Slides - AATS: American Association for Thoracic Surgery
Transcription
Slides - AATS: American Association for Thoracic Surgery
Treatment of Endocarditis Judgment Calls When to Replace vs. Spare the Aortic Valve and Root Tirone E. David University of Toronto Conflict of Interest None AV Endocarditis When to Replace vs. Spare the AV & Root • Infection limited to the aortic cusps Valve replacement Valve repair AV Endocarditis Localized vegetation excision patch repair CORMATRIX Extracellular matrix from porcine jejunal mucosa AV Endocarditis When to Replace vs. Spare the AV & Root • Infection limited to the aortic cusps Valve replacement Valve repair • Infection involving valve annulus and surrounding tissues with abscess formation: Radical resection and reconstruction Anatomy of the Base of Heart PV IVFB AV TV Aorto-Mitral Continuity Aorto-Mitral Continuity Abscess in the Intervalvular Fibrous Body Case Study 79 y.o.♂ with known asymptomatic aortic stenosis developed signs and symptoms of acute sepsis. Blood culture grew Staphylococcus aureus. He was started on appropriate antibiotics but remained febrile after 4 days of treatment. He was transferred for surgical treatment. Coronary angiography showed 75% stenosis of the LAD. Case study: 53 year-old man had AVR with a bioprosthetic valve for bicuspid aortic valve stenosis. Three years later he developed endocarditis due to Staphylococcus aureus. Treatment with antibiotics failed and he developed an extensive aortic root abscess surrounding the left main coronary artery and dominant circumflex. He was transferred to Toronto General Hospital for surgery. TEE: Extensive Aortic Root Abscess TEE: Extensive Aortic Root Abscess TEE: Abscess Involves Circumflex Artery Extensive Aortic Root Abscess TEE: Postoperative Aortic Homograft TEE: Postoperative LV Function 383 patients Mean age: 51±16 years Mean follow-up: 6.1±5.2 years 84% in NYHA class IV 14% in cardiogenic/septic shock 31% paravalvular abscess Surgery for Infective Endocarditis David et al. JTCVS 2007;133:144-9 Native valve: 266 Prosthetic valve: 117 94 – AV 77 – MV 74 – AV + MV 9 – AV + other 12 – Other 66 – AV 32 – MV 15 – AV + MV 1 – PV Surgery for Infective Endocarditis David et al. JTCVS 2007;133:144-9 Microorganisms: 23% - S. Aureus 10% - S. Epidermidis 18% - S. Viridans 5% - Enterococcus Surgery for Infective Endocarditis David et al. JTCVS 2007;133:144-9 PVE, shock, abscess and S.aureus = independent predictors Surgery for Infective Endocarditis David et al. JTCVS 2007;133:144-9 Patients’ survival Surgery for Infective Endocarditis David et al. JTCVS 2007;133:144-9 Freedom from recurrent infective endocarditis David TE et al. Surgical treatment of paravalvular abscess: Long-term results. Eur J Cardiothorac Surg 2007:31:43-8 135 patients Sex: 68% men Mean age: 51 ± 16 years NYHA functional classes I - III = 13% IV = 87% ECG: Sinus - 72% AF - 21% CHB - 7% Clinical Profile of Patients • • • • • • Native valve endocarditis: 51% Prosthetic valve endocarditis: 49% Cardiogenic/septic shock: 17% Preoperative renal failure: 12% Recent stroke (<30 days): 24% Timing of surgery: Same hospitalization - 37% Urgent/emergent - 65% David et al. EJCTS 2007 Clinical Profile of Patients Microorganisms: • • • • • • • 34% - Staphylococcus aureus 19% - Staphylococcus epidermidis 16% - Streptococcus viridans 4% - Enterococcus faecalis 14% - Streptococci - other 8% - Other bacteria 4% - Culture negative 53% Surgical Pathology • Location of abscess: 54% - limited to aortic annulus 20% - limited to mitral annulus 21% - aortic annulus + mitral annulus 3% - aortic annulus + mitral + tricuspid 2% - aortic annulus + tricuspid +/- pulmonary Operations Performed • • • • • • • Reconstruction of LVOFT Reconstruction of posterior MA Recons. LVOFT and posterior MA Bentall Replacement of the ascending aorta Repair of congenital VSD CABG 75% 16% 5% 21% 4% 4% 17% Operations Performed • • • • • • • AVR AVR + MVR AVR + MVR + TV repair AVR + MV repair MVR AVR + PVR AVR + TVR + PVR 43% 26% 4% 9% 6% 1% 1% Operations Performed • Patches used: Fresh autologous pericardium Bovine pericardium Dacron graft MV leaflet of aortic homograft 40% 53% 3% 4% • Heart valve used for replacement: Mechanical Bioprosthetic Aortic homograft 49% 41% 10% Operative Mortality & Morbidity • 21 deaths (15.5%): Shock Renal failure Prosthetic valve AV + MV annuluses • Cox regression analysis: 30% (p=0.03) 31% (p=0.06) 20% (p=0.19) 30% (p=0.08) Odds ratio Shock 2.5 AV + MV annuluses 2.2 Follow-up • • • • • • • Mean follow-up: 6.2±5.2 years 100% complete 34 late deaths 16 bouts of recurrent endocarditis in 15 patients 15 reoperations in 14 patients 4 primary tissue failure 7 paravalvular leakage Percent living Patients’ Survival 100 90 80 70 60 50 40 30 20 10 0 5 yr = 71 ± 4% 10 yr = 57 ± 5% 15 yr = 43 ± 6% 8 – CHF 8 – Endo 3 – AMI 2 – Stroke 2 – Valve Pts at risk 104 0 1 2 72 3 4 5 31 6 7 8 Years 9 10 10 11 12 13 14 15 Surgery for Active Infective Endocarditis Survival: Valve vs. Abscess abscess valve Percent living 100 80 60 1 year 15 year Valve 87% 50% Abscess 81% 43% 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Years David TE et al. J Thorac Cardiovasc Surg 2007:133:144-9 Percent free Freedom from Recurrent Endocarditis 100 90 80 70 60 50 40 30 20 10 0 1 yr = 96 ± 2% 5 yr = 88 ± 3% 10 yr = 82 ± 4% 15 yr = 82 ± 4% 15 patients had 16 episodes of recurrent endocarditis Pts at risk 104 0 1 2 72 3 4 5 31 6 7 8 Years 9 10 10 11 12 13 14 15 Percent free Freedom from Reoperation 100 90 80 70 60 50 40 30 20 10 0 15 reoperations: 5 – patch/valve dehiscence 3 – primary tissue failure 5 – endocarditis 2 – new mitral regurgitation Pts at risk 104 0 1 2 5 yr = 96 ± 2% 10 yr = 84 ± 5% 15 yr = 72 ± 9% 72 3 4 5 31 6 7 8 Years 9 10 10 11 12 13 14 15 Review of the literature Kang DH et al. Early surgery versus conventional treatment for infective endocarditis N Engl J Med. 2012 Jun 28;366:2466-73 CONCLUSIONS: As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism. Conclusions • Surgery for endocarditis of the aortic valve remains challenging and it is associated with high operative mortality and morbidity • Infection of the cusps can be safely treated with AV replacement and occasionally repair. Infections involving the aortic annulus and surrounding structures require extensive resection and sometimes complex reconstruction of the LVOF Conclusions • The type of valve implanted is probably less important than the surgeon’s ability to extirpate all infected tissues • Patients who had one bout of endocarditis are more likely to have a second bout than patients who never had endocarditis Thank you