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BackgroundAspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in‐hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis.Methods and ResultsOutcomes of 361 consecutive patients (mean age, 59.1±15.4 years) who had undergone surgery for IE in 8 European centers of cardiac surgery were recorded prospectively, and a risk factor analysis (multivariable logistic regression) for in‐hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty‐six (15.5%) patients died postsurgery. BMI >27 kg/m2 (odds ratio [OR], 1.79; P=0.049), estimated glomerular filtration rate <50 mL/min (OR, 3.52; P<0.0001), New York Heart Association class IV (OR, 2.11; P=0.024), systolic pulmonary artery pressure >55 mm Hg (OR, 1.78; P=0.032), and critical state (OR, 2.37; P=0.017) were independent predictors of in‐hospital death. A scoring system was devised to predict in‐hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734–0.822). The score performed better than 5 of 6 scoring systems for in‐hospital death after cardiac surgery that were considered.ConclusionsA simple scoring system based on risk factors for in‐hospital death was specifically created to predict mortality risk postsurgery in patients with IE.

Concentrations of vancomycin in sternal bones of 10 patients undergoing cardiac surgery were studied at steady state, 48 h after starting intravenous prophylaxis. A sample of sternal bone was taken before (group I) or after (group II) cardiopulmonary bypass. The mean vancomycin concentrations in sternal bones were not significantly different between the groups and were 9.3 ± 3.0 pg/g. The concentrations of vancomycin in sternal bones were always above the MICs for staphylococci, streptococci, and enterococci.Antibiotic prophylaxis is widely used in cardiac surgery. Methicillin-resistant coagulase-negative staphylococci are among the most common pathogens in this setting, and vancomycin is increasingly being used in patients with infections due to both coagulase-negative and coagulasepositive strains, indwelling devices, and immunosuppression. Vancomycin could be an alternative to cephalosporins (cefazolin and cefamandole) for prophylaxis during cardiac operations in allergic patients or when there are significant numbers of methicillin-resistant coagulase-negative staphylococci. Generally, vancomycin is given intravenously just before surgery (15 mg/kg of body weight) and then at 10 mg/kg every 8 h for 48 h (1, 3). Information on the ability of vancomycin to penetrate the sternum is limited. To evaluate the range of diffusion, we determined vancomycin concentrations in sternal bone at steady state during a dosage regimen ensuring trough levels in serum higher than those required for a bactericidal effect against most Staphylococcus epidennidis strains. Vancomycin (10 mg/kg) was administered prophylactically every 8 h over a 48-h period before surgery in 1-h perfusions.The study design was approved by the local ethics review committee, and all of the subjects gave their written informed consent. Ten patients (eight males and two females) with a mean age of 50 + 11 years undergoing myocardial revascularization (six patients) or valve replacement (four patients) with cardiopulmonary bypass (CPB) were enrolled. Renal and hepatic functions were normal (Table 1). None of the subjects had had an infectious disease in the 6 months prior to surgery.The last preoperative administration of vancomycin (Vancocin; Eli Lilly & Co.) was started 3 h before surgery; vancomycin was not given during the operation but was administered every 8 h for 24 h postsurgery.CPB is known to reduce plasma drug levels. The most likely explanation is the rapid increase in the volume of distribution because of the additional volume in the priming pump, which leads to a rapid change in drug concentration in plasma. This phenomenon has been observed with vancomycin (2, 6). To detect such an effect, patients were divided into two groups. A sample (250 mg) of sternal bone (a mixture of cancellous and cortical bone) was taken before (group I; five patients) or after (group II; five patients) CPB, * Corresponding author. which lasted 53.4 + 26.9 min. The aortic clamp time was 35.2 + 21.7 min; there was no significant difference between the two groups. ...

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In our experience: 1) The risk of paraplegia is related to the extension and the type of the aortic lesions. 2) The preoperative study of the medullar vascularization and the use of extracorporeal circulation with deep hypothermia and sequential aortic unclamping, reduce the risk of severe cord ischemia, and 3) Occurrence of postoperative paraplegia depends on several factors and cannot be totally prevented by the surgical technique.