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Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Carlos-A. Mestres, MD, PhD, FETCS Consultant.

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Presentation on theme: "Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Carlos-A. Mestres, MD, PhD, FETCS Consultant."— Presentation transcript:

1 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Carlos-A. Mestres, MD, PhD, FETCS Consultant Cardiovascular Surgery Hospital Clínico. University of Barcelona Barcelona. Spain

2 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Infective endocarditis is an uncommon disease associated to significant morbidity and mortality. As in any infection within the cardiovascular surgery, early diagnosis and aggresive management are indicated Infective endocarditis is a medical & surgical disease which must be managed by a multidisciplinary team with shared interests

3 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The Team The Hospital Clinico of Barcelona Endocarditis Study Group is a multidisciplinary group specifically dedicated to the study and treatment of infective endocarditis and cardiovascular infections operational for 25 years Infectious Diseases (6), Cardiovascular Surgery (3), Microbiology (3), Surgical Pathology (1), Echocardiography (2)

4 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The Team * Infectious Diseases J.M.Miró, A.Moreno, A. Del Río, N. De Benito, X.Claramonte, J.P.Horcajada * Cardiovascular Surgery C.A.Mestres, R.Cartañá, S.Ninot, J.L.Pomar * Microbiology M.Almela, F.Marco, C.García * Surgical Pathology J.Ramírez, N.Pérez * Echocardiography J.C.Paré, M.Azqueta, M.Sitges

5 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Infective Endocarditis What have we learned? What have we changed? What are we doing? Where are we going? An overview

6 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 A - Short Courses of Therapy for Infective Endocarditis B - Infective Endocarditis in Drug Abusers (IVDAs) C – Surgical experience

7 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Potential number of candidates for short-courses of therapy for right-sided MSSA endocarditis in IVDAs at the Hospital Clínic of Barcelona, Spain (1979-98) Types of endocarditis in IVDAs - Right-sided IE - Left-sided IE - Mixed IE Total MSSA N (%) N 142 46 16 204 104 (73%) 16 (35%) 10 (64%) 130 (64%) 2 wk Tx* 40% * According to methicillin-susceptibility, HIV status and CD4 cell counts (>200/µL)

8 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 6. In our 25-year experience, one of every five episodes of native valve IE (general population + IVDAs) and almost one of every two episodes of IE in IVDAs were considered potential candidates for these short courses (2 wks) of therapy Short Courses of Therapy for Infective Endocarditis CONCLUSIONS 5. Patients allergic to penicillin who must receive vancomycin with or without an aminoglycoside must be treated during 4 wks

9 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Infective Endocarditis in IVDAs & HIV infection SUMMARY 2. HIV-infected IVDA have a higher ratio of right-sided IE and S. aureus endocarditis than HIV-negative IVDA with IE 1. The incidence of IE in IVDA in the AIDS era is decreasing probably due to the change of the drug administration habits in order to avoid HIV-infection 3. Mortality between HIV-infected or non-HIV-infected IVDA with IE is similar. However, mortality among HIV-infected IVDA is higher in IVDA with less than 200 CD4+ cells/µL or with AIDS criteria

10 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 4. IVDA with non-complicated MSSA right-sided IE can be succesfully treated with an IV short-course regimen of nafcillin or cloxacillin plus an aminoglycoside during 2 weeks, although the addition of an aminoglycoside may be avoided or reduced to the first 3-7 days 5. Tricuspid valve replacement using mitral homografts can be a safely alternative to tricuspid valvulectomy for those IVDA with endocarditis who need right heart surgery Infective Endocarditis in IVDAs & HIV Infection SUMMARY “Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1)” Mestres CA et al. Eur J Cardio-thorac Surg 2003; 23:1007-1016

11 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Epidemiology 1990 - 2000 Diagnosis of IE 421 IV (IVDA) drug abuse104 General population317 Native IE213 PVE 75 Pacemaker/AICD 29 Admissions/yr>50

12 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 “Surgical treatment of pacemaker and defibrillator lead endocarditis. The impact of electrode lead extraction on outcome” A.del Río, I.Anguera, J.M.Miró, L.Mont, Fowler VG Jr, M.Azqueta, C.A.Mestres and the Hospital Clinic Endocarditis Study Group Chest 2003; 124:1451-1459 “Infective endocarditis not related to intravenous drug abuse in HIV-1- infected patients: report of eight cases and review of the literature” J.E.Losa, J.M.Miró, A. Del Río, A.Moreno-Camacho, F.Gracia, X.Claramonte, F.Marco, C.A.Mestres, M.Azqueta, J.M.Gatell and the Hospital Clinic Endocarditis Study Group Clin Microbiol Infect 2003; 9:45-54 “Infective endocarditis in intravenous drug abusers and HIV-1 infected patients” J.M.Miró, A. del Río, C.A.Mestres Infect Dis Clin North Am 2002; 16:273-295

13 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 NVE 387 - ADVP 237 - PVE 130 - PM 49 - All 803

14 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 PVE 132

15 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 S.aureus 274

16 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Presumed intravascular catheter source by region ICE International Collaboration on Endocarditis

17 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Specific indications Mechanical valve Young, “good” ring, cured IE Bioprosthesis Elderly (?), “good” ring, cured IE Homograft Complicated IE, abscess, annular destruction

18 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The complicated root 1.Root abscess 2.Aorto-cavitary fistula

19 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Aorto-cavitary fistulae

20 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 L770 - AORTO-CAVITARY FISTULIZATION IN COMPLICATED ENDOCARDITIS. CLINICAL AND ECHOCARDIOGRAPHIC FEATURES OF 76 CASES (1992- 2001) AND PROGNOSTIC FACTORS OF MORTALITY The Spanish Aorto-cavitary Fistula Endocarditis Working Group 42nd ICAAC. San Diego, CA. September 27-30, 2002

21 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 No clinical infective endocarditis (IE) series have been performed studying the development of aorto-cavitary fistulas (ACF) as a result of spread of infection from valvular tissue towards perivalvular structures. Our aims were to investigate the clinical, echocardiographic and microbiologic features and prognostic factors of in-hospital mortality in patients with IE and ACF. Retrospective and multicentre study at 11 Spanish and 1 North- american Hospitals in patients with IE and ACF.

22 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Spread of infection in infective endocarditis (IE) from valvular structures to the surrounding perivalvular tissue results in periannular complications. Rupture of abscesses and pseudoaneurysms in the sinuses of Valsalva result in the development of aorto-cavitary fistulas and intracardiac shunts. Aorto-cavitary fistula formation is an unusual complication of IE. An incidence of 1% of all cases of IE has been estimated. Fistulization of perivalvular abscesses occurs in 6-9% of cases. Basic considerations

23 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 * Multicenter, international, retrospective, descriptive study performed between 1992 and 2001 * Infective endocarditis diagnosed according to Duke criteria * Aorto-cavitary fistulization documented by TTE/TEE * Univariate analysis of prognostic factors of mortality

24 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 General population Native valve Aortic Mitral Other PVE Aortic Mitral Other Pacemaker IV Drug abusers OVERALL 69 38 -- 31 -- 7 76 3147 2105 1056 930 119 872 536 326 10 170 1534 4681 2.2 1.8 3.6 --- 3.5 5.8 --- 0.4 1.6 ACF n Cases IE n Incidence %

25 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Mean age (y) Male gender Previous valve disease Comorbidity Mechanical ventilation IV drug abuse Duration of symptoms (d) Duration to Dx of ACF (d) CHF Neuro events Renal failure Peripheral emboli Complete AV block 50.9±18.7* 36 (80%) 13 (28%) 18 (40%) 6 (13%) 7 (16%) 24.5±18.7 36.2±31.6 31 (69%) 8 (18%) 20 (44%) 8 (18%) 5 (11%) 60.2±13.4* 20 (65%) 31 (100%) 9 (29%) 1 (3%) 0 29.8±37.7 44.1±55.5 16 (52%) 4 (13%) 8 (26%) 7 (23%) 6 (19%) 54.7±17.2 56 (74%) 44 (59%) 27 (36%) 7 (9%) 26.7±27.9 39.4±42.8 47 (62%) 12 (16%) 28 (37%) 15 (20%) 11 (14%) NVE=45PVE=31All=76 Clinical characteristics

26 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Staphylococcus spp S.aureus CNS Streptococcus spp VGS S.bovis Other streptococci Enterococcus spp Culture negative Other (HACEK) 17 (38%)* 13 (29%)* 4 (9%)* 16 (35%) 10 (22%) 2 (4%) 4 (9%) 2 (4%) 5 (11%) 7 (15%) 18 (58%)* 3 (10%)* 15 (48%)* 9 (29%) 5 (16%) -- 4 (13%) 2 (6%) -- 2 (6%) 35 (46%) 16 (21%) 19 (25%) 25 (33%) 15 (20%) 2 (3%) 8 (10%) 4 (5%) 5 (6%) 9 (12%) NVE=45PVE=31All=76 Pathogens NVE vs PVE groups (p<0.05)

27 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Echocardiography Diagnostic yield of TTE and TEE TTE n (%)TEE n (%) Native valve26/44 (59%)31/33 (94%) PVE15/31 (48%)28/28 (100%) Overall40/75 (53%)59/61 (97%)

28 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Patients with vegetations Mean maximal veg. size (mm) Vegetations > 10 mm Patients with abscess Mean maximal abscess diameter Abscess > 10 mm Ventricular septal defect Mean EF (%) Mean LVEDD (mm) Multivalvular infection 83 % 11.7 56 % 78 % 12 mm 54 % 20 % 61.7 54.9 30 % 96 %* 11.5 49 % 71 % 10 mm 44 % 21 % 62.5 55.2 33 % 65 %* 12.1 70 % 87 % 15 mm 67 % 19 % 60.5 54.4 26% Total N=76 Native N=45 Prosthetic N=31 * Native vs prosthetic, p < 0.05 Echo findings

29 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Fistulized sinus of Valsalva (SV) Right SV Left SV Non coronary SV Fistulized cardiac chamber (%) Right atrium Right ventricle Left atrium Left ventricle Multiple Moderate/severe regurgitation 37% 38% 25% 17% 25% 26% 16% 12% 49% 44% 35% 20% 18% 31% 22% 13% 11% 64%* 26% 42% 32% 16% 32% 19% 13%* 26%* Total N=76 Native N=45 Prosthetic N=31 * Native vs prosthetic, p < 0.05 Echo findings

30 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Surgical treatment Time to surgery < 24 hours 2 - 7 days > 7 days Closure of fistula (%) Simple Pericardial patch Gore-tex patch Valve replacement Bioprosthesis Mechanical Homograft 87% 24% 42% 34% 41% 48% 11% 92% 24% 50% 18% 87% 33% 36% 31% 41% 46% 13% 95% 28% 49% 18% 87% 11% 52% 37% 41% 52% 7% 89% 19% 52% 19% Total N=76 Native N=45 Prosthetic N=31

31 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 In-hospital mortality - Surgical group (N=66) - Medical group (N=10) 31 (41%) 28 (42%) 3 (30%) 16 (36%) 13/39 (33%) 3/6 (50%) 15 (48%) 15/27 (55%) 0/4 (-) Total N=76 Native N=45 Prosthetic N=31 Cause of death - Multiorgan failure - Sudden death - Septic shock - Cardiogenic shock - Hemorrhage Medical N=3 Surgical N=28 23% 10% 26% 19% 23% 33% - 33% -

32 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Lost for follow-up Follow-up (mo., mean, range) Residual fistula Late CHF Late valvular replacement Late death 24 Medical * N=7 Surgical N=38 36 (1-96)* - 3 0 1 29 (1-144)* 5 (11%) 7 (16%) 5 (11%) 3 ( 7%) * The 3 patients who died w/o surgery had fatal co-morbid conditions. The remaining 7 patients did not undergo surgery because they did not have cardiac failure, severe valvular regurgitation and echocardiographical abscess.

33 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Age > 65years Male gender Prosthetic endocarditis Symtoms duration >30 d. Moderate or severe CHF Renal failure Neurologic symptoms S.aureus infection Vegetation >10 mm Patients with periannular abscess Periannular abscess > 10 mm Moderate or severe AR Fistulized sinus of Valsalva Fistulized cardiac chamber EF <65% Urgent or emergency surgery 2.8 (1.0-7.9) 0.8 (0.2-2.4) 2.5 (0.9-6.8) 0.8 (0.2-2.6) 2.2 (0.7-5.1) 1.8 (0.7-5.1) 0.6 (0.1-2.8) 1.2 (0.4-3.6) 1.6 (0.5-5.5) 2.3 (0.7-7.3) 0.8 (0.3-2.1) - 1.1 (0.4-3.1) 2.7 (0.9-7.8) 0.05 0.6 0.07 0.7 0.15 0.2 0.5 0.8 0.7 0.4 0.14 0.7 0.9 0.2 0.8 0.06 OR – 95%CI p

34 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Limitations * Ascertainment bias – multicenter nature * Severity of CHF higher – low-grade shunts underdiagnosed * High-risk profles of surgical candidate * Not comparable to medically treated * Not comparing medical and surgical patients

35 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Abscesses vs fistulae

36 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

37 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

38 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

39 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

40 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

41 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Kaplan-Meier estimation of survival from time of diagnosis of periannular complication.

42 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Actuarial freedom from death, heart failure requiring hospital admission and repeat surgery in patients with periannular complications surviving the index hospitalization. A. patients referred to surgical therapy

43 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 B. patients medically-managed

44 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 * Aorto-cavitary fistulization in IE is an unfrequent event and occurs in patients with aortic endocarditis with high grade of local tissue destruction. * It was associated with staphylococci and streptococci native- valve IE and with coagulase-negative staphylococci prosthetic valve IE. * In-hospital mortality was high even when most patients were referred to surgical treatment. * Congestive heart failure identified the subgroup of patients with the worst prognosis. Conclusions

45 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Prosthetic valve endocarditis - What? - When? - Who? - Why?

46 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006

47 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Methods * International Collaboration on Endocarditis Merged Database * Large, multicenter, international registry of patients with definite endocarditis by Duke criteria * Clinical, microbiological, echocardiographic variables to determine * Those factors associated with the use of surgery in PVIE * Logistic regression analysis * Propensity score to match surgery vs medical therapy

48 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 PVIE – Patient characteristics

49 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Complications and outcomes of patients with PVIE

50 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Propensity analysis of surgical treatment of PVIE

51 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Logistic regression analysis of variables independently associated with in-hospital mortality in patients with PVIE and matched propensity for surgical treatment

52 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Conclusions * Despite the frequent use of surgery for the treatment of PVIE this condition continues to be associated with high in-hospital mortality * After adjustment for factors related to surgical intervention, brain embolism and S. aureus infection were independently associated with in-hospital mortality and a trend toward a survival benefit of surgery was evident

53 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Echocardiographic (TTE) Follow-up YearPatientTTETTE FULast TTENYHA BeforeAfter (Yrs) 1991AMGVeg 28 mm Mild TR 13Severe TRII Large RV 1991RPOVeg 22 mmSevere TR 13Severe TRII Severe TR Large RVLarge RV Large RV 1992PERVeg 30 mmSevere TR 5Severe TRI Severe TRRupturedLarge RV chordae 1994JLFVeg 22 mmMild TR 1Mild TRI 1996JFGVeg 28 mmMild TR 1Severe TRI Severe TR

54 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Echocardiographic (TTE) Follow-up YearPatientTTETTE FULast TTENYHA BeforeAfter (Yrs) 2001ERASevere TR Trivial TR podPo Death 2002LMLVeg 20 mmTrivial TR podPo Death Severe TR Large RV Large RV 2002JGRVeg 30 mmMild TR 2.5Mild TRI Severe TR

55 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 YearPatientFUDrug addictionRecurrentHIVOutcome (Yrs)relapseendocarditisstage 1991AMG6Yes14 mosB3Alive (Corynebacterium spp)Late Reop 1991RPO6Yes48, 58, 63 mosB2Alive (MSSA all cases)No Reop 1992PER5NoNoA2Alive Late Reop 1994JLF2.5YesNoA3Death Overdose 1996JFG8.5Yes7, 12 mosA2Alive (MSSA)No reop Outcomes

56 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 YearPatientFUDrug addictionRecurrentHIVOutcome (Yrs)relapseendocarditisstage 2001ERAPONNC3Death 2002LMLPONNB2Death 2002JGR2.5NNoA1Alive

57 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The most complex situation Fibrous Skeletal destruction

58 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Acute pectoralis major myositis in an otherwise healthy young male

59 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 25-year-old male Smoker ½ pack/day Occasional recreational drugs. NO iv abuse Job: Waiter. Physically fit. Contact sports (judo, full- contact…) In the past 2 years 4 episodes of abscess requiring surgical drainage (hand, foot, knee, axilla) No other personal nor familiar medical history of interest 5-day left upper limb and upper left chest pain accompanied by high-degree fever (39°C), chills and malaise

60 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Aortic root replacement with a 20-22 mm cryopreserved aortic homograft Intraoperative findings: Massive AR due to perforation of the right coronary cusp on a morphologically normal aortic valve. Full root subaortic abscess extending towards the left atrial roof Aortic cross-clamp 73 min – CPB 189 min Left ventricular failure and myocardial edema after CPB. Sternum open. Intraaortic ballon pump support

61 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Outcome - I Postop unstable hemodynamics. Urgent TTE showed anterior-septoapical hypokinesia Urgent coronary angiogram showed 70% LMCA stenosis with remaining normal coronaries August 12, 2004: Off-pump LIMA-LAD bypass graft and delayed sternal closure August 12, 2004 2/2 + blood cultures (ORSA)

62 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Outcome - II Early favourable postop. Improved condition, no congestive heart failure August 14, 2004, 2/2 negative blood cultures. Trasnsferred to ward August 22, 2004. Good condition with low-degree fever (37°C) August 24, 2004 new control TTE

63 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Surgery - II September 1, 2004 – Homograft replacement with a 21 mm SJM Toronto-Root porcine heterograft Surgical findings: Subaortic circumferential detachment of the normal functioning homograft. Extensive lesions of the entire fibrous body. Left atrial fistula Post-repair severe mitral regurgitation Profound left ventricular failure. LVAD Abiomed BVS- 5000 implanted All samples to Microbiology

64 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Outcome - IV September 2, 2004 – Unstable under maximal intropic support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation September 3, 2004 – Orthotopic heart transplantation

65 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Final diagnosis 1. Community-acquired ORSA myositis 2. Acute aortic root ORSA infective endocarditis 3. Heart transplantation

66 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Endocarditis and Heart Transplantation 1: Galbraith AJ et al. Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999; 18:805-806 2: Blanche C et al. Heart transplantation for Q fever endocarditis. Ann Thorac Surg. 1994; 58:1768-1769 3: Pulpon LA et al. Recalcitrant endocarditis successfully treated by heart transplantation. Am Heart J 1994; 127:958-960 4: Park SJ et al. Heart transplantation for complicated and recurrent early prosthetic valve endocarditis. J Heart Lung Transplant. 1993; 12:802-803. 5: DiSesa VJ et al. Heart transplantation for intractable prosthetic valve endocarditis. J Heart Transplant. 1990; 9:142-143

67 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Endocarditis and Heart Transplantation “Heart transplantation could be an alternative, not a contraindication, when in Infective Endocarditis all other measures have failed” (1) Galbraith AJ Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999 Aug;18(8):805-6

68 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 CaseAgePathogenValvePositionTiming for HTxConditions 125M. hominisTissueAortic2 monthsSLE 230S viridansMechanicalAortic1 monthPreTX + cultures 358S viridansNativeMitral2 years3 VR’s 432C burnettiNativeMi + Ao14 monthsPersistent fever 554MRSAMechanicalMitral17 daysPrevious HTx

69 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Conclusions * IE is a very serious pathology * It is not popular * Highly demanding * Suboptimal results * Team approach * Risk takers

70 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Parsonnet score Single centre – Subjective factors – Overestimates risk Cleveland score Single centre – Excludes non CABG – Leads to gaming EuroScore Large multicentre database – Fit for all adult cardiac surgical patients – Even correlates with STS

71 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 EuroSCORE 0 – 2 3 – 5 6 – 8 9 – 11 12> 0.88 – 1.51 2.62 – 3.51 6.51 – 8.37 14.02 – 19.12 31.00 – 42.32 Additive Score% mortality

72 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 EuroSCORE Its predictive accuracy has been established Only the additive model has been validated Inconsistencies among the additive and logistic models when applied to the high-risk patients

73 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Cross-over point

74 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Reasons to predict mortality in Cardiac Surgery 1. Helping to determine indications for surgery 2. Quality monitoring Additive EuroScore works well for most purposes

75 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Considerations The relationship between risk factors is not additive Combined impact of two or more factors on operative risk may be more than simple sum Logistic score more realistic

76 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The reality * Infective endocarditis is a high-risk situation * There is lack of data regarding risk assessment before valve surgery

77 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Aim of the study To validate the EuroSCORE preoperative stratification risk model in infective endocarditis

78 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Population PeriodJan 95 – Jan 04 Patients147 Mean age56.33 ± 15.95 Male gender69.4%

79 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Native valve IE N% Aortic6443.5 Mitral2517 Tricuspid21.4 Pulmonary10.7 A + M128.2 M + T10.7

80 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Prosthetic valve IE N% PVE Aortic1711.6 Homograft Ao21.4 PVE Mitral117.5 PVE Ao + M10.7 PVE Ao + PVE Mi21.4 A + PVE Mi10.7

81 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Intravascular leads N% DDD32 AICD10.7 VVI R10.7 VVI21.4 Mitral + DDD21.4

82 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Characteristics Active endocarditis91.2% IV Drug addicts10.9% HIV+ 5.4% ESR – HD 3.4% Reoperation27.2%

83 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Pathogens N% Culture negative106.8 Staphylococcus5537.4 Streptococcus4329.3 Enterococcus149.5 Polimicrobial85.4 Candida10.7 Other149.5

84 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Type of operation Emergency29.9% Urgent21.8% Elective46.9%

85 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 EuroSCORE Additive Range Mean Median 2 – 19 10.15 ±3.81 10

86 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 EuroSCORE Logistic Range Mean Median 1.51 – 94.17% EM 25.59 ± 20.81 18.95

87 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results Overall in-hospital mortality32.7% - Intraoperative death - 30 days po - Regardless the length of stay

88 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower bound Upper bound Sig. All patients.826.036.756.896.000 Asymptotic 95% confidence interval Receiver operating characteristics (ROC) curves Area > 0.7Good correlation Area > 0.8Very good correlation Area > 0.9Excellent correlation

89 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower Bound Upper Bound Sig. Native valve IE.814.045.727.902.000 Prosthetic IE.779.088.607.952.000

90 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower Bound Upper Bound Sig. Aortic position.778.064.652.904.001 Mitral position.937.051.8361.037.001

91 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower Bound Upper Bound Sig. Aortic prostheses.729.125.484.980.112 Mitral prostheses.833.152.5351.132.068

92 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower Bound Upper Bound Sig. Gram +.819.041.739.899.000 Gram -.833.204.4331.233.248

93 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Results AreaSELower Bound Upper Bound Sig. Staphylococci.834.054.727.940.000 Streptococci.856.087.6861.026.002 Enterococci.500.163.181.8291.000 Polymicrobial.800.165.4761.124.180

94 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Aortic valve

95 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Homograft aortic

96 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Mitral valve

97 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Aortic prosthesis

98 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Mitral prosthesis

99 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Comments There is a very good correlation between logistic EuroSCORE and mortality for the entire group Division in subgroups yields a decrease in statistical power but correlation is almost the same in all subgroups The area is good in the prosthetic valve IE although non significant by position

100 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Comments The area is very good for Gram – and polymicrobial although with low statistical power There is statistical power for significance in the Staphylococci and Streptococci groups

101 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Limitations Small sample size Statistical power decreases when analyzing subgroups Just preliminary results

102 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 When to use Logistic EuroScore? -To calculate a precise and realistic risk prediction for a very high-risk patient, particularly when the indication for surgery may not be clear - To monitor quality of care in institutions where a substantial proportion of patients are of very high-risk - To help in the further study of risk modelling by groups and institutions with a scientific interest in the subject - To carry out normal stratification in institutions with easy availability of accesible information technology, especially where high-risk surgery forms a substantial part of the workload

103 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 The Future of risk stratification * Larger sample size * More institutions involved * Subgroup analysis (Pathogens, abscess…) * Team approach * The role of ICE * Changing our approach to patients? * Quality assurance

104 Infective endocarditis and surgery C.A.Mestres for the HC Endocarditis Study GroupESCMID – Santander - 2006 Conclusions * IE is a very serious pathology * It is not popular * Highly demanding * Suboptimal results * Team approach * Risk takers


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