| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1998;65:359-364
© 1998 The Society of Thoracic Surgeons
Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
Dr Bauernschmitt, Dept of Cardiac Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany.
Presented at the "Meet the Expert Session" of the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3–5, 1997.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and MethodsResultsCommentReferences |
|---|
Methods. We present a prospective study on 138 patients operated on from March 1988 to March 1996. Patients were only included if the activity of the infection was proved by positive culture of the valve leaflets or by histologic staining. During the observation period, indication for operation, surgical approach, and postoperative antibiotic therapy were standardized as much as possible. After radical debridement of all parts of infected tissue, valve replacement was carried out with mechanical prostheses.
Results. The early mortality was 11.5% overall. High New York Heart Association functional classification, advanced age, and staphylococcal disease were significant risk factors for early mortality. The site of infection, multiple valve involvement, and prosthetic valve endocarditis did not affect the outcome. Early recurrent endocarditis was recorded in only 3 patients of the entire series.
Conclusions. In case of acute infective endocarditis, valve replacement with mechanical prostheses is a safe procedure, if radical operation and aggressive postoperative antibiotic therapy are performed. For further improvements of the results, earlier operation is advisable in patients with rapidly progressive cardiac deterioration and in most cases of staphylococcal endocarditis.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Several studies were presented in the past to clarify which patients were at highest risk and which surgical procedure may be the most favorable, but because of the heterogenity of the disease and the small number of patients operated per period of time, these studies may as well reflect changes in patient populations, etiology, and general progress in the medical field [2] [3] [4] [5] [6]. We present a series of 138 patients operated on for IE in an 8-year period. During this period, the indications for operation, operative procedures, and the postoperative antibiotic regimen were standardized. The purpose of this study was to report on our experience of operation and postoperative intensive care unit therapy, to draw particular attention to factors influencing the perioperative risk and to establish strategies of perioperative management for more favorable outcomes.
|
Patients and Methods |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
|
|
|
Diagnostic Procedures and Indications for Operation
The diagnosis was made by the combination of typical clinical findings and echocardiography in all patients except the 3 patients mentioned. Preoperative cardiac catheterization was performed in 114 patients. The examination did not add information concerning site and extension of the endocarditis, but detected coronary heart disease requiring coronary artery bypass grafting in 19 patients.
Mandatory preoperative studies included abdominal sonography or computed tomographic scan to rule out septic foci and a cranial computed tomographic scan in case of abnormal neurologic findings. The main indication for operation was progressive cardiac failure (present in >80% of the patients). Major preoperative complications are given in Table 2.
|
After resection of the valves, care was taken to examine the annulus and adjacent structures to detect possible extension of the infective process. All infected or necrotic structures surrounding the valves were resected irrespective of whether the conduction system was jeopardized or large defects in the myocardial or fibrous tissue were created. Abscesses were removed and even the wall of the abscess cavity was resected as completely as possible not to leave any macroscopically infected tissue in situ.
Defects were subsequently closed with Dacron patches or, if possible, by direct sutures. Evacuated abscess cavities were filled with fibrin glue, or more recently, with gentamycin swabs ("Sulmycin-implant") and closed the same way [8]. In 5 patients, ventricular septal defects caused by extension of abscess cavities were closed with Dacron patches. If the valves had to be replaced, mechanical prostheses (St. Jude Medical bileaflet or Medtronic-Hall Monostrut) were chosen. The prostheses were implanted with single Teflon-armed sutures. Prostheses, patch material, and sutures were incubated in gentamicin solution before implantation.
Nineteen patients had additional coronary artery bypass grafting for one- to three-vessel diseases, in 7 patients splenectomy was also performed for severe abscess formation diagnosed preoperatively.
Postoperative Care
Apart from the hemodynamic stabilization, an important goal of postoperative intensive therapy was control of the local and systemic infective process. In general, the antibiotic therapy was specifically directed against the infecting microorganisms. In presence of methicillin-resistant staphylococci, vancomycin was used in combination with tobramycin or rifampicin. Methicillin-susceptible staphylococci were treated with a semisynthetic penicillinase-resistant penicillin and rifampicin; if no rapid disappearance of infective signs could be achieved, therapy was changed to vancomycin alone or in combination. If no microorganism could be isolated, broad antibiotic therapy with imipenem and vancomycin or teicoplanin was used. In each case, intravenous antibiotic therapy was maintained for 6 weeks postoperatively.
The local situation was examined by echocardiography in short intervals to exclude recurrent vegetations or paravalvular leaks. These findings in combination with evidence of persisting infection would give a strong suspicion of ongoing or recurrent endocarditis and per se would justify redo operation.
Data Sampling and Statistics
For each patient, more than 5,000 items describing the preoperative, intraoperative, and postoperative course were sampled and fed into the database of the department’s network. The patient and the primary physician received a questionnaire automatically created by the computer every 6 months after the operation. Follow-up was 100% complete; the mean follow-up period in this patient group was 51 months [9]. Differences between groups were calculated by the 
2 test.
|
Results |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Analyzing risk factors for early death, there was a significant influence of age, presence of staphylococci, the preoperative NYHA classification, and preoperative acute renal failure. The site of infection, presence of annular and myocardial abscesses, additional coronary heart disease requiring coronary artery bypass grafting, and multiple valve involvement did not have significant influence on the operative outcome (Table 3).
|
|
Seven patients had to be reexplored for bleeding. In 1 patient, left ventricular rupture after mitral valve replacement forced emergent operative reintervention. The defect was closed during extracorporeal circulation with deep Teflon-armed polypropylene sutures and secured with surgical glue. This procedure was successful and the patient recovered uneventfully.
Persistent septic symptoms were present in 6 patients postoperatively and led to death from septic multiorgan failure in 3 of them; in these patients, sepsis was not related to persistent or recurrent endocarditis.
Twelve patients suffered from transient postoperative psychologic disorders. Among the 10 patients presenting with preoperative stroke, there was a complete remission of neurologic deficits in 8 patients. One patient had permanent symptoms after operation, and in 1 patient there was worsening caused by a postoperative intracerebral hemorrhage.
Recurrent Endocarditis
There were three recurrences within 60 days after operation, all of them occurring on aortic valve prostheses. The recurrent endocarditis occurred within 8 days and 5 weeks after the primary intervention. These patients were reoperated on immediately after diagnosis and recovered. Another 3 cases of recurrent endocarditis were recorded in the later postoperative period within 3 months and 2 years after operation. In these patients, inadequate antibiotic prophylaxis during invasive interventions possibly was the cause of the prosthetic valve infection. Two patients were reoperated on; 1 of them died of cardiac failure after the operation. In the third patient with a mitral valve prosthesis and infection caused by Streptococcus viridans, the endocarditis was cured by antibiotic therapy alone and did not lead to prosthetic dysfunction or paravalvular leak.
|
Comment |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
Replacement Device and Surgical Technique
In recent years, several investigators suggested a promising solution for the problem of early recurrent endocarditis. The implantation of an allograft valve seemed to diminish perioperative mortality and morbidity in these critically ill patients [4] [5] [10] [11] [12]. Haydock [4] and McGiffin [5] and their colleagues published two comparative studies concerning the question of "resistance" of the allograft valve against recurring or persisting infection. For allograft valves, these researchers demonstrated a lower instantaneous risk for recurrency as compared with mechanical valves or xenografts. Haydock and associates reported an overall incidence of recurrent endocarditis of 10% for allograft versus 17% for prosthetic valves, McGiffin and associates of 0% versus 17%, respectively.
These studies, however, were not randomized, but retrospectively covered a 20-year period. Differences in the outcome may not only be attributable to the replacement device per se, but may as well reflect differences in patient selection, surgical technique, perioperative management and postoperative care.
In our opinion, the clue to success in the surgical treatment is to be really radical when infected tissue parts are removed. As could be demonstrated recently by d’Udekem and colleagues [13] and our group [14], even in patients with paravalvular abscesses, the results using mechanical prostheses are satisfying if the radical surgical approach is used.
To analyze the results of operation for IE using mechanical replacement devices, we present a prospective study on 138 patients operated on in a period of 8 years. All perioperative procedures were standardized as far as possible over the entire period studied: patient selection, management of extracorporeal circulation and myocardial protection, surgical approach, and postoperative antibiotic therapy.
Each patient in this series was in the acute phase of the infection; if the activity of the infective process on the valve could not be proven by histologic staining, the patient was excluded from the study. There were several other conditions determining the high operative risk of these patients. More than half were in NYHA classes IV or V before operation, more than one-third had staphylococcal infections, and paravalvular or myocardial abscesses were present in 41%.
Mortality: Risk Factors
Taking these conditions into consideration, the early mortality of 11.5% compares well with data from other reports in the literature, although the ratio of prosthetic valve diseases was low in our experience. There were several risk factors that had significant influence on the outcome. There is an increase of infective endocarditis in patients of 60 years and older [6]. In our series, the risk of patients aged 60 and older was markedly higher as compared with the younger group, which may reflect a longer duration of myocardial impairment and an immune system not sufficient to meet the demands of a severe multisystem infectious disease.
In our experience, the preoperative NYHA class is important to determine the operative outcome. Only one death was noted when patients were operated on in NYHA class III or less. This could be a strong argument to operate earlier on IE, when cardiocirculatory impairment is mild and before deterioration has occurred [15]. As similarly stated by Jault and co-workers [16], patients arriving in cardiogenic shock had the highest risk in our series; however, in these patients immediate operation was the only treatment option remaining.
Preoperative renal failure only occurred in patients in NYHA classes IV and V and therefore has to be considered the result of systemic hypotension related to sepsis or decreased cardiac output.
If the IE was caused by staphylococci, the mortality was more than 20% as compared with 9% for other microorganisms or if no organisms could be isolated. Staphylococci are prone to cause early invasion of the tissue surrounding the valve, abscess formation, and early extracardiac organ manifestations. A mortality of 20%, however, is markedly less than described in the literature [1] [6] [17]. There may be two reasons for these results. First, aggressive debridement of the entire area surrounding the valve eliminates most of the organisms responsible for the local infectious process. In several patients, these procedures together with the specific antibiotic therapy started preoperatively may be sufficient to cure the systemic infection, but in more than 60% of staphylococcal cases in our series, infectious signs did not disappear 2 days after operation. Thus, the second guideline of our therapy for staphylococcal IE is to switch the antibiotic therapy to vancomycin and rifampicin, if no success of the initial antibiotic combination could be noted early after the operation. Several groups reported treatment failures when penicillinase-resistant penicillins were given for susceptible staphylococci; the most obvious explanation is development of antibiotic tolerance of the microorganisms [18]. In cases of persistent postoperative infection, vancomycin was even used, if the organism initially isolated was methicillin susceptible. Further improvement of the results possibly can be achieved, if operation is performed earlier during staphylococcal endocarditis [2] [3] [17].
Mortality: Factors Without Influence on the Outcome
Surprisingly, several conditions that are usually thought to increase the operative risk did not influence the results in the series presented (see Table 3). Annular abscesses are thought to be an adverse predictor for early mortality and recurrent endocarditis. The presence of abscesses may reflect a longer duration of the disease, infection with more pathogenic microorganisms, or a disturbed immune system of the host and may lead to destruction of the conduction system, to perforation of the ventricular septum, or to bacterial pericarditis and myocarditis. Operation is more difficult, as it requires additional procedures to resect abscess cavities and close them to the bloodstream to prevent late aneurysm formation [19]. Secure fixation of the prosthesis may be another problem, if the annulus is destroyed.
The fact that paravalvular involvement did not lead to a higher mortality in our patients demonstrates the success of radical surgical procedures. If the abscess cavities are completely resected and approximately normal hemodynamic conditions can be restored, the operative mortality is not necessarily higher. The operative risk of multiple valve involvement did not exceed the risk of single-valve diseases of either location. This fact is surprising, because double-valve replacement for noninfective valve disease carries a significantly higher risk than single-valve replacement. As the mean duration of antibiotic therapy was much shorter in this group (<1 week as compared with 2 weeks in the whole collective), there may be one reason for this finding: the occurrence of mitral valve incompetence accelerates the formation of lung congestion and edema and cardiocirculatory deterioration. Therefore, operation has to be performed earlier and the patient is operated on while in a less advanced state of systemic infection.
The duration of the disease until operation was performed, which may be of importance in an analysis of patients with IE, is a question that was not addressed in this study. The onset of IE is not necessarily identical with the beginning of antibiotic therapy. As most patients were admitted by external hospitals, and many of them were treated by their primary physicians before for a variety of other illnesses, the exact onset of the endocarditis could not be defined in each patient.
Major Postoperative Complications
Early recurrent endocarditis still has a low, but not insignificant, prevalence in each surgical series of patients with IE. The use of allograft valves is suggested to be superior in reducing this fatal complication, but we proved that similar results can be achieved with mechanical prostheses, if a radical procedure is performed and aggressive postoperative antibiotic therapy is applied. A rate of 2% of early reinfections is low and compares well with data from researchers using allografts [4] [5]. The advantage of the mechanical prosthesis is the high probability of avoidance of reoperation for graft failure.
Performing a radical operation can, however, lead to destruction of the conduction system. This complication was taken into account for the sake of removing all infectious or necrotic parts of tissue, and it resulted in six new AV blocks after operation. All these patients had large abscesses of the aortic root. Leaving parts of the abscesses in situ to preserve the conduction system would have carried a very high risk of prosthetic infection.
Conclusion
Surgical treatment of acute endocarditis is still one of the most challenging problems in operating for acquired valve diseases. Despite the progress in antibiotic therapy and cardiosurgical management, the operative mortality is high and implantation of prosthetic material into an infected surrounding area always carries the risk of reinfection. The use of allograft valves is one way to meet this problem, but we think similar results can be achieved using mechanical prostheses if operation is radical and postoperative antibiotic therapy is aggressive. Possibly we can control the infection and reduce the incidence of recurrent endocarditis not by the type of replacement device, but by the surgical approach. To further diminish the mortality of IE, early surgical intervention is advisable in patients with rapidly progressing cardiac deterioration and in cases of staphylococcal disease.
|
References |
|---|
|
TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  G. Nucifora, L. P. Badano, P. Viale, P. Gianfagna, G. Allocca, D. Montanaro, U. Livi, and P. M. Fioretti Infective endocarditis in chronic haemodialysis patients: an increasing clinical challenge Eur. Heart J., October 1, 2007; 28(19): 2307 - 2312. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. H.H. Feringa, L. J. Shaw, D. Poldermans, S. Hoeks, E. E. van der Wall, R. A.E. Dion, and J. J. Bax Mitral Valve Repair and Replacement in Endocarditis: A Systematic Review of Literature Ann. Thorac. Surg., February 1, 2007; 83(2): 564 - 570. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Al-Attar, R. Nottin, R. Ramadan, and A. Azmoun Translocation of the aortic valve in severe aortic root abscess. An alternative to homografts Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 509 - 510. [Full Text] [PDF]
|
|
|
|
|
|
R. Nottin, N. Al-Attar, R. Ramadan, A. Azmoun, A. Therasse, C. Kortas, M. Ly, A. Bouchachi, and M.-L. Bourachot-Montanteme Aortic Valve Translocation for Severe Prosthetic Valve Endocarditis: Early Results and Long-Term Follow-Up Ann. Thorac. Surg., May 1, 2005; 79(5): 1486 - 1490. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Murashita, H. Sugiki, Y. Kamikubo, and K. Yasuda Surgical results for active endocarditis with prosthetic valve replacement: impact of culture-negative endocarditis on early and late outcomes Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1104 - 1111. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Shapira, O. Merin, E. Rosenmann, I. Dzigivker, D. Bitran, A. M. Yinnon, and S. Silberman Latent Infective Endocarditis: Epidemiology and Clinical Characteristics of Patients With Unsuspected Endocarditis Detected After Elective Valve Replacement Ann. Thorac. Surg., November 1, 2004; 78(5): 1623 - 1629. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Turkoz, O. Gulcan, E. Uguz, and H. B. Cihan Mitral valve replacement after application of atrial appendix flap in endocarditis with posterior annular abscess Eur. J. Cardiothorac. Surg., October 1, 2004; 26(4): 837 - 838. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 R. G. Leyh, K. Knobloch, C. Hagl, A. Ruhparwar, S. Fischer, T. Kofidis, and A. Haverich Replacement of the aortic root for acute prosthetic valve endocarditis: Prosthetic composite versus aortic allograft root replacement J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1416 - 1420. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. Fukui, S. Suehiro, T. Shibata, K. Hattori, H. Hirai, and T. Aoyama Aortic root replacement with Freestyle stentless valve for complex aortic root infection J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 200 - 203. [Full Text] [PDF]
|
|
|
|
|
|
C. Hagl, J. D. Galla, S. L. Lansman, D. Fink, C. A. Bodian, D. Spielvogel, and R. B. Griepp Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated? Ann. Thorac. Surg., November 1, 2002; 74(5): S1781 - 1785. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. G. Seipelt, J. F. Vazquez-Jimenez, I. M. Seipelt, A. Franke, K. Chalabi, F. A. Schoendube, and B. J. Messmer The St. Jude ""Silzone"" valve: midterm results in treatment of active endocarditis Ann. Thorac. Surg., September 1, 2001; 72(3): 758 - 762. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J M Guerra, M P Tornos, G Permanyer-Miralda, B Almirante, M Murtra, and J Soler-Soler Long term results of mechanical prostheses for treatment of active infective endocarditis Heart, July 1, 2001; 86(1): 63 - 68. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Aagaard and P. V. Andersen Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices Ann. Thorac. Surg., January 1, 2001; 71(1): 100 - 103. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. J. Novick Invited commentary Ann. Thorac. Surg., January 1, 2001; 71(1): 104 - 104. [Full Text] [PDF]
|
|
|
|
|
|
D. Delay, M. Pellerin, M. Carrier, R. Marchand, P. Auger, L. P. Perrault, Y. Hebert, R. Cartier, P. Page, and L. C. Pelletier Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis Ann. Thorac. Surg., October 1, 2000; 70(4): 1219 - 1223. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. J. Baumgartner, B. O. Omari, J. M. Robertson, R. J. Nelson, A. Pandya, A. Pandya, and J. C. Milliken Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features Ann. Thorac. Surg., August 1, 2000; 70(2): 442 - 447. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Alexiou, S. M. Langley, H. Stafford, J. A. Lowes, S. A. Livesey, and J. L. Monro Surgery for active culture-positive endocarditis: determinants of early and late outcome Ann. Thorac. Surg., May 1, 2000; 69(5): 1448 - 1454. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Renzulli, A. Carozza, C. Marra, G. Romano, G. Ismeno, M. De Feo, A. Della Corte, and M. Cotrufo Are blood and valve cultures predictive for long-term outcome following surgery for infective endocarditis? Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 228 - 233. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Moro, J.-i. Hayashi, and O. Namura Implantation of mechanical valves for infective endocarditis Ann. Thorac. Surg., October 1, 1998; 66(4): 1470 - 1470. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
