Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam-Zuidoost, The Netherlands.
Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands.
Eur Heart J. 2017 Jul 7;38(26):2048-2056. doi: 10.1093/eurheartj/ehw591.
Adult congenital heart disease (ACHD) predisposes to infective endocarditis (IE). Surgical advancements have changed the ACHD population, whereas associated prosthetic material may constitute additional IE targets. We aimed to prospectively determine contemporary incidence, risk factors, and predictors of IE in a nationwide ACHD cohort, focusing on the presence of prosthetics.
We identified 14 224 patients prospectively followed in the CONCOR ACHD registry (50.5% female, median age 33.6years). IE incidence was determined using Poisson regression, risk factors and predictors using Cox regression. Overall incidence was 1.33 cases/1000 person-years (124 cases in 93 562 person-years). For risk-factor analysis, presence of prosthetics was forced-as separate time-updated variables for specific prosthetics-into a model with baseline characteristics univariably associated with IE. Valve-containing prosthetics were independently associated with greater risk both short- and long term after implantation [0-6 months: hazard ratio (HR) = 17.29; 7.34-40.70, 6-12 months: HR = 15.91; 6.76-37.45, beyond 12 months: HR = 5.26; 3.52-7.86], non-valve-containing prosthetics, including valve repair, only in the first 6 months after implantation (HR = 3.34; 1.33-8.41), not thereafter. A prediction model was derived and validated using bootstrapping techniques. Independent predictors of IE were baseline valve-containing prosthetics, main congenital heart defect, multiple defects, previous IE, and sex. The model had fair discriminative ability and provided accurate predictions up to 10 years.
This study provides IE incidence estimates, and determinants of IE risk in a nationwide ACHD cohort. Our findings, essentially informing IE prevention guidelines, indicate valve-containing prosthetics as a main determinant of IE risk whereas other prosthetics, including valve-repair, are not associated with increased risk long term after implantation.
成人先天性心脏病（ACHD）易患感染性心内膜炎（IE）。外科技术的进步改变了 ACHD 人群，而相关的人工假体可能构成了额外的 IE 靶点。我们旨在前瞻性地确定全国性 ACHD 队列中 IE 的当代发病率、危险因素和预测因素，重点关注假体的存在。
我们前瞻性地在 CONCOR ACHD 登记处确定了 14224 例患者（50.5%为女性，中位年龄 33.6 岁）。使用泊松回归确定 IE 发病率，使用 Cox 回归确定危险因素和预测因素。总的发病率为 1.33 例/1000 人年（93562 人年中有 124 例）。对于危险因素分析，植入后存在假体的情况作为单独的时间更新变量，用于包含基线特征的模型中，这些特征与 IE 有独立关联。植入后 0-6 个月[危险比（HR）=17.29；95%置信区间（CI）：40.70-40.70]和 6-12 个月（HR=15.91；95%CI：6.76-37.45），植入后 12 个月以上（HR=5.26；95%CI：3.52-7.86），非瓣膜假体（包括瓣膜修复）仅在植入后 6 个月内与更高的风险相关（HR=3.34；95%CI：1.33-8.41），之后则没有。使用 bootstrap 技术得出并验证了预测模型。IE 的独立预测因素是基线含有瓣膜的假体、主要先天性心脏病、多种缺陷、既往 IE 和性别。该模型具有良好的区分能力，并可提供长达 10 年的准确预测。
本研究提供了全国性 ACHD 队列中 IE 发病率估计和 IE 风险的决定因素。我们的研究结果基本上为 IE 预防指南提供了信息，表明含有瓣膜的假体是 IE 风险的主要决定因素，而其他假体，包括瓣膜修复，在植入后长期不会增加风险。
