Heart transplantation as salvage treatment of intractable infective endocarditis

Heart transplantation as salvage treatment of intractable infective endocarditis

BACKGROUND

For infective endocarditis (IE) with extensive perivalvular lesions or end-stage cardiac failure, heart transplantation (HT) may be the last resort.

METHODS

We retrospectively collected all cases of HT for IE within the International Collaboration on Endocarditis (ICE) network.

RESULTS

Between 1991 and 2021, 20 patients (5 women, 15 men), median age 50 years [interquartile range, 29-61], underwent HT for IE in Spain (n = 9), France (n = 6), Switzerland (n = 2), Colombia, Croatia, and USA (n = 1). IE affected prosthetic (n = 10), and native valves (n = 10), primarily aortic (n = 11) and mitral (n = 6). The main pathogens were oral streptococci (n = 8), Staphylococcus aureus (n = 5), and Enterococcus faecalis (n = 2). The major complications included heart failure (n = 18), peri-annular abscess (n = 10), and prosthetic valve dehiscence (n = 4). Eighteen patients had previous cardiac surgery for this episode of IE, and four were on circulatory support before HT (left ventricular assist-device and extra-corporeal membrane oxygenation, 2 patients each). The median time interval between first symptoms of IE and HT was 44.5 days [22-91.5]. The main post-HT complication was acute rejection (n = 6). Seven patients died (35%), four during the first month post-HT. Thirteen (81%) of the 16 patients discharged from the hospital survived with a median follow-up of 35.5 months [4-96.5] after HT, and no relapse of IE.

CONCLUSIONS

IE is not an absolute contraindication for HT: Our case series and the literature review support that HT may be considered as a salvage treatment in highly-selected patients with intractable IE.

Postcardiotomy extracorporeal membrane oxygenation for infective endocarditis in a patient with intravenous drug use and COVID-19 infection: An ethical dilemma

In this report, we present a case of native valve infective endocarditis due to active intravenous drug use in a 29-yearold female patient that presented during the peak of the coronavirus disease 2019 (COVID-19) pandemic. The patient underwent a complex cardiac surgical intervention with aortic valve replacement and mitral valve repair. Postcardiotomy extracorporeal membrane oxygenation (ECMO) support was required due to severe biventricular dysfunction. In this unprecedented situation, multiple ethical dilemmas arose at different stages in the management of this patient. These dilemmas stemmed from the lack of evidence supporting the use of postcardiotomy ECMO in patients with active intravenous drug use and the scarcity of resources due to the COVID-19 pandemic, resulting in pressure put on our healthcare system. In this case report, we present the decisions made by our team, taking into account both the patient"s best interests and the available resources. We hope this decision-making process will serve as a valuable learning experience for other teams and will act as an antecedent for similar situations in the future.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

Heart transplantation for end-stage heart failure combined with Q fever isolated to the heart: a case report

Background 

Active infection is generally considered a contraindication for heart transplantation. The rare combination of a patient with an active Coxiella burnetii infection and a congenital corrected transposition of the great arteries requiring heart transplantation impose challenging treatment decisions. We would like to demonstrate that if Q fever is restricted to the heart only, heart transplantation is also beneficial from an infectious point of view, therefore treating two severe conditions simultaneously.

Case summary 

A patient with end-stage heart failure due to congenital corrected transposition of the great arteries and requiring heart transplantation developed chronic Q fever and endocarditis. Different antibiotic regimes were tried due to severe adverse reactions. Antibiotic treatment was precisely monitored by measuring Q fever polymerase chain reaction (PCRs) and phase I IgG antibody titres. A positron emission tomography scan revealed that Q fever was confined to the heart only after which it was decided to perform heart transplantation. Based on the results of PCR and antibody testing, antibiotic treatment was stopped after 1 year. After 5 years of follow-up, patient is still in an optimal condition.

Discussion 

In case of a patient with end-stage heart failure and chronic Q fever, a combined treatment with PCR-/antibody monitored antibiotics and heart transplantation can cure both conditions.

Salvage heart transplantation for Mycoplasma hominis prosthetic valve endocarditis: A case report and review of the literature

Heart transplantation (HT) has been rarely performed in patients with infective endocarditis (IE) and is considered a "last resort" procedure. Orthotropic HT with bicaval technique was performed in a man with culture-negative endocarditis. Mycoplasma hominis was later detected using 16S ribosomal DNA PCR from surgically removed valve tissue. Literature review and previous results are summarized. HT may be considered as salvage treatment in selected patients with intractable IE. In cases when there is no growth in culture, 16S ribosomal DNA PCR sequencing can be used to identify the pathogen in excised valvular tissue. Mycoplasma spp. is extremely uncommon and difficult to diagnose cause of infective endocarditis (IE). There are no proposed or defined criteria for heart transplantation (HT) in patients with refractory IE, and HT has been rarely performed in this setting. We report a case of M hominis prosthetic valve endocarditis diagnosed by 16S ribosomal DNA PCR in a patient who underwent a salvage HT. We reviewed in the literature other cases of IE caused by Mycoplasma spp.

Heart transplantation for infective endocarditis: Viable option for a limited few?

Active infection in the recipient is considered a relative contraindication for solid organ transplantation. However, heart transplantation (HT) can be curative in patients with ventricular assist device infections. For patients with infective endocarditis (IE), valve replacement is part of the management strategy based on emergent, acute, or elective indications. HT has been utilized as an uncommon and sporadic treatment option for carefully selected patients with refractory or recurrent IE after all other surgical treatment options have been exhausted or are not feasible. Herein, we review 19 published cases of IE in whom HT was undertaken in the setting of ongoing active infection with reported good outcomes. We attempt to propose general criteria for HT in the setting of IE and discuss challenges and hurdles that clinicians might encounter when considering HT for active IE in the absence of robust data or clearly defined criteria.

Heart transplantation as salvage therapy for progressive prosthetic valve endocarditis due to methicillin-resistant Staphylococcus epidermidis (MRSE)

BACKGROUND

Prosthetic valve endocarditis (PVE) has the highest in-hospital mortality among all cases of infective endocarditis (IE), it is estimated at about 40 %. Orthotopic heart transplantation (OHT) as a measure of last resort, may be considered in selected cases where repeated surgical procedures and conservative efforts have failed to eradicate persistent or recurrent IE. Only few clinical data are available regarding this rare indication for OHT, since active IE has traditionally been considered as a contraindication for OHT.

CASE PRESENTATION

We report on a 55 year old male patient who underwent prosthetic valve replacement with a mechanical valved conduit ten years ago and developed now persistent PVE with severe complications due to methicillin-resistant Staphylococcus epidermidis (MRSE). Repeated surgical procedures and conservative efforts have failed to eradicate the pathogen. Regarding the lack of curative options, salvage OHT was discussed as a measure of last resort. 28 months after the first diagnosis of PVE, the patient was successfully transplanted and is now doing well under close follow-up (6 months post-OHT).

CONCLUSIONS

PVE remains a challenging condition regarding diagnosis and treatment. The presented case underscores the urgent need for an integrated and multidisciplinary approach to patients with suspected and definitive IE - especially in PVE. OHT might be a feasible measure of last resort in selected patients with IE. Our case report adds published clinical experience to this rarely performed procedure and consolidates previous findings.

Infective Endocarditis With Paravalvular Extension: 35-Year Experience

BACKGROUND

We investigated our surgical strategy and clinical results in patients from active infective endocarditis (AIE) complicated by paravalvular involvement to determine the risk factors of early and late death and reoperation.

METHODS

From October 1979 to December 2014, 955 patients underwent operations for AIE; among them 207 had AIE with paravalvular extension. The patients were a mean age of 59.9 ± 15.4 years, and 162 (78%) were male. Of these patients, 137 (66%) had isolated aortic valve endocarditis, and 138 (67%) had native valve endocarditis. Follow-up was 99% complete.

RESULTS

The operative mortality of the cohort was 16% (n = 34). Abnormal communication, mechanical valve implantation, and renal failure were independent predictors of 30-day death. Survival at 1, 5, 10, and 15 years was 90.3% ± 2.3%, 62.4% ± 3.7%, 49.3% ± 4.1%, and 37.9% ± 4.4%, respectively. Streptococcus endocarditis (all species), complex annular repair, and preoperative heart failure were independent predictors of long-term death. A reoperation was required in 29 patients (14%). Streptococcus pneumoniae endocarditis was the only independent predictor of early reoperation (within 30 days after the operation or during the same hospitalization). Freedom from reoperation at 1, 5, 10, and 15 years was 91.9% ± 2.2%, 89.6% ± 2.6%, 89.6% ± 2.6%, and 87.0% ± 3.5%, respectively. Independent predictors of late reoperation were urgent/emergency operation, prosthetic valve endocarditis, and complex annular repair.

CONCLUSIONS

AIE complicated by paravalvular involvement remains a surgical challenge. Valve replacement (particularly using bioprosthesis) associated with ad hoc reconstruction seems to be a reliable option and showed very encouraging results in this context.