pts developed 44 TEC (40%), the presenting feature in 14 pts (12%). 22 pts (19%) were diagnosed with CVE (18 AIS; 4 cerebral mycotic aneurysms); 23 pts (20%) had non-CVE. Only older age (>3yrs) correlated with either CVE (p=0.04), or non-CVE (p=0.004). Conversely, TEC (p=0.06), AIS, or non-CVE did not predict mortality (p=0.5). Anticoagulation usage included: a) heparin/low molecular weight (3 pts), warfarin (8 pts), and antiplatelet therapy (22 pts); no major bleeding occurred. Overall, 5-yr mortality rate was 15%. Risk factors for mortality by univariate analysis included vegetations (p=0.001), vegetation size (p=0.01), and heart failure (p<0.001), of which vegetations (OR: 11.1, 95%CI: 1.5–88; p=0.005) and heart failure (OR: 145.0, 95%CI: 18–1221; p<0.0001) were confirmed by multivariate logistic regression. Overall survival at 1 month from IE diagnosis in patients without or with heart failure was approximately 92% and 75%, respectively (p<0.0001). Conclusions: Our single tertiary centre study reports a growing, high incidence rate of TEC in children with confirmed IE over the last three decades. Children >3yrs had a higher risk to develop any type of TEC; however, neither CVE nor non-CVE were associated with an increased mortality. While no major bleeding events occurred in pts treated with anticoagulants, there are limitations to comment on its safety in this condition. Mortality rate remained stable over time; heart failure and the presence of vegetations significantly increased the risk for death. Disclosures: No relevant conflicts of interest to declare.
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How this classification was reachedexpand
Direct model labels (unvalidated)
Per-model category and study-design labels from the labeling rounds. They are machine output, unvalidated, and the disagreement between models ships as data. No study design here is MEDLINE-validated yet.
| Model arm | Categories | Study design | Confidence |
|---|---|---|---|
| gemma | no category Domain: not available · Genre: Empirical About the Canadian research system: no · About a Canadian topic: no | Observational | low |
| gpt | no category Domain: not available · Genre: Empirical About the Canadian research system: no · About a Canadian topic: no | Observational | low |
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedLabeled directly by 2 models reading the full record.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".