Asian Cardiovasc Thorac Ann 2002;10:298-301
© 2002 Asia Publishing EXchange Pte Ltd
Early Surgical Intervention for Infective Endocarditis
Zhu Hong Sheng, MD,
Yao Pei Yan, MD,
Zheng Jia Hao, MD,
A Thomas Pezzella, MD1
Ren Ji Hospital Shanghai Second Medical University Shanghai, People's Republic of China
1 Division of Cardiothoracic Surgery Department of Surgery University of Massachusetts Medical Center Worcester, Massachusetts, USA
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For reprint information contact: A Thomas Pezzella, MD Tel: 1 605 399 4810 Fax: 1 618 241 3831 email: Thomas_Pezzella_MD{at}ssmhc.com Department of Cardiothoracic Surgery, Good Samaritan Hospital, 605 North 12th Street, Mount Vernon, IL 62864, USA.
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ABSTRACT
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Infective endocarditis remains a serious and complex disease with significant morbidity and mortality. Sixty cases of infective endocarditis were retrospectively reviewed, consisting of 41 males and 19 females aged 7 to 50 years (mean, 30 years). Congenital heart disease was diagnosed in 19 of the patients and rheumatic heart disease in 41. Congestive heart failure occurred in 36 and systemic embolism in 8 cases. Blood cultures were positive in only 21.7% of the cases, while vegetations were detected by 2-dimensional echocardiography in 70%. Elective surgery was performed in 57 patients and emergent operation for systemic arterial embolization and/or intractable congestive heart failure in 3 patients. Two patients required reoperation for postoperative bleeding. All but 2 patients had been followed up for 6 to 160 months with no evidence of reinfection. Three patients with mechanical valve implantation later died of intracranial bleeding due to over-anticoagulation. The remaining 55 resumed normal activity. The encouraging outcomes were the result of an aggressive diagnostic approach and early surgical intervention.
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INTRODUCTION
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Infective endocarditis (IE) remains a serious disease with severe morbidity and high mortality, especially in China.1 The prognosis has improved as a result of aggressive antibiotic treatment and earlier surgical intervention. A retrospective review of 60 consecutive patients with IE who underwent surgical treatment during a 16-year period highlights a significant improvement in outcome as a result of an aggressive diagnostic and early surgical approach.
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PATIENTS AND METHODS
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From 1980 through 1996, 60 consecutive patients (41 males and 19 females) treated for IE, aged 7 to 50 years (mean, 30 years), were retrospectively studied. The pathology is summarized in Table 1
. Rheumatic heart disease was diagnosed in 41 patients and congenital heart disease in 19. The clinical features and predisposing conditions are summarized in Table 2. Congestive heart failure (CHF) occurred in 36 patients, systemic embolism in 8, and pulmonary embolism or infarction in 3. Fever lasted from 7 to 260 days. A probable etiology or primary source of infection, including upper respiratory tract infection, pneumonia, periodontitis, and suppurative pericarditis, was noted in 11 patients. A new murmur was found in all patients, in addition to the typical murmur of the underlying cardiac lesion or anomaly. Blood cultures were positive in only 13 cases (21.7%): Streptococcus viridans and Staphylococcus aureus in 4 each, Staphylococcus epidermidis in 1, and Alcaligenes faecalis and Candida albicans in 2 each. Cardiac enlargement was demonstrated on chest radiographs, as well as hypertrophy of the left or right or both ventricles. Complete right bundle branch block was present in 2 patients (3.3%). Vegetations were detected by 2-dimensional echocardiography in 42 patients (70%). Vegetations were found intraoperatively either on the valve or the endocardial surface of the atria or ventricles in 51 patients (85%). Operative specimens were not routinely cultured. Elective operation was performed in 57 patients, usually within 7 days after infection was under control. Emergency valve replacement was necessary for intractable CHF and systemic arterial embolization in 2 cases and severe CHF in 1.
Antimicrobial treatment was administered in cases with a negative blood culture on an empirical basis. Cefazolin, imipenem, or other antibiotics sensitive to gram-positive and negative microorganisms were usually used in combination to broaden the antimicrobial spectrum. When a patient responded well to antibiotic treatment, that is, body temperature returned to normal and the general condition improved, treatment was maintained. If there was a strong indication for early surgical intervention, the patient was advised after 1 week of treatment. If the patient declined operation, antimicrobial treatment was continued for another 3 to 5 weeks.
The operative findings and management are summarized in Table 3. The Medtronic Hall tilting disc valve (Medtronic, Inc., Minneapolis, MN, USA) was used for mitral valve replacement and the St. Jude HP bileaflet valve (St. Jude Medical, St. Paul, MN, USA) for the aortic valve. In a patient with tetralogy of Fallot, primary definitive surgery was performed after electrocautery to eradicate multiple vegetations scattered over the endocardium of the right ventricle and irrigation with an antibiotic solution. In a patient with right ventricular outflow tract obstruction, reconstruction was performed after resection of the stenosis and the localized vegetations. After removal of the infected bovine pericardial valves in 6 patients, the vegetations extensively distributed over almost the entire left atrial endothelial wall were cleared by electrocautery.
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RESULTS
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Two patients underwent successful reoperation for early postoperative bleeding and delayed cardiac tamponade secondary to bleeding, respectively. There was no 30-day or hospital mortality. All patients were discharged with improved cardiac function (Table 4). The New York Heart Association functional status improved by 1 to 2 classes in all patients, except for 1 who remained in class I. Fifty-eight patients were followed for 6 to 160 months. Three patients with mechanical valve implantation died of intracranial hemorrhage secondary to anticoagulation therapy. They were readmitted 3, 4, and 11 months, respectively, after valve replacement. They were comatose, and their computed tomographic scan, prolonged prothrombin time, and raised International Normalized Ratio were consistent with the diagnosis. One of them underwent decompression craniotomy but never became conscious. The other 2 patients died despite optimization of anticoagulation and medical treatment. The remaining 55 patients resumed normal activity without further evidence of recurrent infection.
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DISCUSSION
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In our series, early and accurate diagnosis of IE was made according to the signs and symptoms of generalized infection, positive blood cultures of pathogenic microorganisms, and echocardiographic features. The Von Reyn or Duke criteria2,3 for diagnosis were not utilized in this series. If there was additional evidence of recent valvular dysfunction or a history of valve surgery, IE was highly suspected.
When varying degrees of atrioventricular block develop, the formation of periannular abscess should be suspected. In this series, blood cultures were positive in only 21.7% of the cases, which is much lower than that reported in the Western literature. This is a reflection of poor techniques in our earlier experience. To raise the sensitivity of cultures, it is advisable to increase the amount of blood sample to 30 mL and to repeat the culture 2 to 3 times. It has been reported that intraoperative swabs of heart valves in patients with active IE were associated with low sensitivity and a high rate of sterile cultures, probably due to operative antibiotic treatment, as well as a risk of contamination either during surgery or subsequent handling of the specimen.4 Since we routinely use Betadine solution (povidone-iodine) to prevent the infection from spreading, negative cultures resulted. Tissue cultures of excised valves were all negative. Analyses such as polymerase chain reaction tests may be employed to improve sensitivity.
When vegetations are detected by echocardiography or abnormal displacement of the valve prosthesis is demonstrated, the diagnosis of IE is confirmed. In our series, vegetations were found by echocardiography in 70% of the patients, but this rate is still lower than the 80% reported by Amsterdam5 and O’Brien and Geiser.6 Chambers obtained a positive rate of 95% to 100% with transesophageal echocardiography.7 Our rate of detection gradually improved, which was probably due to increasing experience. It is interesting to note the detection rate of 100% in our patients with an implanted bovine pericardial valve. Extensive deposition of vegetations on the bovine pericardium probably aided detection.
Patients with IE tend to develop valve dysfunction and subsequent heart failure even when infection is controlled temporarily. Once CHF occurs, the mortality rate approaches 70% to 100% if left untreated. Indications for operation include intractable CHF, major systemic arterial embolization, varying degrees of atrioventricular block, and infection refractory to medical treatment.8 Nevertheless, operative mortality remained high. Our operative results improved when surgery was performed after infection was controlled medically. During operation, every effort was made to limit the spilling of infective debris and to eradicate the foci of infection with wide debridement of vegetations, necrotic tissue, and infected, damaged cusps. Perivalvular and/or topical application of antiseptics was employed. It is important to resect all vegetations along with all necrotic tissue. Cauterization of the infected site is a realistic alternative particularly when radical resection is rendered impossible for anatomical or functional reasons. In patients treated with cauterization, no reinfection was noted in follow-up. IE after prosthetic valve replacement carries a high mortality. Kirklin and colleagues9 reported an overall actuarial mortality of 50%. They emphasized that reoperation should be performed in the presence of deterioration of cardiac function or severe aortic regurgitation. The use of homografts may be effective in minimizing the recurrence of infection.10 This modality was not available at the time of this study. Silzone-coated mechanical valves also had been advocated to reduce the recurrence of IE. However, increased risk of paravalvular leak resulting in reoperation led to its recall by the manufacturer.11
In a 10-year review12 of medical and surgical therapy for IE, medical treatment of aortic and prosthetic endocarditis was observed to be associated with a higher mortality (58% and 67%, respectively) when compared with combined medical and surgical treatment (28% and 38%, respectively). Unfortunately, although extensive surgical experience has evolved since 1965,13,14 there have been no randomized studies comparing medical with surgical treatment.15 Strong indications for surgical intervention suggested by evidence-based studies include heart failure unresponsive to medical therapy; valve ring abscess; onset of prosthetic valve infection within 60 days of surgery; prosthetic valve infection by Staphylococcus aureus, gram-negative bacilli not including HACEK organisms, and yeasts; endocarditis caused by filamentous fungi not including yeasts; sinus of Valsalva aneurysm; and valve occlusion by very large vegetations.15
We are encouraged by the results in our series of patients treated surgically without operative mortality. Comparison of the mortality rates of surgical treatment for IE with and without CHF (24% versus 11%)14 indicates the importance of early surgery. A coordinated team including the cardiologist, cardiac surgeon, and infectious disease specialist should outline a management plan with early surgical intervention recommended for intractable IE.
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REFERENCES
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ABSTRACT
INTRODUCTION
