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 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

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 1940s 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)

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

Indications for Surgery

Hemodynamic compromise/ Heart failure Persistent sepsis Peripheral embolization Extravalvular extension of infxn

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

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

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

CHF Meta-analysis
Mortality Medical Med/Surgical

No CHF

15%

11%

CHF
Moon, et al. Prog Cardiovasc Dis. 1997

60%

29%

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

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%

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

Persistent Sepsis/Surgery risk

Risk
Recurrent IE after successful medical Rx PVE after valve replacement in active IE
Alsip et al, Am J Med 78:138-148, 1985

Mortality

10%

10%

10%

Approaches 50%

Persistent Sepsis

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

Splenic abcess

Image: Roberts, Cornell Univ Web Site:Vascular infections

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

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

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,

2Mugge

et al. Eur Heart J, 16 (supplement B), 94-98. 1995 et al. JACC 14:631-638. 1989

Moon, et al. Prog Cardiovasc Dis 1997

Vegetation on atrial surface of PMVL

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%
persistent veg in 50% despite clinical healing, no independent association with late complications in the absence of valvular dysfxn, persistent vegetation on echo shouldnt be criterion for valve replacement in absence of other indications

Vuille, et al2

1Rohmann,

et al. J Am Soc Echo 4:465-474, 1991

Peripheral Embolization

recurrent emboli are relative indication for surgery (class IIa) but should not be considered absolute indication

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

24hrs
Extension or expansion of infarct

2wks
<10%

4wks
2%

50%

Mortality

67%

<20%

<10%

Eishi, et al. J Thorac Cardiovasc Surg 110:1745-1755, 1995

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

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)

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

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

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

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

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

TTE (L) and TEE (R) showing evidence of AV vegetation and paravalvular abscess

Otto. Textbook of Clinical Echocardiography 2nd Ed. Chp 13

communicating Ao root abscess

Dec 2001 ECHO case of the month, www.acc.org

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

Meta-analysis

Moon, et al. Prog Cardiovasc Dis. 1997

Moon, et al. Prog Cardiovasc Dis 1997

Predictors of operative mortality

Moon, et al. Prog Cardiovasc Dis 1997

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

Conclusions