Timing of Surgery in Endocarditis

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Timing of Surgery in Endocarditis

• Jimmy Klemis, MD
• CT Surgery Conference

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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

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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)
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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

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Indications for Surgery

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

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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 66151-157, 1974
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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
84579-84, 1982
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CHF

• Johannesburg, SA 1982-19881
• 203pt with active IE and early valve replacement
• Urgent surgery (lt48hrs) in 53
• Mortality
• Urgent 7
• Overall 4
• long term 6 pt followed 38 22mos

1Middlemost S, et al. JACC 18663-667, 1991
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CHF Meta-analysis
Moon, et al. Prog Cardiovasc Dis. 1997
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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

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Persistent Sepsis

• Postive Cx _at_ time of surgery predicts poorer
  outcome
• DAgostino, et al Ann Thor Surg 1985
• 108pt with NVE
• 87pt Bld Cx (-) gt90 1 year complication free
  survival (no perivalvular leak, IE recurrence)
• 19 pt Bld Cx () lt70

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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 7323-30,
1977
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Persistent Sepsis/Surgery risk
Alsip et al, Am J Med 78138-148, 1985
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Persistent Sepsis

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

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Splenic abcess
Image Roberts, Cornell Univ Web SiteVascular
infections
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Infectious etiology

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

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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
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Peripheral Embolization

• embolic events common 30-40 of IE
• braingtlimbs, coronary, spleen, kidney
• directly responsible for 25 of fatalities1
• recurrence rate 54 within 30d
• incidence falls after initiation of Abx therapy
  2wks
• risk
• size gt 10mm (47 vs 19)2
• staph, candida, GNR
• mobile, pedunculated, mitralgtaortic

1Acar, et al. Eur Heart J, 16 (supplement B),
94-98. 1995
2Mugge et al. JACC 14631-638. 1989
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Moon, et al. Prog Cardiovasc Dis 1997
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Vegetation on atrial surface of PMVL
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Peripheral Embolization

• Rohmann, et al1
• 64 vegetations resolved/decreased
• 36 no change/increased
• valve replacement 2 vs 45
• perivalvular abcess 2vs 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 shouldnt be criterion for
  valve replacement in absence of other indications

1Rohmann, et al. J Am Soc Echo 4465-474, 1991
2Vuille, et al. Am Heart J 128 1200-1209. 1994
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Peripheral Embolization

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

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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
1101745-1755, 1995
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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
19951101745-55
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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 5118-22, 1991
2Zisbrod, et al. Circulation 76V109-V112, 1987
(suppl V)
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Ruptured mycotic aneurysm in MCA territory
(causative agent Aspergillus)
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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

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Extravalvular Extension

• annular abscess
• operative mortality 19-43 (vs gt75 medically
  treated)1
• extensive tissue necrosis/structural damage
  including interventricular septum, conduction
  system, and fibrous skeleton of heart
• In NVE mitral (1-5) lt 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
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• 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

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Cormier et al. Eur Heart J 1995 (16) suppl B 68-71
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TTE (L) and TEE (R) showing evidence of AV
vegetation and paravalvular abscess
Otto. Textbook of Clinical Echocardiography 2nd
Ed. Chp 13
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communicating Ao root abscess
Dec 2001 ECHO case of the month, www.acc.org
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Extravalvular Extension

• Conduction disturbances in 30 with abscess vs
  lt2 if no abscess
• 1st degree gt 7d, new 2nd or 3rd degree block
  requires eval for abcess - TEE

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Meta-analysis
Moon, et al. Prog Cardiovasc Dis. 1997
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Moon, et al. Prog Cardiovasc Dis 1997
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Predictors of operative mortality
Moon, et al. Prog Cardiovasc Dis 1997
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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

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Conclusions