1. Challenges in the Surgical Management of Aortic and Mitral Valve Endocarditis (IE)
Oct 2016 Epworth P Skillington, CT surgeon

2. Challenges in the Surgical Management of Aortic and Mitral Valve Endocarditis
valve repair vs replacement (mitral)
choice of prosthesis (aortic and mitral)
technical challenges – mainly relates to surgical management of annular abcess and its complications (eg intra cardiac fistula)
management of pts with neurological Cx

3. Traditional Indications for early Surgery in Endocarditis (< 7 days)
Uncontrolled Heart Failure
Failure to control Sepsis with AB’s
Large Vegetations, embolization (non cerebral)
Certain specific responsible pathogens
C/I Neurological Complications (cerebral emb)

4. Timing of Surgery – when to operate very early (<48hrs)
virulent acute staph. Aureus, fungal infection
prosthetic valve endocarditis with valve dehiscence
demonstrated abcess or internal fistula (1 week)
incipient acute respiratory or multi-system failure

5. Mitral Valve Repair or Replacement
generally, repair gives better outcomes than replacement in non-infective degenerative mitral valve disease
however feasability of repair in acute infective endocarditis depends on the extent of leaflet destruction, as complete resection of all involved tissues is required

6. Mitral v. Repair Anterior leaflet
superfiscial defects without full thickness destruction
full thickness defects not involving free edge
full thickness defects – less than 1/3rd leaflet
Posterior leaflet

7. Mitral Valve Repair posterior leaflet -quadrangular resection
anterior leaflet patch repair
Commissural lesions managed by plication or patch
prosthetic ring annuloplasty best avoided

8. Mitral Valve Repair
operative mortality for valve repair in “active endocarditis” depends on definitions of acuity, time delay till surgery
reported mortality of 0 –11.8% in significant series reported over past 20 years
low re-infection rates - < 3%
re- operation rates 0 –14% at 5 – 10 yrs ( higher than valve replacement)

9. Presenting on a recently published paper on Surgical Management of Endocarditis: The Society of Thoracic Surgeons Clinical Practice Guideline Report form STS Workforce on Evidenced-based Surgery.
Published in June Annals of Thoracic Surgery 9

11. Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE)
MITRAL VALVE – STS 2011
Native Valve Endocarditis (NVE)
Prosthetic Valve Endocarditis (PVE)
technically feasible
Yes
Repair (Class I, LOE B) No
Replacement (Class IIa, LOE B)
Redo-surgery
Replacement (Class IIb, LOE C)
Mechanical
Bioprosthesis

12. STS – Mitral Valve Repair vs Replacement for Endocarditis
* For active endocarditis, only 16% repair rate – mortality rate was 10.6% for repair, 15% for MVR

13. Mitral Valve Repair or Replacement
whilst there are some groups that claim high repair rates, generally the best valves for repair are those cases caused by low grade virulent organism (eg strept.viridans), with little in the way of valve leaflet destruction, operated on often 1-2 weeks after onset of Rx

14. Mitral Valve Repair or Replacement
“as patients undergoing valve replacement often have more severely damaged valves as a result of IE, simple retrospective comparison between outcome of valve repair and those of valve replacement may be misleading”
repair should always be considered
Yamaguchi, Annals Thorac Cardiovasc Surg Vol 13, no. 3 (2007) - Review

15. Mitral Valve Replacement
No difference in re – infection rates between bioprosthetic valves and mechanical valves shown
generally bioprosthetic valves reserved for older (> 70yrs) patients because of poor durability in younger patients (10 – 12yrs)

16. Prosthetic Valve Endocarditis

17. Aortic Valve Endocarditis
high early surgical mortality of 4 –20% ( mean 15%)

18. Aortic Valve Endocarditis
greater destruction of valve leaflet tissue
aortic regurgitation gives a greater haemodynamic burden to heart, thus increased heart failure
Abcess formation more likely
Complications of abcess increased - fistula

19. Aortic Valve Endocarditis
surgical intervention more likely
more often required in the early stages of active infection
acute AR not well tolerated
left ventricular function suffers, and may take years to recover
valve repair rarely possible

20. Choice of prostheses greater for AVR
mechanical valve
bioprosthetic (xenograft)
aortic allograft (homograft)
ross procedure (pul. Autograft)

21. Aortic Allograft( homograft)
resistance to early re-infection
permeated by antibiotics in the blood
mitral leaflet can be used to reconstruct defects caused by tissue destruction in the aortic root
excellent durability in young patients
Caution : requires expertise in allograft insertion techniques; in short supply, which limits use

22. Aortic Allograft –tailoring for use
trim off segments not required

23. Insertion of Allograft using Root Replacement technique
reimplantation of coronary arteries
previously considered valve of choice for AVR for acute IE

24. O’Brien et al,2001
Aortic Homograft Durability vs Age: Freedom from Re-op

25. Ross Procedure best durability of any tissue valve
double valve operation
2 valves require f/up
lengthy procedure
associated with increased mortality whe used for acute IE

26. Anatomy of Aortic Root
infection confined to aortic valve leaflets– easy
location of annular abcess (50 –70%) dictates risk of heart block, type of reconstruction required
also likelihood of fistula, and possible rupture in to pericardium

27. Localized Abcess in non – coronary annulus
management by excision of all infected tissue and autologous pericardial patch repair

28. Abcess can drain in to pericardial cavity after patching

29. Aorto – ventricular separation

30. Choice between Mechanical valve,Tissue valve vs Aortic Allograft in aortic valve endocarditis
1990’s – aortic allograft shown in some studies – lower reinfection
since 2000, now shown that there is little difference between various prostheses, providing all infective tissue is excised

31. Abcess can drain in to pericardial cavity after patching

32. Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE)
AORTIC VALVE – STS 2011
Native Valve Endocarditis (NVE)
Prosthetic Valve Endocarditis (PVE)
Confined to valve / annulus
Mechanical or Bioprosthesis
± Homograft (Class IIb, LOE B)
Extensive Disease
1. Periannular Abscess 2. Annular / Ao Wall Destruction
Homograft (Class IIb, LOE B)
Confined to valve / annulus
Mechanical or Bioprosthesis
± Homograft (Class IIa, LOE B)
Extensive Disease
1. Periannular Abscess 2. Annular / Ao Wall Destruction
Homograft (Class IIa, LOE B)

33. Neurological Complications (affects 15 –30% cases of IE)
Traditionally, for cases presenting with a neurological deficit, with proven brain imaging, or if this develops during medical treatment, surgery was deferred for 4-6 weeks, because of the perceived risk of worsening the deficit
Problem is that further cerebral emboli can occur whilst waiting

34. Primary Endpoint a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization
N Engl J Med, 2012
Jun 28; 366(26):

35. N Engl J Med, Jun 28; 366(26):

40. Guidelines for Surgical Management of IE
STS guidelines 2011 out of date
AHA/ACC 2014 guidelines for Valvular Heart Disease do not really address timing of intervention except to say that Early intervention (during hospitalization) should be performed for the usual indications
2015 European Society of Cardiology ESC have made some new recommendations in this area

41. 2015 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis: 9.Neurological complications

42. 2015 European Society of Cardiology (ESC) guidelines for the management of IE: (Neurological complications –affects 15-30%)
For a patient presenting with neurological complications of IE, providing the usual indications for early surgical intervention are present, and providing the patient doesn’t have either of:
Intracranial Haemorrhage Coma CVA with severe neurological deficit
Should proceed with “early” surgery

43. 2015 ESC guidelines for the management of infective endocarditis

44. This paper addresses whether or not proceeding to early surgery (< or = 7days) leads to increased mortality, or worsens neurological outcomes

45. Oh et al, Asian Cardiovasc Thorac Ann 2016
….brain imaging for a clinically diagnosed preoperative neurological event. Patients were categorized as early surgery (< or = 7days of clinical or cerebral imaging diagnosis of stroke) or delayed surgery (>7 days after diagnosis)

46. Conclusion
IE of aortic and mitral valves requiring surgery has a high mortality
mitral valve repair should be performed where possible, although in reality, if tissue destruction too great , replacement may be required
aortic valve IE causes Acute AR, leads to early heart failure, and thus surgery common

47. Conclusion (cont.) annular abcesses common in aortic valve IE
these patients need excision of all infected tissue, to minimize recurrent infection
reconstruction of aortic annulus with autologous pericardium before valve replaced
aortic allografts have theoretical advantages including resistance to early reinfection, and very good durability

48. Conclusion (cont.)
aortic allografts require increased surgical expertise, and are in short supply – limits use
No difference in reinfection rates between any of the prostheses providing all infected cardiac tissue excised
Ross procedure good for elective surgery for healed IE, in patients with chronic AR, higher mortality in acute IE in patients presenting with heart failure

49. Conclusion (cont.)
Patients with cerebral embolization complicating IE, providing haemorrhage is excluded, coma is not present, and the resultant stroke is not too severe, should proceed to early surgical intervention, if otherwise indicated
If intracranial haemorrhage is present, surgery should be delayed 4 weeks
Intracranial mycotic aneurysms should be managed in conjunction with neuro interventionalist

56. Aortic Root Enlargement

57. Prostheses lower profile and better haemodynamic function

58. STS – Mechanical vs Tissue AVR for Endocarditis