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Infective endocarditis and surgery
Carlos-A. Mestres, MD, PhD, FETCS
Consultant
Cardiovascular Surgery
Hospital Clínico. University of Barcelona
Barcelona. Spain
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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)
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Infective Endocarditis
What have we learned?
What have we changed?
What are we doing?
Where are we going?
An overview
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
A - Short Courses of Therapy for Infective Endocarditis
B - Infective Endocarditis in Drug Abusers (IVDAs)
C – Surgical experience
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
MSSA
N N (%)
in IVDAs
- Right-sided IE
- Left-sided IE
- Mixed IE
Total
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)
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Infective Endocarditis in IVDAs & HIV infection
SUMMARY
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
2. HIV-infected IVDA have a higher ratio of right-sided IE and S.
aureus endocarditis than HIV-negative IVDA with IE
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Infective Endocarditis in IVDAs & HIV Infection
SUMMARY
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
“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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Epidemiology
Diagnosis of IE
IV (IVDA) drug abuse
General population
Native IE
PVE
Pacemaker/AICD
Admissions/yr
C.A.Mestres for the HC Endocarditis Study Group
1990 - 2000
421
104
317
213
75
29
>50
ESCMID – Santander - 2006
Infective endocarditis and surgery
“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
“Infective endocarditis not related to intravenous drug abuse in HIV-1infected 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
“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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
NVE 387 - ADVP 237 - PVE 130 - PM 49 - All 803
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
PVE 132
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
S.aureus 274
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
ICE
Presumed
intravascular
catheter source by
region
International Collaboration on
Endocarditis
100
Peripheral/other IV; P =0.13 between regions
Central catheter; P = 0.017 between regions
80
Tunnelled catheter; P < 0.0001 between regions
60
Any catheter source; P = NS between regions
40
20
0
North Ame rica
South Ame rica
C.A.Mestres for the HC Endocarditis Study Group
Australia/Ne w Ze aland
Europe /Middle East
ESCMID – Santander - 2006
Infective endocarditis and surgery
Specific indications
Mechanical valve
Young, “good” ring, cured IE
Bioprosthesis
Elderly (?), “good” ring, cured IE
Homograft
Complicated IE, abscess, annular destruction
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
The complicated root
1. Root abscess
2. Aorto-cavitary fistula
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Aorto-cavitary fistulae
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
42nd ICAAC. San Diego, CA. September 27-30, 2002
L770 - AORTO-CAVITARY FISTULIZATION IN
COMPLICATED ENDOCARDITIS. CLINICAL AND
ECHOCARDIOGRAPHIC FEATURES OF 76 CASES (19922001) AND PROGNOSTIC FACTORS OF MORTALITY
The Spanish Aorto-cavitary Fistula Endocarditis Working Group
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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 Northamerican Hospitals in patients with IE and ACF.
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Basic considerations
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.
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
* 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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
General population
Native valve
Aortic
Mitral
Other
PVE
Aortic
Mitral
Other
Pacemaker
IV Drug abusers
OVERALL
ACF n
69
38
38
--31
31
---7
76
C.A.Mestres for the HC Endocarditis Study Group
Cases IE n
3147
2105
1056
930
119
872
536
326
10
170
1534
4681
Incidence %
2.2
1.8
3.6
----3.5
5.8
------0.4
1.6
ESCMID – Santander - 2006
Infective endocarditis and surgery
Clinical characteristics
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
C.A.Mestres for the HC Endocarditis Study Group
NVE=45
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%)
PVE=31
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%)
All=76
54.7±17.2
56 (74%)
44 (59%)
27 (36%)
7 (9%)
7 (9%)
26.7±27.9
39.4±42.8
47 (62%)
12 (16%)
28 (37%)
15 (20%)
11 (14%)
ESCMID – Santander - 2006
Infective endocarditis and surgery
Pathogens
Staphylococcus spp
S.aureus
CNS
Streptococcus spp
VGS
S.bovis
Other streptococci
Enterococcus spp
Culture negative
Other (HACEK)
NVE=45
17 (38%)*
13 (29%)*
4 (9%)*
16 (35%)
10 (22%)
2 (4%)
4 (9%)
2 (4%)
5 (11%)
7 (15%)
PVE=31
18 (58%)*
3 (10%)*
15 (48%)*
9 (29%)
5 (16%)
-4 (13%)
2 (6%)
-2 (6%)
All=76
35 (46%)
16 (21%)
19 (25%)
25 (33%)
15 (20%)
2 (3%)
8 (10%)
4 (5%)
5 (6%)
9 (12%)
NVE vs PVE groups (p<0.05)
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Echocardiography
Diagnostic yield of TTE and TEE
TTE n (%)
TEE n (%)
Native valve
26/44 (59%)
31/33 (94%)
PVE
15/31 (48%)
28/28 (100%)
Overall
40/75 (53%)
59/61 (97%)
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Native Prosthetic
N=45
N=31
Patients with vegetations
96 %*
65 %*
Mean maximal veg. size (mm)
11.5
12.1
Vegetations > 10 mm
49 %
70 %
Patients with abscess
71 %
87 %
Mean maximal abscess
10 mm
15 mm
diameter
Abscess > 10 mm
44 %
67 %
Ventricular septal defect
21 %
19 %
Mean EF (%)
62.5
60.5
Mean LVEDD (mm)
55.2
54.4
Multivalvular infection
33 %
26%
Echo findings
Total
N=76
83 %
11.7
56 %
78 %
12 mm
54 %
20 %
61.7
54.9
30 %
*Native vs prosthetic, p < 0.05
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Echo findings
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
Native
N=45
Prosthetic
N=31
Total
N=76
44%
35%
20%
26%
42%
32%
37%
38%
25%
18%
31%
22%
13%
11%
64%*
16%
16%
32%
19%
13%*
26%*
17%
25%
26%
16%
12%
49%
* Native vs prosthetic, p < 0.05
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
Native
N=45
Prosthetic
N=31
Total
N=76
87%
87%
87%
33%
36%
31%
11%
52%
37%
24%
42%
34%
41%
46%
13%
95%
28%
49%
18%
41%
52%
7%
89%
19%
52%
19%
41%
48%
11%
92%
24%
50%
18%
ESCMID – Santander - 2006
Infective endocarditis and surgery
Native
N=45
In-hospital mortality
- Surgical group (N=66)
- Medical group (N=10)
Cause of death
- Multiorgan failure
- Sudden death
- Septic shock
- Cardiogenic shock
- Hemorrhage
C.A.Mestres for the HC Endocarditis Study Group
16 (36%)
13/39 (33%)
3/6 (50%)
Prosthetic
N=31
Total
N=76
15 (48%)
15/27 (55%)
0/4 (-)
31 (41%)
28 (42%)
3 (30%)
Medical
N=3
Surgical
N=28
33%
33%
33%
-
23%
10%
26%
19%
23%
ESCMID – Santander - 2006
Infective endocarditis and surgery
Lost for follow-up
Follow-up (mo., mean, range)
Residual fistula
Late CHF
Late valvular replacement
Late death
Medical *
N=7
Surgical
N=38
2
4
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.
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
OR – 95%CI
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
C.A.Mestres for the HC Endocarditis Study Group
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)
1.2 (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)
p
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
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Abscesses vs fistulae
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Kaplan-Meier estimation of survival from time of diagnosis of
periannular complication.
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
B. patients medically-managed
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Conclusions
* 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 nativevalve 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.
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Prosthetic valve endocarditis
- What?
- When?
- Who?
- Why?
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
PVIE – Patient characteristics
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Complications and outcomes of patients with PVIE
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Propensity analysis of surgical treatment of PVIE
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Logistic regression analysis of variables independently
associated with in-hospital mortality in patients with PVIE
and matched propensity for surgical treatment
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Echocardiographic (TTE) Follow-up
Year
Patient TTE
Before
TTE
After
FU Last TTE
(Yrs)
1991
AMG
Veg 28 mm
Mild TR
1991
RPO
Veg 22 mm
Severe TR
Large RV
Severe TR 13
Large RV
1992
PER
Veg 30 mm
Severe TR
1994
JLF
Veg 22 mm
Severe TR
Ruptured
chordae
Mild TR
1996
JFG
Veg 28 mm
Severe TR
Mild TR
C.A.Mestres for the HC Endocarditis Study Group
13
NYHA
Severe TR
Large RV
Severe TR
Large RV
II
5
Severe TR
Large RV
I
1
Mild TR
I
1
Severe TR
I
II
ESCMID – Santander - 2006
Infective endocarditis and surgery
Echocardiographic (TTE) Follow-up
Year
Patient TTE
Before
TTE
After
FU
(Yrs)
Last TTE
2001
ERA
Severe TR
Trivial TR
pod
Po Death
2002
LML
Veg 20 mm
Severe TR
Large RV
Trivial TR
Large RV
pod
Po Death
2002
JGR
Veg 30 mm
Severe TR
Mild TR
2.5
Mild TR
C.A.Mestres for the HC Endocarditis Study Group
NYHA
ESCMID – Santander - 2006
I
Infective endocarditis and surgery
Outcomes
Year
Patient FU
(Yrs)
Drug addiction
relapse
Recurrent
endocarditis
1991
AMG
6
Yes
14 mos
B3
(Corynebacterium spp)
Alive
Late Reop
1991
RPO
6
Yes
48, 58, 63 mos
B2
(MSSA all cases)
Alive
No Reop
1992
PER
5
No
No
A2
Alive
Late Reop
1994
JLF
2.5
Yes
No
A3
Death
Overdose
1996
JFG
8.5
Yes
7, 12 mos
(MSSA)
A2
Alive
No reop
C.A.Mestres for the HC Endocarditis Study Group
HIV
stage
Outcome
ESCMID – Santander - 2006
Infective endocarditis and surgery
Year
Patient FU
(Yrs)
Drug addiction
relapse
Recurrent
endocarditis
HIV
stage
Outcome
2001
ERA
PO
N
N
C3
Death
2002
LML
PO
N
N
B2
Death
2002
JGR
2.5
N
No
A1
Alive
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
The most complex situation
Fibrous Skeletal destruction
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Acute pectoralis major myositis in an
otherwise healthy young male
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
• 25-year-old male
• Smoker ½ pack/day
Occasional recreational drugs. NO iv abuse
• Job: Waiter. Physically fit. Contact sports (judo, fullcontact…)
• 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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
• 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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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)
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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 BVS5000 implanted
• All samples to Microbiology
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Final diagnosis
1. Community-acquired ORSA myositis
2. Acute aortic root ORSA infective endocarditis
3. Heart transplantation
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Case
Age
Pathogen
Valve
Position
Timing for HTx
Conditions
1
25
M. hominis
Tissue
Aortic
2 months
SLE
2
30
S viridans
Mechanical
Aortic
1 month
PreTX + cultures
3
58
S viridans
Native
Mitral
2 years
3 VR’s
4
32
C burnetti
Native
Mi + Ao
14 months
Persistent fever
5
54
MRSA
Mechanical
Mitral
17 days
Previous HTx
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Conclusions
* IE is a very serious pathology
* It is not popular
* Highly demanding
* Suboptimal results
* Team approach
* Risk takers
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
EuroSCORE
Additive
Score
% mortality
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Cross-over point
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Reasons to predict mortality in Cardiac Surgery
1. Helping to determine indications for surgery
2. Quality monitoring
Additive EuroScore works well for most purposes
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
The reality
* Infective endocarditis is a high-risk situation
* There is lack of data regarding risk assessment
before valve surgery
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Aim of the study
To validate the EuroSCORE preoperative
stratification risk model in infective endocarditis
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Population
Period
Patients
Mean age
Male gender
C.A.Mestres for the HC Endocarditis Study Group
Jan 95 – Jan 04
147
56.33 ± 15.95
69.4%
ESCMID – Santander - 2006
Infective endocarditis and surgery
Native valve IE
N
%
Aortic
64
43.5
Mitral
25
17
Tricuspid
2
1.4
Pulmonary
1
0.7
A+M
12
8.2
M+T
1
0.7
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Prosthetic valve IE
N
%
PVE Aortic
17
11.6
Homograft Ao
2
1.4
PVE Mitral
11
7.5
PVE Ao + M
1
0.7
PVE Ao + PVE Mi
2
1.4
A + PVE Mi
1
0.7
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Intravascular leads
N
%
DDD
3
2
AICD
1
0.7
VVI R
1
0.7
VVI
2
1.4
Mitral + DDD
2
1.4
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Characteristics
Active endocarditis
IV Drug addicts
HIV+
ESR – HD
Reoperation
C.A.Mestres for the HC Endocarditis Study Group
91.2%
10.9%
5.4%
3.4%
27.2%
ESCMID – Santander - 2006
Infective endocarditis and surgery
Pathogens
Culture negative
Staphylococcus
Streptococcus
Enterococcus
Polimicrobial
Candida
Other
C.A.Mestres for the HC Endocarditis Study Group
N
10
55
43
14
8
1
14
%
6.8
37.4
29.3
9.5
5.4
0.7
9.5
ESCMID – Santander - 2006
Infective endocarditis and surgery
Type of operation
Emergency
Urgent
Elective
C.A.Mestres for the HC Endocarditis Study Group
29.9%
21.8%
46.9%
ESCMID – Santander - 2006
Infective endocarditis and surgery
EuroSCORE
Additive
Range
Mean
Median
C.A.Mestres for the HC Endocarditis Study Group
2 – 19
10.15 ±3.81
10
ESCMID – Santander - 2006
Infective endocarditis and surgery
EuroSCORE
Logistic
Range
Mean
Median
C.A.Mestres for the HC Endocarditis Study Group
1.51 – 94.17% EM
25.59 ± 20.81
18.95
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Overall in-hospital mortality
32.7%
- Intraoperative death
- 30 days po
- Regardless the length of stay
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Receiver operating characteristics (ROC) curves
All patients
Area
SE
.826
.036
Lower
bound
.756
Upper
bound
.896
Sig.
.000
Asymptotic 95% confidence interval
Area > 0.7
Area > 0.8
Area > 0.9
C.A.Mestres for the HC Endocarditis Study Group
Good correlation
Very good correlation
Excellent correlation
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Area
Native valve IE
.814
Lower Upper Sig.
Bound Bound
.045 .727
.902 .000
Prosthetic IE
.779
.088
C.A.Mestres for the HC Endocarditis Study Group
SE
.607
.952
.000
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Area
Aortic position
.778
Lower Upper Sig.
Bound Bound
.064 .652
.904 .001
Mitral position
.937
.051
C.A.Mestres for the HC Endocarditis Study Group
SE
.836
1.037
.001
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Area
Aortic prostheses
.729
Lower Upper Sig.
Bound Bound
.125 .484
.980 .112
Mitral prostheses
.833
.152
C.A.Mestres for the HC Endocarditis Study Group
SE
.535
1.132
.068
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Area
Gram +
.819
Lower Upper Sig.
Bound Bound
.041 .739
.899 .000
Gram -
.833
.204
C.A.Mestres for the HC Endocarditis Study Group
SE
.433
1.233
.248
ESCMID – Santander - 2006
Infective endocarditis and surgery
Results
Area
SE
.054
Lower
Bound
.727
Upper
Bound
.940
Staphylococci .834
Streptococci
Enterococci
.000
.856
.087
.686
1.026
.002
.500
.163
.181
.829
1.000
Polymicrobial .800
.165
.476
1.124
.180
C.A.Mestres for the HC Endocarditis Study Group
Sig.
ESCMID – Santander - 2006
Infective endocarditis and surgery
Aortic valve
ROC Curve
VÁLVULA: A
1,00
,75
Sensitivity
,50
Case Processing Summaryb
Exitus po
Pos itivea
Negative
Mis sing
Valid N
(listwise)
16
46
2
Larger values of the tes t res ult variable(s ) indicate
s tronger evidence for a pos itive actual state.
a. The pos itive actual state is S.
b. VÁLVULA = A
,25
0,00
Area Under the Curvec
0,00
,25
,50
,75
1,00
1 - Specificity
Diagonal segments are produced by ties.
C.A.Mestres for the HC Endocarditis Study Group
Tes t Result Variable(s): Logís tico (%)
Area
,778
a
Std. Error
,064
Asymptotic
b
Sig.
,001
Asymptotic 95% Confidence
Interval
Lower Bound Upper Bound
,652
,904
The test res ult variable(s ): Logís tico (%) has at leas t one tie between the
pos itive actual s tate group and the negative actual s tate group. Statis tics
may be bias ed.
a. Under the nonparametric ass umption
b. Null hypothesis: true area = 0.5
c. VÁLVULA = A
ESCMID – Santander - 2006
Infective endocarditis and surgery
Homograft aortic
ROC Curve
VÁLVULA: HA
1,00
,75
Case Processing Summaryb
Exitus po
Pos itivea
Negative
Valid N
(listwise)
1
1
Larger values of the tes t res ult variable(s ) indicate
s tronger evidence for a pos itive actual state.
a. The pos itive actual state is S.
b. VÁLVULA = HA
Sensitivity
,50
,25
0,00
0,00
,25
,50
,75
1,00
Area Under the Curvec
Tes t Result Variable(s): Logís tico (%)
Area
1,000
1 - Specificity
C.A.Mestres for the HC Endocarditis Study Group
a
Std. Error
,000
Asymptotic
b
Sig.
,317
Asymptotic 95% Confidence
Interval
Lower Bound Upper Bound
1,000
1,000
a. Under the nonparametric ass umption
b. Null hypothesis: true area = 0.5
c. VÁLVULA = HA
ESCMID – Santander - 2006
Infective endocarditis and surgery
Mitral valve
ROC Curve
VÁLVULA: M
1,00
,75
Case Processing Summaryb
Sensitivity
,50
,25
0,00
Area Under the Curvec
Exitus po
Pos itivea
Negative
Valid N
(listwise)
7
18
Larger values of the tes t res ult variable(s ) indicate
s tronger evidence for a pos itive actual state.
a. The pos itive actual state is S.
b. VÁLVULA = M
0,00
,25
,50
,75
1,00
Tes t Result Variable(s): Logís tico (%)
Area
,937
1 - Specificity
C.A.Mestres for the HC Endocarditis Study Group
a
Std. Error
,051
Asymptotic
b
Sig.
,001
Asymptotic 95% Confidence
Interval
Lower Bound Upper Bound
,836
1,037
a. Under the nonparametric ass umption
b. Null hypothesis: true area = 0.5
c. VÁLVULA = M
ESCMID – Santander - 2006
Infective endocarditis and surgery
Aortic prosthesis
ROC Curve
VÁLVULA: PA
1,00
,75
Sensitivity
,50
Case Processing Summaryb
Exitus po
Pos itivea
Negative
Valid N
(listwise)
9
8
Larger values of the tes t res ult variable(s ) indicate
s tronger evidence for a pos itive actual state.
a. The pos itive actual state is S.
b. VÁLVULA = PA
,25
0,00
0,00
,25
,50
,75
1,00
Area Under the Curvec
Tes t Result Variable(s): Logís tico (%)
1 - Specificity
Diagonal segments are produced by ties.
C.A.Mestres for the HC Endocarditis Study Group
Area
,729
a
Std. Error
,125
Asymptotic
b
Sig.
,112
Asymptotic 95% Confidence
Interval
Lower Bound Upper Bound
,484
,975
The test res ult variable(s ): Logís tico (%) has at leas t one tie between the
pos itive actual s tate group and the negative actual s tate group. Statis tics
may be bias ed.
a. Under the nonparametric ass umption
b. Null hypothesis: true area = 0.5
c. VÁLVULA = PA
ESCMID – Santander - 2006
Infective endocarditis and surgery
Mitral prosthesis
ROC Curve
VÁLVULA: PM
1,00
,75
Case Processing Summaryc
b
Exitus po
Pos itivea
Negative
Valid N
(listwise)
6
5
Sensitivity
,50
,25
0,00
Area Under the Curvec
Tes t Result Variable(s): Logís tico (%)
0,00
,25
b. The tes t res ult variable(s ): Logís tico (%) has at
leas t one tie between the pos itive actual s tate
group and the negative actual s tate group.
,50
,75
1,00
Area
,833
Larger values of the tes t res ult variable(s ) indicate
s tronger evidence for a pos itive actual s tate.
a. The pos itive actual s tate is S.
a
Std. Error
,152
Asymptotic
b
Sig.
,068
Asymptotic 95% Confidence
Interval
Lower Bound Upper Bound
,535
1,132
a. Under the nonparametric ass umption
1 - Specificity
b. Null hypothesis: true area = 0.5
c. VÁLVULA = PM
c. VÁLVULA = PM
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Limitations
Small sample size
Statistical power decreases when analyzing subgroups
Just preliminary results
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
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
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006
Infective endocarditis and surgery
Conclusions
* IE is a very serious pathology
* It is not popular
* Highly demanding
* Suboptimal results
* Team approach
* Risk takers
C.A.Mestres for the HC Endocarditis Study Group
ESCMID – Santander - 2006