Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis

Atrioventricular conduction disorders in aortic valve infective endocarditis

BACKGROUND

Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases.

AIM

To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis.

METHODS

Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year.

RESULTS

High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up.

CONCLUSIONS

High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

Impact of Aortic Root Abscess on Surgical Outcomes of Infective Endocarditis

Locally destructive infective endocarditis (IE) of the aortic valve complicated by abscess formation in the aortic root may seriously affect patients' outcomes. Surgical repair of such conditions is often challenging. This is a single-center observational analysis of consecutive patients treated surgically for IE between 2009 and 2019. We divided the cohort into two groups considering the presence of an aortic root abscess and compared the characteristics and postoperative outcomes of patients accordingly. Moreover, we examined three different procedures performed in abscess patients regarding operative data and postoperative results: an isolated surgical aortic valve replacement (AVR), AVR with patch reconstruction of the aortic root (AVR + RR) or the Bentall procedure. The whole cohort comprised 665 patients, including 140 (21.0%) patients with an aortic root abscess and 525 (78.9%) as the control group. The abscess group of patients received either AVR (66.4%), AVR + RR (17.8%), or the Bentall procedure (15.7%). The mean age in the whole cohort was 62.1 ± 14.8. The mean EuroSCORE II was 8.0 ± 3.5 in the abscess group and 8.4 ± 3.7 in the control group (p = 0.259). The 30-day and 1-year mortality rates were 19.6% vs. 11.3% (p = 0.009) and 40.1% vs. 29.6% (p = 0.016) in the abscess compared to the control group. The multivariable regression analysis did not reveal aortic root abscess as an independent predictor of mortality. Rather, age > 60 correlated with 30-day mortality and infection with Streptococcus spp. correlated with 1-year mortality. In the analysis according to the performed procedures, KM estimates exhibited comparable long-term survival (log-rank p = 0.325). IE recurrence was noticed in 12.3% of patients after AVR, 26.7% after AVR + RR and none after Bentall (p = 0.069). We concluded that patients with an aortic root abscess suffer worse short and long-term outcomes compared to other IE patients. The post-procedural survival among ARA patients did not significantly vary based on the procedures performed.

Surgery for Infective Endocarditis after Primary Transcatheter Aortic-Valve Replacement-A Retrospective Single-Center Analysis

Transcatheter aortic-valve replacement (TAVR) is increasingly being used for the treatment of aortic-valve stenosis. Therefore, the total number of patients with an aortic-valve prosthesis is increasing, causing the incidence of prosthetic-valve endocarditis to increase.

METHODS

Between March 2016 and July 2019, ten patients underwent surgery due to prosthetic-valve endocarditis after TAVR. They were identified in our institutional database and analyzed.

RESULTS

Infective endocarditis was diagnosed 17 ± 16 month after TAVR. Mean age was 79 ± 4.4 years. Microbiological detection showed 6/10 positive blood cultures for enterococcus faecalis. Median EuroScore II was 24.64%. The mean size of the surgically replaced aortic prosthesis was 23.6 ± 1.3 and that of the TAVR was 28.4 ± 2.3 mm. The surgically implanted aortic valves had a mean gradient of 8.5 ± 2.2 mmHg. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 9 ± 8 month.

CONCLUSIONS

With a rising number of patients after TAVR, prosthetic-valve endocarditis will increasingly occur in patients who were previously considered high or intermediate risk. Our results show that patients with TAVR infective endocarditis can be operated on with good results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis.

Transcatheter aortic valve implantation in patients with unruptured aortic root pseudoaneurysm: an observational study

AIMS

Unruptured aortic root pseudoaneurysm (UARP) is a rare complication of aortic valve endocarditis. Infectious spread to the valvular annulus or myocardium can cause septic complications that manifest as wall thickening, and spontaneous abscess drainage leads to pseudoaneurysm formation. We report the first patient series in which transcatheter aortic valve implantation (TAVI) using a single valve-resolved aortic valvulopathy associated with UARP was performed.

METHODS

At our center, from December 2017 to October 2019, 138 patients underwent TAVI for aortic valve stenosis and/or regurgitation, 20 of whom (12 female patients, 8 male patients) had associated incidental UARP and were considered as our study population. The average age of these patients was 76.9 ± 5.2 years. All patients were assessed using preprocedural and postprocedural multimodality imaging, including transthoracic echocardiography, transesophageal echocardiography, and cardiac computed tomography angiography (CCTA).

RESULTS

In all cases, the final angiographic examination showed correct valve positioning with complete coverage of the false aneurysm. Post-TAVI CCTA showed presence of total or subtotal UARP thrombosis. The mean follow-up period was 17.5 months (12-23 months). During follow-up, imaging showed normal prosthetic valve function, no significant leakage (trace or mild), and complete UARP exclusion in all patients, without any complications.

CONCLUSION

In conclusion, percutaneous valve positioning can simultaneously solve pseudoaneurysm complications by excluding the sac and promoting thrombosis.

Impact of aortic root repair or replacement in severe destructive aortic valve endocarditis with paravalvular abscesses on long-term survival

OBJECTIVES

Surgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis.

METHODS

A total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63).

RESULTS

Patients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39-0.95; P = 0.031).

CONCLUSIONS

Aortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis.

CLINICAL TRIAL REGISTRATION

UN4232 382/3.1 (retrospective study).

Pseudoaneurysm of the aortic root following aortic valve endocarditis - a case with 2 rare life - threatening complications

Infective endocarditis can have peri-annular spread and involve the valvular annulus and adjacent cardiac structures, leading to tissue necrosis and peri-annular abscess. This process may cause pseudoaneurysm formation and other rare and potentially life-threatening complications, so their identification and correct diagnosis are crucial.

We describe a case of an 81-year-old woman, with a history of aortic valve replacement and worsening of symptoms, that presents at the imaging a pseudoaneurysm of the aortic root complicated at the same time by 2 life-threatening conditions: fistulization in the Right Ventricular Outflow Tract (RVOT) and the compression of Right Coronary Artery (RCA).

This case underlines the importance of imaging, especially Coronary Computed Tomography Angiography (CCTA), in the diagnosis and follow-up of infective endocarditis and its complications, especially in a patient not eligible for surgery.

Mechanical Prosthetic Valve Sparing for Aortic Root Abscess Complicated by Infective Endocarditis

Aortic root abscess complicated by infective endocarditis of a mechanical prosthetic valve is associated with morbidity and death. We retrospectively report our experience with a valve-sparing technique for managing this condition. From October 2014 through November 2017, 41 patients at our center underwent surgery for aortic root abscess complicated by infective endocarditis of a mechanical prosthetic valve. Twenty (48.7%) met prespecified criteria for use of our valve-sparing technique after careful assessment of the mechanical valve and surrounding tissues. Our technique involved draining the abscess, aggressively débriding all infected and necrotic tissues, and then repairing the resulting defect by suturing a Gelweave patch to the healthy aortic wall and to the cuff of the valve. We successfully preserved the mechanical aortic valve in all 20 patients. Two (10%) died early (≤30 d postoperatively) of low cardiac output syndrome with progressive heart failure, superadded septicemia, and multisystem organ failure. At 1-year follow-up, the 18 surviving patients (90%) were symptom free and had a well-functioning mechanical aortic valve with no paravalvular leak. We conclude that, in certain patients, our technique for managing aortic root abscess and sparing the mechanical aortic valve is a safe and less time-consuming approach with relatively low mortality and encouraging midterm follow-up outcomes.

Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes

OBJECTIVES

To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically.

METHODS

From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data.

RESULTS

Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%).

CONCLUSIONS

Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.

Imaging of the aortic root on high-pitch non-gated and ECG-gated CT: awareness is the key!

The aortic pathologies are well recognized on imaging. However, conventionally cardiac and proximal aortic abnormalities were only seen on dedicated cardiac or aortic studies due to need for ECG gating. Advances in CT technology have allowed motionless imaging of the chest and abdomen, leading to an increased visualization of cardiac and aortic root diseases on non-ECG-gated imaging. The advances are mostly driven by high pitch due to faster gantry rotation and table speed. The high-pitch scans are being increasingly used for variety of clinical indications because the images are free of motion artifact (both breathing and pulsation) as well as decreased radiation dose. Recognition of aortic root pathologies may be challenging due to lack of familiarity of radiologists with disease spectrum and their imaging appearance. It is important to recognize some of these conditions as early diagnosis and intervention is key to improving prognosis. We present a comprehensive review of proximal aortic anatomy, pathologies commonly seen at the aortic root, and their imaging appearances to familiarize radiologists with the diseases of this location.

Surgical treatment and long-term outcome of aortic valve endocarditis with periannular abscess

Objectives

Aortic valve endocarditis is occasionally complicated by periannular spreading of the infection and abscess formation, leading to a more aggressive course of the disease and life-threatening complications. This retrospective observational study investigated the long-term outcomes of patients with this complication, which was surgically managed with annular reconstruction and aortic valve replacement.

Methods

Between 1998 and 2018, 69 patients were identified with aortic valve endocarditis complicated by periannular abscess formation. All patients were treated with debridement of the infected tissue, gentamicin filling of abscess cavities, annulus reconstruction with bovine pericardium, and valve replacement. Long-term follow-up was performed to detect the rate of recurrence of endocarditis, aortic valve reoperation and survival.

Results

Mean age was 58 ± 15 years, 81% of patients were male, and the infected valve was native in 51% of all patients. The overall mortality was 36%, with a 30-day mortality of 13% and 120–day mortality of 16%. Five- and 10-year survival was 69.4 ± 12.0% and 55.7 ± 14.3%, respectively. Ten-year freedom from recurrent endocarditis was 83.5 ± 13.3%.

Conclusion

Endocarditis with annular abscess remains associated with high morbidity and mortality and aggressive treatment of the infected tissue and abscess cavities is crucial. Compared with earlier literature, long-term outcome of annular reconstruction in this series is comparable to that of aortic root replacement.

Solo Smart Stentless Bioprosthesis for Infective Valve Endocarditis with Aortic Annular Abscess

So far, there is still controversy regarding the optimal prosthetic valve for patients with active infective valve endocarditis with annular abscess. Here, we report the case of a 65-year-old woman who was diagnosed with infective endocarditis associated with extensive annular abscess. The patient underwent debridement of the abscess cavity followed by aortic valve replacement using a Solo Smart (SS) stentless bioprosthesis. Postoperative recovery was uneventful, with no signs of recurrent infection. Since the SS valve is designed for supra-annular and subcoronary implantation, it is considered to be an alternative to conventional prosthetic valves in patients with infective endocarditis with aortic annular abscess.

Outcome for surgical treatment of infective endocarditis with periannular abscess

BACKGROUND

Surgical treatment of infective endocarditis (IE) with aortic periannular abscess (PA) is a challenging issue with high mortality and morbidity rate in the current era. The present study is to review the results of surgical treatment for IE-PA based on an anatomy-guided surgical procedure selection for either aortic valve replacement (AVR) or aortic root reconstruction (ARR).

METHODS

Patients with IE-PA received surgical treatment in National Taiwan University Hospital during the years 2001-2017 were retrospectively reviewed. The selection of surgical procedure was based on the intraoperative anatomical finding. The AVR group consisted of isolated AVR or AVR with patch repair if PA involved less than one cusp of the annulus. The ARR group included aortic root replacement if PA involved more than one cusp, causing commissural/sub-commissural destruction. In-hospital mortality and mid-term outcome and the risk factors were examined.

RESULTS

In-hospital mortality was 13% in the AVR group (24 patients) and 25% in the ARR group (8 patients) (p = 0.578). The composite adverse events (cardiac death, valve reoperation, or paravalvular leak) rate was 31% in the AVR group and 40% in the ARR group at one year; 48% in the AVR group and 40% in the ARR group at five years; 55% in the AVR group and 40% in the ARR group at ten years.

CONCLUSION

Anatomy-guided surgical procedure selection for IE-PA is feasible. With the appropriate selection, ARR may be associated with fewer adverse events in mid-term follow-up. Careful intraoperative judgment and management and long-term follow-up are warranted for these patients.

Cardiothoracic surgical emergencies in the intensive care unit

Patients with cardiothoracic surgical emergencies are frequently admitted to the ICU, either prior to operative intervention or after surgery. Recognition and appropriate timing of operative intervention are key factors in improving outcomes. A collaborative team approach with the cardiothoracic service is imperative in managing this patient population.

Life Saver: Aortic Wrapping

Reoperative aortic root reconstruction remains a formidable surgical challenge. Thereof, the wrapping of Dacron graft using remnants of native aorta may be reasonable to avoid complications such as bleeding and infection. Our case that had a modified Bentall procedure at our institute was reoperated because of discontinuity between left ventricular outflow and valved aortic conduit. During reoperation, proximal portion of the valved conduit was partially separated from its attachment in the left ventricular outflow tract. The residual native aorta that was wrapped around the Dacron graft was like in a shape of sac. This technique may play a major role in preventing rupture of the ascending aorta in case of separation of valved conduit from left ventricular outflow.

Aortico-Left Atrial Fistula: A Rare Complication of Bioprosthetic Aortic Valve Endocarditis Secondary to Enterococcus faecalis

Paravalvular aortic root abscess with intracardiac fistula formation is an exceedingly rare complication of infective endocarditis. This condition is even more rarely encountered in patients with bioprosthetic valve endocarditis. We report an unusual case of a 68-year-old Bosnian female with a bioprosthetic aortic valve, who developed an extensive aortic root abscess, complicated by an aortico-left atrial intracardiac fistula. This case illustrates that a high index of suspicion, prompt diagnosis by echocardiography, proper antibiotic therapy, and early surgical intervention are crucial to improving treatment outcomes for this rare condition.

Recalcitrant prosthetic valve endocarditis requiring repeated reconstruction: running out of options

In this report we describe a previously healthy 36-year-old man who presented with septic shock secondary to bacterial endocarditis with multiple cerebral, mesenteric, and peripheral embolic phenomena. He underwent emergent porcine prosthetic valve replacement with aortic annular reconstruction. Subsequently, he developed recalcitrant Candida parapsilosis endocarditis requiring treatment with multiple antifungal agents and 4 repeated complex reconstructions of the aortic root and fibrous trigones over 3 years, before the infection was successfully controlled. This case underscores the significant morbidity associated with fungal endocarditis and importance of an early combined medical and surgical approach.

Paravalvular abscess of the mitral valve with fistula to the left ventricle and detachment of the coronary sinus in a young woman

Infective endocarditis (IE) of the mitral valve (MV) manifesting paravalvular abscess (PA) is challenging. A 30-year-old woman presented with PA fistulating to the left ventricle, detachment of the coronary sinus and systemic embolization. During a course of fever of unknown origin, the patient received laparoscopic surgery under the diagnosis of strangulating intestinal obstruction due to colitis. Following abdominal surgery, abscess having blood flow within it from the left ventricle was pointed out at the left ventriculo-atrial junction by transthoracic echocardiography. Emergency surgery was performed under the diagnosis of PA of MV. Abscess debridement followed by reconstruction of the mitral annulus and coronary sinus with fresh autologous pericardium and mitral valve replacement (MVR) using a mechanical prosthetic valve were successfully performed. Timely and accurate diagnosis followed by the early surgical intervention with aggressive debridement of abscess and reconstruction with autologous pericardium should improve the outcome of this high-risk disease.