The ability of vegetation size on echocardiography to predict clinical complications: A meta-analysis,☆☆,

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Abstract

To clarify whether echocardiographic detection of a vegetation 10 mm or larger in size in patients with left-sided infective endocarditis poses an increased risk for complications, we performed a meta-analysis of English-language publications identified by a computerized search of the key words infective endocarditis and echocardiography. A pooled odds ratio was calculated by using the Robins, Greenland, and Breslow estimate of variance. The pooled odds ratio for increased risk of systemic embolization in the presence of a vegetation >10 mm (10 studies, 738 patients) was 2.80 (95% confidence interval [CI] 1.95 to 4.02; p < 0.01). The odds ratio of requiring valve-replacement surgery (seven studies, 549 patients) was 2.95 (95% CI 1.90 to 4.58; p < 0.01). The odds ratio of death (six studies, 476 patients) was 1.55 (95% CI 0.92 to 2.60; p = 0.10). Thus this analysis supports the hypothesis that echocardiographically detected left-sided vegetations >10 mm pose a significantly increased risk of (1) systemic embolization and (2) a need for valve-replacement surgery than cases where either no or smaller vegetations are detected. (J Am Soc Echocardiogr 1997;10:562-8.)

Section snippets

Methods

Studies were identified by means of a computerized literature search (MEDLINE) using the key words infective endocarditis and echocardiography. The computerized search was supplemented by a manual review of references cited in the bibliographies of these studies. Studies were limited to English-language works and excluded case reports and abstracts. Because tricuspid valve endocarditis is most often associated with intravenous drug use and is generally caused by Staphylococcus aureus, studies

Results

Does vegetation size >10 mm increase the risk of systemic embolization? Ten studies enrolling a total of 738 patients were included in the analysis (Figure 1).**

. Systemic emboli. Odds ratio with 95% confidence intervals for each of 10 studies and the pooled result. An odds ratio greater than 1 implies that larger vegetation size is associated with an increased risk of embolization.

Individually, four of the studies demonstrated a significantly increased risk for

Discussion

There has been considerable debate regarding the significance of vegetation size in patients with infective endocarditis. While some investigators have failed to detect significant correlations between vegetation size and frequency of complications,16 others have found vegetation size to be an important correlate of clinical outcomes.5, 9 Much of the discrepancy is likely related to the small sample sizes in several of these studies and the attendant problem of low statistical power to detect

Conclusions

This analysis supports the hypothesis that echocardiographically detected left-sided vegetations >10 mm pose a significantly increased risk of (1) systemic embolism and (2) need for valve-replacement surgery than cases where either no or smaller vegetations are detected. A similar effect on mortality was not detected, although the pooled number of fatal outcomes was small. While this analysis supports the assertion that vegetation size is an important determinant of systemic embolization, there

References (26)

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    Citation Excerpt :

    Embolic events are a life-threatening complication. Predictors of cerebral embolism have been identified in previous studies and include size and mobility of vegetations, causal microorganism and the affected valve.23–25 Our study identified mitral valve IE as an independent predictor of embolism.

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From the Cardiology Unit, University of Vermont College of Medicine and Fletcher Allen Health Care, Burlington.

☆☆

Reprint requests: Marc D. Tischler, MD, Director, Cardiac Ultrasound Laboratory, Cardiology Unit, McClure 1, Medical Center Hospital of Vermont, Burlington, VT 05401.

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