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Timing of Surgery in Endocarditis

Timing of Surgery in Endocarditis. Jimmy Klemis, MD CT Surgery Conference. Endocarditis. Potentially lethal disease with varying etiologic agents and different clinical situations (NVE vs PVE, etc) No “cookbook” approach to proper therapy, esp when considering surgery

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Timing of Surgery in Endocarditis

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  1. Timing of Surgery in Endocarditis Jimmy Klemis, MD CT Surgery Conference

  2. Endocarditis • Potentially lethal disease with varying etiologic agents and different clinical situations (NVE vs PVE, etc) • No “cookbook” approach to proper therapy, esp when considering surgery • In select patients, combined medical and surgical Rx offers substantial benefit compared with medical Rx alone • However, surgery carries risk and decision on whether or not to operate must be carefully thought out with good communication between surgical and medical teams

  3. Endocarditis • In pre-Abx era, largely fatal disease • 1885 – Sir William Osler in Gulstonian lectures referred to IE as the “malignant endocarditis”, 30 years later he expressed pessimism about ever finding a “cure” for IE • 1940’s – PCN revived hope for a cure of IE, however morbidity and mortality only partially altered • resistant organisms and shifting etiology (IVDA) Chamoun. Am J Med Sci. Oct 2000; 320 (4)

  4. Endocarditis – surgical Rx • 1961 – Kay et al first to report surgical cure of pt with medically resistant IE (fungal TV) • 1965 Wallace, et al – first report of successful valve replacement in active endocarditis • early success in many studies of selected patients led to “paradigm shift” in management of complicated endocarditis

  5. Indications for Surgery • Hemodynamic compromise/ Heart failure • Persistent sepsis • Peripheral embolization • Extravalvular extension of infxn

  6. Heart Failure • Mills, et al. UCSF 19741 • 79/144 pt developed CHF within 6mos of admit • 60% moderate-severe • MR – 50% developed CHF, 1/2 severe • AR – 80% CHF, 2/3 severe • 6 month survival with severe CHF/AR • medical 7 % med/surgical 64% 1Mills J, et al. Chest 66:151-157, 1974

  7. CHF • Lewis, et al. Johannesburg, South Africa, 1975-801 • early valve replacement in 95 hemodynamically unstable pt – 64% emergent 88% 48hrs • Mortality • urgent surgery 15% (13/84) • elective 18% (2/11) • 5 year survival 60% • Periprosthetic leaks in 13% (10/80) of survivors 1Lewis BS, et al. J Thorac Cardiovasc Surg 84:579-84, 1982

  8. CHF • Johannesburg, SA 1982-19881 • 203pt with active IE and early valve replacement • Urgent surgery (<48hrs) in 53% • Mortality • Urgent 7% • Overall 4% • long term 6% pt followed 38± 22mos 1Middlemost S, et al. JACC 18:663-667, 1991

  9. CHF – Meta-analysis Moon, et al. Prog Cardiovasc Dis. 1997

  10. Persistent Sepsis • nonsterile Bld Cx 3-5d after dx • lack of improvement sxs after 1wk appropriate Abx • usually due to • Bacterial resistance • valvular/perivalvular infections • non cardiac septic foci (splenic, renal, cerebral abcess, mycotic aneurysm • GNR, staph or fungal infxn • surgery may eliminate septic focus, but not necessarily improve pt hemodynamic condition unless significant valvular regurg • +Bld Cx at surgery predict adverse outcome

  11. Persistent Sepsis • Postive Cx @ time of surgery predicts poorer outcome • D`Agostino, et al Ann Thor Surg 1985 • 108pt with NVE • 87pt Bld Cx (-) >90% 1 year complication free survival (no perivalvular leak, IE recurrence) • 19 pt Bld Cx (+) <70%

  12. Persistent Sepsis • although ↑ complication if Bld Cx +, still important to intervene esp in face of further destruction of valvular/annular tissue • Boyd, et al. NYU 19771 • operative mortality risk in uncontrolled infxn better when operated earlier (within 10d of admit) (17%) than when abx continued for 4-6wks (90%) 1Boyd et al. J Thorac Cardiovasc Surg 73:23-30, 1977

  13. Persistent Sepsis/Surgery risk Alsip et al, Am J Med 78:138-148, 1985

  14. Persistent Sepsis • may also be from extracardiac source/emboli • splenic, renal, cerebral abcesses • ? proper Rx – surgery?, incidence of recurrent endocarditis in these situations?

  15. Splenic abcess Image: Roberts, Cornell Univ Web Site:Vascular infections

  16. Infectious etiology • S. aureus • highly destructive • meta-analysis showed higher mortality with medical (39/76 56% ) compared with med/surgical Rx (24/77 31% ) p<.03 • not absolute indication but more aggressive surgical approach should be considered, esp if other factors • Gram (-)/serratia/pseudomonas

  17. Infectious Etiology • Fungal • most common: Aspergillus, Candida, Torulopsis glabrata • risk: prev cardiac surgery, Abx use and hyperalimentation, long therm IV cath, IVDA • clinical: neg Bld Cx/fever, changing murmur, chorioretinitis, and large peripheral emboli • overall survival with medical Rx 25% c/w med/surgical rx 58% • compelling if not absolute indication for surgery Rubenstein and Lang. Fungal Endocarditis. Eur Heart J 1995

  18. Peripheral Embolization • embolic events common 30-40% of IE • brain>limbs, coronary, spleen, kidney • directly responsible for ~25% of fatalities1 • recurrence rate 54% within 30d • incidence falls after initiation of Abx therapy ~ 2wks • risk • size > 10mm (47% vs 19%)2 • staph, candida, GNR • mobile, pedunculated, mitral>aortic 1Acar, et al. Eur Heart J, 16 (supplement B), 94-98. 1995 2Mugge et al. JACC 14:631-638. 1989

  19. Moon, et al. Prog Cardiovasc Dis 1997

  20. Vegetation on atrial surface of PMVL

  21. Peripheral Embolization • Rohmann, et al1 • 64% vegetations resolved/decreased • 36% no change/increased • valve replacement 2% vs 45% • perivalvular abcess 2%vs 13% • mortality 0% vs 10% • Vuille, et al2 • persistent veg in 50% despite clinical healing, no independent association with late complications • in the absence of valvular dysfxn, persistent vegetation on echo shouldn’t be criterion for valve replacement in absence of other indications 1Rohmann, et al. J Am Soc Echo 4:465-474, 1991 2Vuille, et al. Am Heart J 128: 1200-1209. 1994

  22. Peripheral Embolization • recurrent emboli are relative indication for surgery (class IIa) but should not be considered absolute indication

  23. Emboli – Cerebral (Con) • surgical intervention with cardiopulm bypass can cause extension of infarct or hemorrhagic transformation of previously bland infarct • Eishi et al – cerebral emboli + surgery Eishi, et al. J Thorac Cardiovasc Surg 110:1745-1755, 1995

  24. Fig. 1. Computed tomographic scans of a patient with right middle cerebral artery infarction resulting from infective endocarditis. This patient underwent a Bentall-type operation for graft infection on the same day, resulting in massive brain swelling, and died 3 days later. Top row, Preoperative computed tomographic scans; bottom row, postoperative scans. Eishi,et al. J Thorac Cardiovasc Surg 1995;110:1745-55

  25. Emboli – Cerebral (Pro) • Ting, et al – smaller, bland cerebral infarcts 31pt1 • operative mortality 19% • survivors (81%) • 5pt with cerebral hemorrhage  CVA • others: • 12% exacerbated CNS sxs • 16% unchanged • 20% partial resolution • 52% complete resolution • Other studies have shown complete neurologic recovery in pt with coma or dense hemiparesis after valve replacement, but recommended delay if bleed2 1Ting, et al. Ann Thorac Surg 51:18-22, 1991 2Zisbrod, et al. Circulation 76:V109-V112, 1987 (suppl V)

  26. Ruptured mycotic aneurysm in MCA territory (causative agent: Aspergillus)

  27. Emboli - Cerebral • single cerebral embolus not indication for surgery unless assoc with large mobile veg and that further CNS injury might preclude meaningful chance at recovery/rehabilitation • bland infarct – if stable hemodynamics, 2-3 wks Abx before considering surgery to minimize provoking further CNS injury • hemorrhagic infarct – surgery postponed as long as possible – optimally if full course Abx can be given and recovery of neurologic dysfxn

  28. Extravalvular Extension • annular abscess • operative mortality 19-43% (vs >75% medically treated)1 • extensive tissue necrosis/structural damage including interventricular septum, conduction system, and fibrous skeleton of heart • In NVE mitral (1-5%) < aortic (25-50%) • clinically have more valvular regurgitation • hi risk (staph/fungal, new heart block, PVE) should undergo TEE (90% detection vs 50% TTE) 1Moon, et al. Prog Cardiovasc Dis 1997 Nov-Dec 40(3) p246

  29. ECHO findings in Annular abscess • anterior or posterior Ao root wall thickness≥ 10mm • perivalvular density in IVS ≥ 14mm • sinus of valsalva defect/aneurysm • rocking of prosthetic valve • Sens and Spec 85% if 1 of above seen

  30. Cormier et al. Eur Heart J 1995 (16) suppl B 68-71

  31. TTE (L) and TEE (R) showing evidence of AV vegetation and paravalvular abscess Otto. Textbook of Clinical Echocardiography 2nd Ed. Chp 13

  32. communicating Ao root abscess Dec 2001 ECHO case of the month, www.acc.org

  33. Extravalvular Extension • Conduction disturbances in 30% with abscess vs <2% if no abscess • 1st degree > 7d, new 2nd or 3rd degree block requires eval for abcess - TEE

  34. Meta-analysis Moon, et al. Prog Cardiovasc Dis. 1997

  35. Moon, et al. Prog Cardiovasc Dis 1997

  36. Predictors of operative mortality Moon, et al. Prog Cardiovasc Dis 1997

  37. Conclusions • Combined medical/surgical rx of selected populations offers substantial morbidity and mortality benefit. • careful attention to hemodynamic status, infecting organism (staph aureus, fungi, GNR), valve(s) involved (AV), clinical manifestations (emboli, abscess, conduction abnl, CHF), and findings on imaging (TTE/TEE, etc) allow a tailored approach to proper Rx in each patient to minimize morbidity and mortality

  38. Conclusions

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