INFECTIVE ENDOCARDITIS Still a challenge !! DIAGNOSTIC DILEMMA : *Vague general manifestations *Empirical antibiotics. *Diagnostic criteria . MANAGEMENT DILEMMA : *When to operate ? * What to do ? Repair or Replace ? *What valve substitute ?
INFECTIVE ENDOCARDITIS Problems at surgery: 1- Friable Tissues & distorted anatomy. 2- Bad general condition, progressive Hepatorenal and heart failure . 3- Extension of infection may lead to : *LEAFLET DESTUCTION . *ABSCESS FORMATION . *VEGETATION >>>> EMBOLISATION . *LOCAL EXTENSION >>>> FISTULATION
INFECTIVE ENDOCARDITISOLD STRATIGY:* 4-6 WEEKS OF ANTIBIOTICS .* LOCAL & SYSTEMIC STRELIZATIONWHY??* To reduce surgical risk.* To reduce recurrence rate.
Complicated infective endocarditis• Heart failure• No control of infection• Big vegetations and embolic risk• Perivalvular infection• Valvular obstruction• Unstable prosthesis• Prosthetic infective endocarditis• Fungal infective endocarditis• Difficult-to-treat microorganisms• Neurological complications
When to operate ?
When to operate ?Current best practices and guidelines Indications for surgical intervention in infective endocarditisLars Olaison, MD, PhD(a), Go¨ sta Pettersson, MD, PhD(b) a -Department of Infectious Diseases, Sahlgrenska University Hospital, S-416 85 Go¨ teborg, Sweden b- The Cleveland Clinic Foundation, Thoracic and Cardiovascular Surgery/F25,9500 Euclic Avenue, Cleveland, OH 44195, USA Infect Dis Clin N Am 16 (2002) 453–475
BACTERIAL ENDOCARDITIS Between Jan 2000 and Oct. 2010 148 patients Age 6 – 70 ( mean 34.4 y ) 39% Male Female 61%
CONCLUSIONSDecision is based on :* Careful daily clinical evaluation.* Microbiological tests ( Follow up Bl. Cultyres). * Repeated Echocardiography
CONCLUSIONSWhen to operate ?* A team work decision .* Decision is dictated by clinical condition, Laboratory tests and echocardiography.* Reluctance leads to deterioration.* Few days of antibiotics are enough .* Risk should be explained .
CONCLUSIONSSURGICAL RULES :* Maximum debridement .* Local sterilization .* Consider changing operative strategy .* Biological valves are better than prosthetic .* Prosthetic valves are better than delay .
When Exaclty To Operate ?Indication Evidence basedEmergency indication for cardiac surgery (same day)1. Acute AR with early closure of mitral valve A2. Rupture of a sinus Valsalva aneurysm into theright heart chamber A3. Rupture into the pericardium A
When Exactly To Operate ?Urgent indication for cardiac surgery (within 1–2 days)4. Valvular obstruction A5. Unstable prosthesisA6. Acute AR or MR with heart failure, NYHA III–IV A7. Septal perforationA8. Evidence of annular or aortic abscess, sinus or aortic trueor false aneurysm, fistula formation, or new onset conductiondisturbancesA9. Major embolism+mobile vegetation >10 mm+appropriateantibiotic therapy <7–10 d B10. Mobile vegetation >15 mm+appropriate antibiotic therapy<7–10 d C11. No effective antimicrobial therapy available A
When Exactly To Operate ?Elective indication for cardiac surgery (earlier is usuallybetter)12. Staphylococcal prosthetic valve endocarditis B13. Early prosthetic valve endocarditis (£2 mo after surgery) B14. Evidence of progressive paravalvular prosthetic leak A15. Evidence of valve dysfunction and persistent infection after7–10 d of appropriate antibiotic therapy, as indicated bypresence of fever or bacteremia, provided there are nononcardiac causes for infection A16. Fungal endocarditis caused by a moldA17. Fungal endocarditis caused by a yeast B18. Infection with difficult-to-treat organisms B19. Vegetation growing larger during antibiotic therapy >7 dC
Main indications of surgery Uncontrolled infection 11% 9% Large vegetation23% CHF 30% Aortic root abcess 27% Recc. Emboli
Outside Inside Aotric wall abscess
Surgery for Native I.E* If vegetations are larger than 10 mm onthe mitral valve or if they are increasing insize despite antibiotic therapy or if theyrepresent mitral kissing vegetations,early surgery should also be considered.* The prognosis of right-sided IE isfavourable. Surgery is necessary if tricuspidvegetations are larger than 20 mm afterrecurrent pulmonary emboli. esc Guidelines 2004
Surgery for Prosthetic I.EThe following indications are accepted:* Early PVE (less than 12 months after surgery) + * Late PVE complicated by prosthesisdysfunction including significant perivalvular leaksor obstruction, persistent positive blood cultures,abscess formation,conduction abnormalities, andlarge vegetations, particularly if staphylococci arethe infecting agents esc Guidelines 2004
Surgery for Native I.E* Heart failure due to acute aortic regurgitation;* Heart failure due to acute mitral regurgitation;* Persistent fever and demonstration of bacteremia formore than 8 days despite adequate antimicrobialtherapy;* Demonstration of abscesses, pseudoaneurysms, abnormalcommunications like fistulas or rupture of one ormore valves, conduction disturbances, myocarditisor other findings indicating local spread (locallyuncontrolled infection);* Involvement of microorganisms which are frequentlynot cured by antimicrobial therapy (e.g. fungi;Brucella and Coxiella) or microorganisms which havea high potential for rapid destruction of cardiacstructures (e.g. S. lugdunensis). esc Guidelines 2004
CONCLUSIONSWhen to operate ?* A team work decision .* Decision is dictated by clinical condition.* Reluctance may allow deterioration.* Few days of antibiotics are enough .* Risk should be explained .