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

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Presentation on theme: "Timing of Surgery in Endocarditis Jimmy Klemis, MD CT Surgery Conference."— Presentation transcript:

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) 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 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 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 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 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 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 1940’s – PCN revived hope for a cure of IE, however morbidity and mortality only partially altered resistant organisms and shifting etiology (IVDA) 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) 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 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 early success in many studies of selected patients led to “paradigm shift” in management of complicated endocarditis

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

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

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

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

12 CHF – Meta-analysis Mortality MedicalMed/Surgical No CHF15%11% CHF60%29% Moon, et al. Prog Cardiovasc Dis. 1997

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

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

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

16 Persistent Sepsis/Surgery risk RiskMortality Recurrent IE after successful medical Rx 10% PVE after valve replacement in active IE 10%Approaches 50% Alsip et al, Am J Med 78: , 1985

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

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

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

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

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

22 Moon, et al. Prog Cardiovasc Dis 1997

23 Vegetation on atrial surface of PMVL

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

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

26 Emboli – Cerebral (Con) surgical intervention with cardiopulm bypass can cause extension of infarct or hemorrhagic transformation of previously bland infarct 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 – cerebral emboli + surgery 24hrs2wks4wks Extension or expansion of infarct 50%<10%2% Mortality67%<20%<10% Eishi, et al. J Thorac Cardiovasc Surg 110: , 1995

27 Eishi,et al. J Thorac Cardiovasc Surg 1995;110: 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.

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

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

30 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 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 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 hemorrhagic infarct – surgery postponed as long as possible – optimally if full course Abx can be given and recovery of neurologic dysfxn

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

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

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

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

35 communicating Ao root abscess Dec 2001 ECHO case of the month,

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

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

38 Moon, et al. Prog Cardiovasc Dis 1997

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

40 Conclusions Combined medical/surgical rx of selected populations offers substantial morbidity and mortality benefit. 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 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

41 Conclusions


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