Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features

Surgical outcomes and optimal approach to treatment of aortic valve endocarditis with aortic root abscess - systematic review and meta-analysis

BACKGROUND

Data on the postoperative outcomes for patients with infective endocarditis complicated by an aortic root abscess is sparse due to the condition's low incidence and high mortality rates. This systematic review and meta-analysis aims to evaluate existing data on the impact of aortic root abscesses on the postoperative outcomes and to inform optimal surgical approach.

METHODS

The online databases MEDLINE, EMBASE and Cochrane library were searched from 1990 to 2022 for studies comparing cohorts of surgically managed infective endocarditis patients with and without an aortic root abscess. Data was extracted by two independent investigators and aggregated in a random-effects model. Risk of bias was assessed using an adapted version of the Newcastle-Ottawa scale.

RESULTS

Six clinical studies were included in the meta-analysis (n 1982). The abscess group was associated with increased in-hospital mortality (OR 1.74 95%: CI 1.18-2.56) and late mortality (HR 1.27 95% CI:1.03-1.58). The reoperation meta-analysis was complicated by high rates of heterogeneity (I2 = 59%) and found no significant differences in reoperation between abscess and no abscess groups (HR=1.48: 95% CI:0.92-2.40). Post-hoc scatter graph showed a strong linear relationship (r 0.998), suggesting hospitals with higher rates of aortic root replacement achieve lower rates of reoperation for aortic root abscess patients compared with patch reconstruction.

CONCLUSIONS

The presence of an aortic root abscess in aortic valve endocarditis is associated with elevated early and late mortality despite modern standards of care. Additionally, aortic root replacement should be considered to have a favourable postoperative profile for use in this context.

Occult deterioration of an aortic annular abscess: how do we diagnose a pseudoaneurysm periaortic valve? A case report

BACKGROUND

Infectious endocarditis (IE) is a disease caused by the colonization of toxic microorganisms on the endocardium of heart valves [1]. Although much progress has been made in the diagnosis and treatment of IE, its complications, such as annular abscesses [2], still have a high mortality rate. In this case, we describe a patient with infective endocarditis complicated by occult deteriorated aortic annular abscess.

CASE PRESENTATION

A 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h. He had recurrent fevers for 1 month before admission. Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve, moderate aortic regurgitation and a possible aortic annular abscess. Blood cultures were negative and empiric antibiotic therapy was begun. The patient did not have fever again and seem to be clinically improved. However, follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm. The patient underwent mechanical prosthetic valve replacement and annulus reconstruction successfully. Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved, which requires us to pay more attention.

DISCUSSION

Occult deterioration of an aortic annular abscess is rare and more attention should be paid. Re-evaluation of echocardiography is required even if the patient's symptoms improve.

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.

Expanding utility of cardiac computed tomography in infective endocarditis: A contemporary review

There is increasing evidence on the utility of cardiac computed tomography (CCT) in infective endocarditis (IE) to investigate the valvular pathology, the extra-cardiac manifestations of IE and pre-operative planning. CCT can assist in the diagnosis of perivalvular complications, such as pseudoaneurysms and abscesses, and can help identify embolic events to the lungs or systemic vasculature. CCT has also been shown to be beneficial in the pre-operative planning of patients by delineating the coronary artery anatomy and the major cardiovascular structures in relation to the sternum. Finally, hybrid nuclear/computed tomography techniques have been shown to increase the diagnostic accuracy in prosthetic valve endocarditis. This manuscript aims to provide a contemporary update of the existing evidence base for the use of CCT in IE.

Surgical outcomes and optimal approach to treatment of aortic valve endocarditis with aortic root abscess

OBJECTIVES

To evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach.

METHODS

Between 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic-valve IE were included in a retrospective cohort study. Multivariable and propensity-weighted analyses were used to adjust for demographic imbalances between those without (n = 93; NARA) and with an ARA (n = 50). Additionally, empirical subgroup analysis appraised the two most used surgical techniques; patch reconstruction (PR) and aortic root replacement (ARR).

RESULTS

Demographic characteristics were similar between ARA and NARA except for logistic EuroSCORE, previous valve surgery, and multivalvular infection. In-hospital mortality was 8% and 12% in NARA and ARA, respectively (p = .38), with mortality rates consistently nonsignificantly higher in ARA across all time periods. The overall reoperation rate was also higher in ARA (27% vs. 14%; p = .09) and ARA was shown to be associated with late reoperation (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.18-6.36). Patients treated with an ARR showed a 16% increase in late mortality when compared with PR (40% vs. 24%; p = .27) and a 17% lower reoperation rate (14% vs. 31%; p = .24). Propensity-weighted analysis identified ARR as a significant protective factor for reoperation (hazard ratio = 0.05; 95% CI = 0.01-0.34).

CONCLUSIONS

The presence of an ARA in aortic valve endocarditis was not associated with significantly higher early and late mortality but is linked with a higher reoperation rate at our institution. ARR in ARA is protective from reoperation so should be considered best practice in this setting.

Application of the Konno procedure for infective endocarditis in native bicuspid aortic valve with annular abscess extending into the interventricular septum

Annular abscess is a serious complication of infective endocarditis, which often requires complex surgery and has a very high post-operative mortality rate. The Konno procedure involves valve annuloplasty for a narrow aortic annulus or left ventricular outflow tract stenosis in children; it is also performed for various cardiac conditions in adults. Here, we report a case of the Konno procedure performed in a patient with aortic valve infective endocarditis, with an annular abscess extending into the interventricular septum (IVS). A 58-year-old man who presented to our hospital with fever was diagnosed with aortic valve infective endocarditis caused by Streptococcus saccharolyticus. On echocardiography, an annular abscess in the direction of the IVS was detected, and surgery was planned. The Konno procedure was performed to secure an adequate surgical field and to debride and reconstruct the cavity created by the interventricular septal abscess. The patient was discharged uneventfully 29 days after surgery.

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.

Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis

The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).

Infective endocarditis and neurologic events: indications and timing for surgical interventions

A therapeutic dilemma arises when infective endocarditis (IE) is complicated by a neurologic event. Postponement of surgery up to 4 weeks is recommended by the guidelines, however, this negatively impacts outcomes in many patients with an urgent indication for surgery due to uncontrolled infection, disease progression, or haemodynamic deterioration. The current literature is ambiguous regarding the safety of cardiopulmonary bypass in patients with recent neurologic injury. Nevertheless, most publications demonstrate a lower risk for secondary haemorrhagic conversion of uncomplicated ischaemic lesions than the risk for recurrent embolism under antibiotic treatment. Here, we discuss the current literature regarding neurologic stroke complicating IE with an indication for surgery.

More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess

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MV abscesses and aneurysms are uncommon complications of IE.

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Serial echocardiography is important to identify perivalvular complications.

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Three-dimensional transesophageal echocardiography has incremental value in diagnosis.

Outcomes of patients with acute prosthetic aortic valve endocarditis

BACKGROUND

Prosthetic valve endocarditis is burdened by high mortality and morbidity. We reviewed our experience in the management of patients with acute prosthetic aortic valve infection and studied the implications and outcomes associated with surgical treatment and medical therapy.

METHODS

Data of 118 consecutive patients admitted during the period 2008-2018 with definite acute prosthetic aortic valve endocarditis, and presenting a surgical indication, were retrieved from the hospital database. Univariate and multivariate analysis were undertaken to study the association of preoperative characteristics with hospital mortality and the probability of undergoing a reoperation. Survival was assessed with Kaplan-Meier analysis.

RESULTS

In the overall population, prosthesis dehiscence was independently associated with the possibility of undergoing surgical reoperation, while presentation with embolic stroke was associated with medical treatment. Hospital mortality was 24%, medical treatment was found to be independently associated with early death. One hundred (85%) patients underwent redo procedures; aortic valve replacement was performed in 53 and full root replacement in 47. Postoperative hospital mortality was 17%. Survival at 1-, 5-, and 8-years was 78%, 74%, and 66%, respectively. Freedom from reoperation and recurrent endocarditis was 95% at 8-year follow-up.Hospital mortality in patients who did not receive a redo operation was 61% with a survival rate of 17% at 1-year follow-up.

CONCLUSIONS

Surgical mortality after reoperation for prosthetic aortic valve endocarditis is still high but mid-term outcomes are satisfactory. Failure to undertake surgery when indicated is an independent risk factor for early death.

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.

Infective endocarditis: innovations in the management of an old disease

The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.

Aortic valve endocarditis complicated by proximal false aneurysm

Background

Aortic valve endocarditis remains a life-threatening condition, especially in cases of periannular complications. Aorto-ventricular discontinuity associated with proximal false aneurysm represents a severe picture caused by extensive tissue disruption and is usually associated with prosthetic valve infection. Complex surgical repair is required in these cases and continues to be associated with high mortality and morbidity rates.

Methods

We retrieved information for 32 patients undergoing operation for infective aortic valve/prosthetic valve endocarditis complicated by pseudoaneurysm arising from aorto-ventricular discontinuity. Patients were relatively young, mostly male and most of them had a prior cardiac operation. Aortic root replacement with valve graft conduit was performed in all cases; it was associated with other procedures in seven patients: CABG (n=2), MV surgery (n=3), MV surgery + CABG (n=1) and pulmonary valve replacement (n=1). We reported and analysed patient outcomes at early and mid-term follow-up.

Results

Pre-discharge mortality was 22% (n=7). The postoperative course was complicated in 24 (75%) cases. Eighteen patients (56%) sustained low cardiac output resulting in multiple organ failure syndrome and death in five cases. One patient (3%) experienced a major neurologic deficit with a permanent cerebral stroke. Acute kidney injury complicated the course in 12 cases (37%), continuous renal replacement therapy was necessary in four patients (12%). Overall survival and freedom from endocarditis and reoperation at 5-year was 59% and 89%, respectively.

Conclusions

Patients with complicated aortic valve endocarditis presented generally in a poor preoperative state. Surgical treatment poses a non-negligible risk of postoperative mortality and morbidity but provides an acceptable survival rate and a satisfactory recovery at mid-term.

Role of Echocardiography in the Diagnosis of Aorto-Right Ventricular Fistula: A Rare Complication of Surgical Aortic Valve Replacement Successfully Closed by Bovine Pericardial Patch

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AoRV fistula is a rare complication of prosthetic aortic valve replacement.

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A high index of suspicion is required for detection.

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Postprocedural follow-up with echocardiography is key to early diagnosis.

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Repair is eventually required if cardiac decompensation ensues.

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.

Left ventricular pseudoaneurysm as a complication of prosthetic mitral valve infective endocarditis

We report a case of infective endocarditis complicated with left ventricular pseudoaneurysm originating from the posterior annulus of the prosthetic mitral valve in a 56-year-old woman. Despite prolonged antibiotic treatment, transesophageal echocardiography (TEE) showed partial detachment of the prosthesis from the posterior mitral annulus. Three-dimensional rotational computed tomography clearly demonstrated a pseudoaneurysm toward the posterolateral portion of the mitral prosthetic valve, which was not evident by TEE. Valve replacement and repair of the pseudoaneurysm were performed 83 days after initiation of antibiotic therapy. Left ventricular pseudoaneurysm is a rare but serious complication of mitral prosthetic valve endocarditis. It requires prompt diagnosis and early surgical intervention. <Learning objective: We present a case of infective endocarditis (IE) complicated with left ventricular pseudoaneurysm originating from the prosthetic mitral valve. Repeated transesophageal echocardiography is recommended for all IE patients when perivalvular extension is suspected. Electrocardiography-gated three-dimensional-computed tomography is useful for detection and evaluation of pseudoaneurysm, especially in planning surgical procedures.>.

Surgical treatment in active infective endocarditis: results of a four-year experience

Background. Aim of present investigation was to analyze survival and recurrence rate in patients with active endocarditis referred to our centre for surgical treatment. Methods. 80 consecutive patients with active infective endocarditis (52 males, 28 females, mean age 59.2 years) were referred to our institution for surgical treatment. 78 patients underwent surgery, and 2 patients died before intervention. Results. Fifty patients had native valve endocarditis, 30 prosthetic valve involvement. Hospital mortality has been 10.2%. Three discharged patients (4.9%) died at an average 18-month followup. Endocarditis recurred in 4 (2 being S. aureus prosthetic tricuspid endocarditis in drug addicts). All patients who underwent valve repair or homograft implant were alive and free of recurrence. Conclusions. Our results suggest that with proper surgical treatment patients with active endocarditis discharged alive from hospital have a survival >90% at 18 months with a low recurrence rate.

Intracardiac Fistulae: A Rare Complication of Infective Endocarditis

We present the case of a diabetic gentleman who was admitted to the hospital with an infected right foot. Swabs were positive for <i>Staphylococcus aureus</i> and <i>Pseudomonas aeruginosa.</i> His right big toe was amputated. Postoperatively, the patient experienced recurrent episodes of chest pain. He was therefore transferred to the coronary care unit, where he deteriorated rapidly. The patient was subsequently transferred to intensive care. Transthoracic and transesophageal echocardiograms revealed evidence of aortic dissection, but this finding was not confirmed in a computed tomography scan. The patient subsequently experienced cardiac arrest and died. The postmortem examination revealed no aortic dissection but did show a vegetation on the mitral valve with a fistula that tracked into a ruptured epicardium.

Treatment of prosthetic valve endocarditis complicated by destruction of the aortic annulus

PURPOSE

It has been reported that surgical treatment for prosthetic valve endocarditis complicated by destruction of the aortic annulus is associated with high mortality and morbidity. The aim of this study was to evaluate the efficacy of our surgical strategy for this situation.

METHODS

Between October 2003 and April 2009, eight patients (mean age 68.6 years) with prosthetic valve endocarditis complicated by destruction of the aortic annulus were surgically treated at our hospital. We use a relatively simple procedure consisting of a patch plasty of the abscess cavity in addition to complete removal of the infected tissue of the abscess cavity followed by standard aortic valve replacement. All patients had active endocarditis and were in New York Heart Association functional class III or IV. Preoperative echocardiography revealed that four patients had moderate or severe aortic regurgitation, and two had mitral valve endocarditis as well.

RESULTS

There were no operative deaths (≤30 days). Cardiac complications included paroxysmal atrial fibrillation in three patients and transient atrioventricular block in one. One patient died of multiple organ failure 66 days after the surgery. The overall in-hospital mortality was 12.5%. Patients were followed-up for 6-49 months (mean 31 months). There was no recurrent prosthetic valve endocarditis. One patient required reoperation (mitral annuloplasty and redo aortic valve replacement). There were two late deaths: lung cancer in one and multiple organ failure related to pneumonia after the aforementioned redo operation in the other.

CONCLUSION

Our simple procedure for complicated prosthetic valve endocarditis yielded excellent early and midterm outcomes.

Three-dimensional transthoracic echocardiography in identification of aorto-right atrial fistula and aorto-right ventricular fistulas

We report the case of a 72-year-old woman who developed new onset right ventricular failure after redo aortic valve replacement. The diagnosis of left to right shunt was initially made using two-dimensional transthoracic echocardiography (2DTTE) and 2D transesophageal echo with color Doppler (TEE). Definite diagnosis of aorto-right atrial and aorto-right ventricular fistula was made using three-dimensional transthoracic echocardiography (3DTTE) with color flow Doppler imaging. Early recognition and diagnosis of this rare surgical complication is imperative for prompt surgical repair of this lethal defect. 3DTTE should be utilized in cases of new onset heart failure with unclear etiology to diagnose unusual causes of this potentially fatal condition.

Aortocavitary fistula without aneurysm and transient incomplete atrioventricular block due to infective endocarditis

A 67-year-old man with persistent fever and moderate aortic valve regurgitation was transferred. He suffered from incomplete atrioventricular block (AVB), and temporary pacing was needed. Left-to-right shunt flow from the aorta to the right atrium was found without an aneurysm. Operative findings indicated that the aortic valve was highly calcified. The orifice of an aortocavitary fistula (ACF) was detected in the sinus of Valsalva and the right atrium. Patch repair of the aortic annulus with complete débridement of the abscess cavity was performed, a procedure that consisted of aortic valve replacement directly to the Gore-Tex patch and aortic root replacement. His postoperative course was uneventful, but a pacemaker was implanted owing to complete AVB. To our knowledge, this is a rare case in which infective endocarditis was complicated by ACF without an aneurysm of the sinus of valsalva (SV) on the noncoronary cusp to the right atrium and transient incomplete AVB (Mobitz type II) occurring simultaneously.

Swedish guidelines for diagnosis and treatment of infective endocarditis

Swedish guidelines for diagnosis and treatment of infective endocarditis (IE) by consensus of experts are based on clinical experience and reports from the literature. Recommendations are evidence based. For diagnosis 3 blood cultures should be drawn; chest X-ray, electrocardiogram, and echocardiography preferably transoesophageal should be carried out. Blood cultures should be kept for 5 d and precede intravenous antibiotic therapy. In patients with native valves and suspicion of staphylococcal aetiology, cloxacillin and gentamicin should be given as empirical treatment. If non-staphylococcal etiology is most probable, penicillin G and gentamicin treatment should be started. In patients with prosthetic valves treatment with vancomycin, gentamicin and rifampicin is recommended. Patients with blood culture negative IE are recommended penicillin G (changed to cefuroxime in treatment failure) and gentamicin for native valve IE and vancomycin, gentamicin and rifampicin for prosthetic valve IE, respectively. Isolates of viridans group streptococci and enterococci should be subtyped and MIC should be determined for penicillin G and aminoglycosides. Antibiotic treatment should be chosen according to sensitivity pattern given 2-6 weeks intravenously. Cardiac valve surgery should be considered early, especially in patients with left-sided IE and/or prosthetic heart valves. Absolute indications for surgery are severe heart failure, paravalvular abscess, lack of response to antibiotic therapy, unstable prosthesis and multiple embolies. Follow-up echocardiography should be performed on clinical indications.

Interrogation of the aortic valve

OBJECTIVE

To review the essential elements of the transesophageal echocardiographic examination of the aortic valve, with emphasis on the technique for performing a two-dimensional examination, the quantification of aortic stenosis and regurgitation, and the effect of this modality on cardiac surgical decision making.

DESIGN

Literature review.

DISCUSSION

Transesophageal echocardiographic examination of the aortic valve can provide detailed information on aortic valve structure and function, provided proper technique is utilized. This review presents the current recommendations from the American Society of Echocardiography for the performance of a two-dimensional examination of the aortic valve and for the quantification of aortic stenosis or aortic regurgitation by application of Doppler techniques. To demonstrate the applicability of transesophageal echocardiography in clinical practice, the effect of transesophageal echocardiography on the cardiac surgical management of patients with aortic valvular disease is described.

Clinical Patterns of Surgical Endocarditis

BACKGROUND

This study was aimed at defining clinical and anatomic patterns in cases of surgical endocarditis (SE).

METHODS

SE cases done between 1981 and 1997 at our metropolitan county hospital were retrospectively analyzed.

RESULTS

A total of 106 consecutive episodes of SE involving 125 valves in 100 patients were studied. SE included 71 aortic, 42 mitral, and 12 tricuspid valves. The etiologies included intravenous drug abuse (IVDA) in 48 (45%) and dental source in 30 (28%). A congenitally deformed valve was present in 19 (18%). Compared to non-IVDA, IVDA episodes of SE were more often superimposed on previously normal valves (38/48 [79%] vs. 30/58 [52%])**, S. aureus infections (17/43 [40%] vs. 9/54 [17%])*, active endocarditis (38/48 [79%] vs. 32/58 [55%])*, and surgically treated on an urgent basis (10/48 [21%] vs. 4/58 [7%])*. Overall, macroemboli occurred in 53 (50%) of SE and was associated with pseudoaneurysm*, preoperative neurologic dysfunction,** and operative death.** The operative mortality (defined by Society of Thoracic Surgeons) for SE was 5/106 (4.7%). Macroembolism,** aortoventricular discontinuity,** abscesses,* pseudoaneurysm,** and preoperative renal failure* were associated with mortality. Prosthetic valve endocarditis was present in 10 of 106 episodes of SE (9.4%). *p < or = 0.05; **p < or = 0.01.

CONCLUSION

(1) The aortic valve is most commonly associated with SE, (2) SE of a previously normal valve is more likely to occur with IVDA than other etiologies, (3) macroemboli occur in half of SE and is associated with an increased operative mortality.

Surgical Treatment of Paraannular Aortic Abscess

BACKGROUND

Aortic valve endocarditis with paraannular abscess remains a challenging problem in the surgical treatment of native and prosthetic valve endocarditis. The purpose of this study is to evaluate the long-term outcome of surgical intervention for aortic paraannular abscess.

METHODS

From January 1989 to November 2004, 32 consecutive patients (24 men, 8 women) were studied. Mean age was 50.6 +/- 16.2 (range, 17-80) years. Twenty-four had native valve endocarditis and 8 had prosthetic valve endocarditis. Eight of 24 patients who suffered from native valve endocarditis had bicuspid valve endocarditis. The predominant microorganism was Streptococcus viridans. No microorganisms were identified in 11 patients. Most patients were desperately ill at the time of surgery. Repair was performed by aggressive eradication of infected tissue and reconstruction of the defect with autologous pericardium (n = 24), bovine pericardium (n = 3), Dacron patch (n = 4), and primary closure (n = 1).

RESULTS

Although postoperative complications were common, early mortality occurred in only 4 patients (12.5%). Operative survivors have been followed for 5 months to 16 years (mean, 92.7 months). There were 2 late deaths but all were noncardiac deaths. Five patients (15.6%) underwent reoperation at a mean of 55.4 months after the initial surgery. The actuarial survival at 1, 5, and 10 years was 87.4% +/- 5.9%, 83.2% +/- 6.9%, and 79.1% +/- 7.7%, respectively. The freedom from reoperation at 1, 5, and 10 years was 88.7% +/- 6.2%, 79.8% +/- 8.1% and 75.4% +/- 8.8%, respectively.

CONCLUSION

These data suggest that aggressive surgical intervention and meticulous antibiotic therapy for aortic valve endocarditis with paraannular abscess yields a high success rate with relatively low mortality and good long-term results.

Prosthetic Valve Endocarditis Caused by Acinetobacter lwoffi

We are reporting a case of recurrent prosthetic-valve endocarditis (PVE) caused by an unusual pathogen. The patient suffered 2 consecutive relapses of Acinetobacter lwoffi bacteremia, although he had completed a full course of treatment with antibiotics to which the microorganism was susceptible. He was finally successfully operated with replacement of the infected aortic valve. Acinetobacter spp are relatively low-grade but potentially virulent pathogens, and endocarditis caused by these species can be fulminant, accompanied by septic complications, and fatal. Although some patients with relapsed PVE may respond to a second course of antibiotics and medical treatment rather than early valve replacement is suggested in A lwoffi PVE, combined antibiotic treatment and early surgical intervention may be considered as the first option in these patients. There are only a few cases of Acinetobacter endocarditis in the literature, and it is the first case reported in Greece to our knowledge.

Risk factor analysis of hospital mortality in patients with endocarditis with ring abscess

BACKGROUND

Endocarditis associated with ring abscess is a pathology with high morbidity and mortality.

AIM OF THE STUDY

The purpose of this study was to analyze hospital mortality risk factors in patients with ring abscess due to endocarditis.

METHODS

From January 1982 to December 2000, 104 patients underwent surgical intervention at the Heart Institute of the University of São Paulo Medical School for valve endocarditis with ring abscess. The age ranged from 6 years to 73 years, with an average of 40.3 years and 72.1% were male. According to NYHA functional class (FC), 12 (11.5%) were in FC II, 62 (59.6%) in FC III, and 30 (28.9%) in FC IV. Seventy-seven (74.0%) patients had endocarditis on a bioprosthesis, 58 (55.8%) in the aortic position and 19 (18.3%) in the mitral position. Twenty-nine (26.9%) patients had atrioventricular blockage prior to the operation. Univariate analysis was performed comparing variables and hospital mortality with a level of significance of 5%. Multivariate analysis was performed by logistic regression.

RESULTS

The hospital mortality was 19.2% (20 patients). Univariate analysis showed that atrioventricular blockage, age, and prosthetic valve endocarditis significantly influenced hospital mortality. Multivariate analysis identified atrioventricular blockage as an independent predictor of hospital mortality.

CONCLUSIONS

Preoperative atrioventricular blockage is an independent risk factor for hospital mortality in the surgical treatment of endocarditis with ring abscess.

Predictors of Mortality in Paravalvular Abscess

BACKGROUND

Paravalvular abscess formation is an ominous complication of infective endocarditis; however, prognostic variables in paravalvular abscess are poorly defined.

METHODS

We examined our experience in patients with paravalvular abscess between 1987 and 2004. Clinical, echocardiographic, microbiologic, and surgical data were examined.

RESULTS

There were 45 patients (17 females), age 57 +/- 17 years. Twenty-four patients had prosthetic valve endocarditis. Methicillin-sensitive Staphylococcus aureus and coagulase-negative S. aureus were the most common organisms accounting for 25 (56%) cases. Thirty-eight patients (84%) underwent surgery during initial admission. Surgical mortality was 7%, in-hospital mortality was 31%, and 1-year mortality was 38%. Between patients who died and patients who survived, there were no differences in age (61 +/- 20 years vs 55 +/- 15 years, P = .3), type of microorganism, presence of prosthetic heart valves (47% vs 57%), presence of moderate to severe or severe regurgitation of involved valve (47% vs 57%, P = .37), presence of associated valvular vegetation (93% vs 93%), area of abscess (5.6 +/- 2.9 cm2 vs 4.4 +/- 3.2 cm2, P = .39), left ventricular systolic function (56% +/- 13% vs 56% +/- 10%, P = .9), white cell count (13 +/- 4 vs 13 +/- 7, P = .9), or polymorphonuclear leukocytosis (86% +/- 6% vs 81% +/- 9%, P = .1). Patients who died were sicker on admission compared with those who survived (33% had stroke or altered mental status vs 7%, P = .03) and had worse renal function compared with those who survived (creatinine 4 +/- 4 mg/dL vs 1.6 +/- 1.9 mg/dL, P = .009).

CONCLUSION

Neurologic impairment and renal impairment are significant determinants of 1-year survival in patients who present with paravalvular abscess.

Emergent mitral valvuloplasty with an autologous pericardial patch in an octogenarian with active infective endocarditis

An 83-year-old woman with suppurative spondylitis was referred to our hospital due to active infective endocarditis with an expanding mobile vegetation and a high echoic mass on the posterior mitral leaflet. During the operation, the high echoic mass was found to be a chronically organized abscess, which was located at the base of the vegetation on the posterior leaflet and extended toward the annulus. The patient underwent a successfully emergent resection of the vegetation and mass, and valvuloplasty using an autologous pericardial patch with an excellent outcome.

Prosthetic valve endocarditis presenting as loss of the metallic click sound

Prosthetic valve endocarditis is a significant infection. It is often serious, and may result in a complicated course leading to valvular malfunction. We present the case of a 50-year-old male with an aortic Medtronic Hall valve, who presented with loss of his normal metallic click. A transthoracic echocardiogram confirmed the diagnosis of endocarditis and of an aortic-root abscess. Blood cultures were positive for nutritionally deficient Streptococcus. He underwent successful surgery and later was discharged. Patients with mechanical heart valves are often bothered by the metallic sound. It can interfere with their daily life. However, the loss of the click may indicate valvular dysfunction, dehiscence of the prosthesis, and/or tissue infection with abscess formation.

Mortality in patients with paravalvular abscess diagnosed by transesophageal echocardiography

BACKGROUND

Paravalvular abscess is a complication of endocarditis that may lead to persistent infection, conduction abnormalities, fistula formation, worsening congestive heart failure, and death.

METHODS

Between 1991 and 2001, paravalvular abscess was identified on transesophageal echocardiography in 24 patients who subsequently underwent surgical treatment. Echocardiographic findings were reviewed for location of abscess, presence of a valvular prosthesis, valvular function, and presence of vegetations. Information gathered included the time interval between transesophageal echocardiography diagnosis and operation, inhospital mortality, and microbiologic data.

RESULTS

Of 24 patients, 9 died, for a mortality of 38%. Of the patients who died, the average survival after operation was 43 days, with a range of 1 to 238 days. Of the 14 patients with significant valvular or paravalvular regurgitation, 8 died (57%). However, of the 10 patients with mild or no regurgitation, only 1 died (10%). This difference was statistically significant (P =.02).

CONCLUSION

Patients without preserved valve function (those with moderate or severe regurgitation) have a significantly worse outcome (57% mortality) than do those with normal valvular function (10% mortality).

Factors Influencing the Results of Double-Valve Surgery in Patients with Fulminant Endocarditis: The Importance of Valve Selection

BACKGROUND

Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome.

PATIENTS

Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age (+/-SD) was 53 +/- 14.2 years; there were 37 men and 16 women.

METHODS

The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion.

RESULTS

All patients with destructive endocarditic doublevalve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis. Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 +/- 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 +/- 10.4 mm Hg and 12 +/- 5.7 mm Hg, respectively, for the homografts and 24 +/- 8.4 mm Hg and 15 +/- 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular out- flow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation.

CONCLUSIONS

The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.