Predictors of embolic events in pediatric infective endocarditis

Infective endocarditis is an uncommon disease in children, but is often associated with significant morbidity and mortality. Embolization of vegetation to systemic or pulmonary circulation is a major contributor to morbidity and mortality of infective endocarditis, its incidence in adults varies from 22% to 40%. Very little data exists on the incidence and predictors of embolisation in children. We analysed the clinical and echocardiographic data of 50 consecutive children admitted to our centre with infective endocarditis over a five year period to determine the predictors of embolization.

This was a retrospective study of children below 12 years of age, who were admitted in the ward with a diagnosis of infective endocarditis. Their demographic, clinical, hematological and echocardiographic data were analysed to look for predictors of embolic events. The details of treatment and course in the hospital were also recorded.

The mean age was 6 +/- 3.6 years with a range from 4 months to 12 years. Congenital heart disease was the underlying diagnosis in 44 cases. Twenty three cases had undergone cardiac surgery earlier. Blood cultures were positive in only 19 cases (38%). Seven children grew fungus in their blood culture. Echocardiography revealed vegetation in all; the size of vegetation was > 10 mm in 18 cases and < 3 mm in 11. Clinically obvious embolisation occurred in 23 cases (46%), the size of vegetation was > 10 mm in 13. Embolic events were more common when vegetation was present in the right sided valves or chambers (16/24, 66%). Embolic events were acutely fatal in 7 cases, 6 of these had vegetations which were > 10 mm. Repeat echocardiography failed to show regression of vegetation size in 19/23 cases with embolic events, as against 15/27 without embolic events. A total of 11 patients died. Thirteen patients underwent surgery, 9 within two weeks of treatment.

In our study, large vegetations (> 10 mm) at presentation and failure to diminish in size on treatment are predictors of embolisation. Vegetations on right side of the heart are more likely to embolise.