Surgical Techniques and Outcomes in Patients With Intra-Cardiac Abscesses Complicating Infective Endocarditis

Aortic Root Replacement Versus Patch Repair for Aortic Valve Endocarditis With Root Abscesses: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

BACKGROUND & AIMS

Complex aortic valve infective endocarditis (IE) is a serious condition requiring surgical intervention. The optimal surgical approach remains a topic of debate. We sought to evaluate and compare the immediate and long-term results of aortic root replacement (ARR) versus patch repair (PR) in patients with aortic valve IE and root abscess.

METHODS

A comprehensive search of multiple electronic databases was completed to identify relevant studies published from inception to April 2023. We included studies reporting outcomes of ARR and PR in patients with aortic valve IE complicated by root abscess. Primary endpoints were short and long-term mortality and re-operation rates. Secondary endpoints included permanent pacemaker implantation, single-arm pooled incidence of mortality, recurrence, and re-operation.

RESULTS

A total of 32 studies met the inclusion criteria (n=2,554). We found no difference in short-term mortality (odds ratio [OR] 1.12; 95% confidence interval [CI] 0.70-1.80; I2=34%). The PR group had superior long-term survival (hazard ratio [HR] 0.69; 95% CI 0.52-0.90; I2=25%), however, they also had a significantly increased need for re-operation (HR 1.79; 95% CI 1.11-2.88; I2=0%). There were no differences in postoperative permanent pacemaker insertion (OR 0.62; 95% CI 0.34-1.12; I2=0%). Using a meta-analysis of proportions, the pooled rate of documented IE recurrence following was 5% after ARR and 8% after PR.

CONCLUSIONS

Our review shows a long-term survival benefit associated with PR for aortic root abscesses. This benefit is offset by a higher incidence of re-operations and IE recurrence. ARR appears to confer better protection against recurrence. However, based on the available weak evidence, individualised approaches should still be considered until further robust data is available to guide treatment decisions.

Prosthetic Valve Endocarditis and Aortic Root Abscess: A Case of High-Risk Infection

Aortic root abscess is a severe complication of infective endocarditis (IE), particularly in patients with prosthetic valves, nearly doubling mortality risk. Due to the potential for rupture and systemic spread, urgent surgical intervention is recommended. We present the case of a 77-year-old man with a recent aortic valve replacement and a history of discitis who presented with non-specific symptoms, complete heart block, and persistent Staphylococcus epidermidis bacteremia. Multimodal imaging, including positron emission tomography (PET) and CT coronary angiography, confirmed an aortic root abscess. Following the IE multidisciplinary team (MDT) recommendations, the patient underwent successful aortic valve and root repair. Post-operatively, he required a pacemaker and dual antibiotic therapy for eight weeks, with no further infection detected. This case highlights the diagnostic challenges of prosthetic valve endocarditis, the critical role of multimodal imaging in detecting complications, and the necessity of early surgical intervention. The development of a heart block underscores the impact of aortic root abscess on conduction pathways. MDT management was essential in optimising patient outcomes.

Clinical Features and Patient Outcomes in Infective Endocarditis with Surgical Indication: A Single-Centre Experience

BACKGROUND

Infective endocarditis (IE) is marked by a heightened risk of embolic events (EEs), uncontrolled infection, or heart failure (HF).

METHODS

Patients with IE and surgical indication were enrolled from October 2015 to December 2018. The primary endpoint consisted of a composite of major adverse events (MAEs) including all-cause death, hospitalizations, and IE relapses. The secondary endpoint was all-cause death.

RESULTS

A total of 102 patients (66 ± 14 years) were enrolled: 50% with IE on prosthesis, 33% with IE-associated heart failure (IE-aHF), and 38.2% with EEs. IE-aHF and EEs were independently associated with MAEs (HR 1.9, 95% CI 1.1-3.4, p = 0.03 and HR 2.1, 95% CI 1.2-3.6, p = 0.01, respectively) and Kaplan-Meier survival curves confirmed a strong difference in MAE-free survival of patients with EEs and IE-aHF (p < 0.01 for both). IE-aHF (HR 4.3, 95% CI 1.4-13, p < 0.01), CRP at admission (HR 5.6, 95% CI 1.4-22.2, p = 0.01), LVEF (HR 0.9, 95% CI 0.9-1, p < 0.05), abscess (HR 3.5, 95% CI 1.2-10.6, p < 0.05), and prosthetic detachment (HR 4.6, 95% CI 1.5-14.1, p < 0.01) were independently associated with the all-cause death endpoint.

CONCLUSIONS

IE-aHF and EEs were independently associated with MAEs. IE-aHF was also independently associated with the secondary endpoint.

Results of the inoperable and operable with aortic valve endocarditis

Objectives

To evaluate the results of the inoperable and operable with aortic valve endocarditis, focus on risk factors, significance, and management of destruction of the aortic annulus in aortic valve endocarditis.

Methods

The retrospective study was completed to investigate patients with aortic valve endocarditis undergoing cardiac surgery between January 2006 and November 2022 at our hospital.

Results

512 patients were divided into group with destruction of the aortic annulus (n = 80) and without destruction of the aortic annulus (n = 432). There were 32 operative deaths (6.3%, 32/512). By univariate and multivariate analysis, destruction of the aortic annulus is found to be statistically significantly associated with in-hospital mortality (P < 0.001), prolonged mechanical ventilation time (mechanical ventilation time > 96 h, P = 0.018), early aortic paravalvular leak (P < 0.001), and 1-year mortality following cardiac surgery (P < 0.001), respectively.

Conclusions

In our study, destruction of the aortic annulus increases mortality and health care costs. Optimization of pre-, peri-, and postoperative factors can reduce mortality and morbidity in aortic valve endocarditis. Aortic root replacement could be recommended as the best practice choice for aortic valve endocarditis with periannular abscess and destruction of the aortic annulus.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.