ESCTS 2012

1. SURGICAL TREATMENT OF
BACTERIAL ENDOCARDITIS
Kasr Elaini Experience
El-Sayed AKL (MD) , Tarek Mohsen
(MD), Ihab Abdelfattah (MD),
Hosam Fathy and A. Badreldin
Cairo University .
March -2012

2. INFECTIVE ENDOCARDIRTIS
INFECTIVE
1986

3. INFECTIVE ENDOCARDIRTIS
2003

4. 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 ?

5. 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

6. INFECTIVE ENDOCARDITIS
OLD STRATIGY:
* 4-6 WEEKS OF ANTIBIOTICS .
* LOCAL & SYSTEMIC STRELIZATION
WHY??
* To reduce surgical risk.
* To reduce recurrence rate.

7. 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

8. When to operate ?

9. When to operate ?
Current best practices and guidelines
Indications for surgical intervention
in infective endocarditis
Lars 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

10. BACTERIAL ENDOCARDITIS
Between Jan 2000 and Oct. 2010
148 patients
Age 6 – 70 ( mean 34.4 y )
39%
Male
Female
61%

11. Underlying Cardiac Disease
 Rheumatic H.D. = 65
 Prosthetic V.E. = 32
 Degenerative = 2
 Infected PM = 2
 Congenital = 11
 Infected homograft = 1
Healthy Native Valve = 24 %

12. Blood Culure +ve in 60 %
Causative organisms
Staph. Aureus
4% Strep. Viridans
4% E. Coli
9%
24%
5% Aspergillus
7% Staph. Coagulase
- ve
Bartonella
9% 15% Microaerophilic
strept
11% 12% Candida
Brucella
Others

13. Main indications of surgery
Uncontrolled
infection
11% 9%
Large vegetation
23%
CHF
30%
Aortic root abcess
27%
Recc. Emboli

14. Main indications of surgery
 Congestive Heart failure = 74
 Large Vegetations = 68
 Uncontrolled Infection = 47
 Recurrent Emboli = 18
 aortic root Abscess = 17
More than one indication in > 40%

15. Valve Affection
 Isolated Mitral Valve = 64
 Isolated Aortic Valve = 40
 Isolated Tricuspid Valve = 16
 Mitral + Aortic = 20
 Mitral + Aortic + Tricuspid= 6
 Mitral + Tricuspid = 2

16. Types of Surgery for Mitral valve
endocarditis
30
25
20
15
10 Mitral valve
5 endocarditis
0
M
M
M
V
V
V
R
bi
re
op
pa
ro
ir
th
es
is

17. Mitral valve procedures ( 64 patients ) :
.Prosthetic MVR 45
.MV repair 17
.MV bioprosthesis 2

18. Isolaed Mitral Valve Endocarditis

20. Fungal prosthetic endocarditis,
4th time redo – Omental flap

21. Mitral Repair

22. Aortic valve procedures (40 patients) :
. Homograft 6
. AVR 28
.AVR+VSD 1
.AVR+subaortic membrane 2
. Bental 3

23. Extension to pericardium

24. Aortic root abscess

25. Huge Vegetation

26. At Operation

27. Abscess wall Huge veget.

29. Aortic root replacement With
coronary reimplantation
Right coronary Left coronary

30. Aortic Valve Replacement

31. Huge fungal pseudoaneurysm

32. Homograft Root
Replacement

33. Tricuspid Valve Operations=16
 Bioprosthesis TVR = 11
 Tricuspid V Repair = 5

34. Types of surgery for Tricuspid valve
endocarditis
4
3.5
3
2.5
2
1.5
1 TV
0.5
endocarditis
0
TV
TV
bi
re
op
pa
ir
ro
th
es
is

35. Tricuspid Endocarditis

36. Isolated Tricuspid Valve Endocarditis = 4

37. Isolated Tricuspid Valve Replacement

38. Surgical Outcome
28 Patients = 19 %
 Operative = 2 (1.5%)
 Postoperative = 26 (17.5%)

39. CONCLUSIONS
Decision is based on :
* Careful daily clinical evaluation.
* Microbiological tests ( Follow up Bl.
Cultyres).
* Repeated Echocardiography

40. CONCLUSIONS
When 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 .

41. CONCLUSIONS
SURGICAL RULES :
* Maximum debridement .
* Local sterilization .
* Consider changing operative strategy .
* Biological valves are better than
prosthetic .
* Prosthetic valves are better than delay .

42. Thank you

43. When Exaclty To Operate ?
Indication Evidence based
Emergency indication for cardiac surgery (same day)
1. Acute AR with early closure of mitral valve A
2. Rupture of a sinus Valsalva aneurysm into the
right heart chamber A
3. Rupture into the pericardium A

44. When Exactly To Operate ?
Urgent indication for cardiac surgery (within 1–2 days)
4. Valvular obstruction A
5. Unstable prosthesis
A
6. Acute AR or MR with heart failure, NYHA III–IV A
7. Septal perforation
A
8. Evidence of annular or aortic abscess, sinus or aortic true
or false aneurysm, fistula formation, or new onset conduction
disturbances
A
9. Major embolism+mobile vegetation >10 mm+appropriate
antibiotic therapy <7–10 d B
10. Mobile vegetation >15 mm+appropriate antibiotic therapy
<7–10 d C
11. No effective antimicrobial therapy available A

45. When Exactly To Operate ?
Elective indication for cardiac surgery (earlier is usually
better)
12. Staphylococcal prosthetic valve endocarditis B
13. Early prosthetic valve endocarditis (£2 mo after surgery) B
14. Evidence of progressive paravalvular prosthetic leak A
15. Evidence of valve dysfunction and persistent infection after
7–10 d of appropriate antibiotic therapy, as indicated by
presence of fever or bacteremia, provided there are no
noncardiac causes for infection A
16. Fungal endocarditis caused by a mold
A
17. Fungal endocarditis caused by a yeast B
18. Infection with difficult-to-treat organisms B
19. Vegetation growing larger during antibiotic therapy >7 d
C

46. Main indications of surgery
Uncontrolled
infection
11% 9%
Large vegetation
23%
CHF
30%
Aortic root abcess
27%
Recc. Emboli

47. S.A.M
Abscess wall

49. Outside
Inside
Aotric wall abscess

50. Surgery for Native I.E
* If vegetations are larger than 10 mm on
the mitral valve or if they are increasing in
size despite antibiotic therapy or if they
represent mitral kissing vegetations,
early surgery should also be considered.
* The prognosis of right-sided IE is
favourable. Surgery is necessary if tricuspid
vegetations are larger than 20 mm after
recurrent pulmonary emboli.
esc Guidelines 2004

51. Surgery for Prosthetic I.E
The following indications are accepted:
* Early PVE (less than 12 months after surgery) +
* Late PVE complicated by prosthesis
dysfunction including significant perivalvular leaks
or obstruction, persistent positive blood cultures,
abscess formation,conduction abnormalities, and
large vegetations, particularly if staphylococci are
the infecting agents
esc Guidelines 2004

52. 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 for
more than 8 days despite adequate antimicrobial
therapy;
* Demonstration of abscesses, pseudoaneurysms, abnormal
communications like fistulas or rupture of one or
more valves, conduction disturbances, myocarditis
or other findings indicating local spread (locally
uncontrolled infection);
* Involvement of microorganisms which are frequently
not cured by antimicrobial therapy (e.g. fungi;
Brucella and Coxiella) or microorganisms which have
a high potential for rapid destruction of cardiac
structures (e.g. S. lugdunensis).
esc Guidelines 2004

53. Pattern of Valve Affection
 Isolated Mitral Valve = 36
 Isolated Aortic Valve = 28
 Isolated Tricuspid Valve = 4
 Double or Triple Valve = 30

54. Isolaed Mitral Valve Endocarditis = 36

55. Types of Surgery for Mitral valve
endocarditis
30
25
20
15
10 Mitral valve
5 endocarditis
0
M
M
M
V
V
V
R
bi
re
op
pa
ro
ir
th
es
is

56. Isolaed Aortic Valve Endocarditis = 28

57. Types of surgery for Aoric valve
endocarditis
20
18
16
14
12
10
8
6 Ao. Valve
4 endocarditis
2
0
A
B
A
A
A
en
VR
VR
VR
o
Ho
tal
+
+
m
VS
p
SA
og
ro
D
M
c
ra
ed
ft
ur
e

58. Aortic Valve Replacement

59. Types of surgery for Tricuspid valve
endocarditis
4
3.5
3
2.5
2
1.5
1 TV
0.5
endocarditis
0
TV
TV
bi
re
op
pa
ir
ro
th
es
is

60. Surgical Outcome
12 Patients = 12 %
 Operative =4
 Postoperative =8

61. CONCLUSIONS
When 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 .