Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Carlos-A. Mestres, MD, PhD, FETCS
ConsultantCardiovascular Surgery
Hospital Clínico. University of BarcelonaBarcelona. Spain
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis is an uncommon diseaseassociated to significant morbidity and mortality.
As in any infection within the cardiovascular surgery,early diagnosis and aggresive management are
indicated
Infective endocarditis is a medical & surgical diseasewhich must be managed by a multidisciplinary
team with shared interests
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The Team
The Hospital Clinico of Barcelona Endocarditis Study Group is a multidisciplinary group specifically
dedicated to the study and treatment of infective endocarditis and cardiovascular infections operational
for 25 years
Infectious Diseases (6), Cardiovascular Surgery (3), Microbiology (3),Surgical Pathology (1), Echocardiography (2)
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The Team
* Infectious Diseases J.M.Miró, A.Moreno, A. Del Río, N. De Benito, X.Claramonte, J.P.Horcajada
* Cardiovascular Surgery C.A.Mestres, R.Cartañá, S.Ninot, J.L.Pomar
* Microbiology M.Almela, F.Marco, C.García
* Surgical Pathology J.Ramírez, N.Pérez
* Echocardiography J.C.Paré, M.Azqueta, M.Sitges
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective Endocarditis
What have we learned?What have we changed?What are we doing?Where are we going?
An overview
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
A - Short Courses of Therapy for Infective Endocarditis
B - Infective Endocarditis in Drug Abusers (IVDAs)
C – Surgical experience
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Potential number of candidates for short-courses of therapy for right-sided MSSA endocarditis in IVDAs at the
Hospital Clínic of Barcelona, Spain (1979-98)
Types of endocarditisin IVDAs
- Right-sided IE- Left-sided IE- Mixed IE Total
MSSAN (%)N
1424616
204
104 (73%)16 (35%)10 (64%)
130 (64%)
2 wk Tx*40%
* According to methicillin-susceptibility, HIV status and CD4 cell counts (>200/µL)
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
6. In our 25-year experience, one of every five episodes of native valve IE (general population + IVDAs) and almost one of every two episodes of IE in IVDAs were considered potential candidates for these short courses (2 wks) of therapy
Short Courses of Therapy for Infective EndocarditisCONCLUSIONS
5. Patients allergic to penicillin who must receive vancomycin with or without an aminoglycoside must be treated during 4 wks
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective Endocarditis in IVDAs & HIV infectionSUMMARY
2. HIV-infected IVDA have a higher ratio of right-sided IE and S. aureus endocarditis than HIV-negative IVDA with IE
1. The incidence of IE in IVDA in the AIDS era is decreasing probably due to the change of the drug administration habits in order to avoid HIV-infection
3. Mortality between HIV-infected or non-HIV-infected IVDA with IE is similar. However, mortality among HIV-infected IVDA is higher in IVDA with less than 200 CD4+ cells/µL or with AIDS criteria
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
4. IVDA with non-complicated MSSA right-sided IE can be succesfully treated with an IV short-course regimen of nafcillin or cloxacillin plus an aminoglycoside during 2 weeks, although the addition of an aminoglycoside may be avoided or reduced to the first 3-7 days
5. Tricuspid valve replacement using mitral homografts can be a safely alternative to tricuspid valvulectomy for those IVDA with endocarditis who need right heart surgery
Infective Endocarditis in IVDAs & HIV InfectionSUMMARY
“Long-term results after cardiac surgery in patients infected with the human immunodeficiency virus type-1 (HIV-1)”Mestres CA et al. Eur J Cardio-thorac Surg 2003; 23:1007-1016
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Epidemiology 1990 - 2000
Diagnosis of IE 421IV (IVDA) drug abuse 104General population 317Native IE 213PVE 75Pacemaker/AICD 29Admissions/yr >50
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
“Surgical treatment of pacemaker and defibrillator lead endocarditis. The impact of electrode lead extraction on outcome”A.del Río, I.Anguera, J.M.Miró, L.Mont, Fowler VG Jr, M.Azqueta, C.A.Mestres and the Hospital Clinic Endocarditis Study GroupChest 2003; 124:1451-1459
“Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature”J.E.Losa, J.M.Miró, A. Del Río, A.Moreno-Camacho, F.Gracia, X.Claramonte, F.Marco, C.A.Mestres, M.Azqueta, J.M.Gatell and the Hospital Clinic Endocarditis Study GroupClin Microbiol Infect 2003; 9:45-54
“Infective endocarditis in intravenous drug abusers and HIV-1 infected patients”J.M.Miró, A. del Río, C.A.MestresInfect Dis Clin North Am 2002; 16:273-295
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
NVE 387 - ADVP 237 - PVE 130 - PM 49 - All 803
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
PVE 132
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
S.aureus 274
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
0
20
40
60
80
100
North America South America Australia/New Zealand Europe/Middle East
Peripheral/other IV; P =0.13 between regions
Central catheter; P = 0.017 between regions
Tunnelled catheter; P < 0.0001 between regions
Any catheter source; P = NS between regions
0
20
40
60
80
100
North America South America Australia/New Zealand Europe/Middle East
Peripheral/other IV; P =0.13 between regions
Central catheter; P = 0.017 between regions
Tunnelled catheter; P < 0.0001 between regions
Any catheter source; P = NS between regions
Presumed intravascular
catheter source by region
ICEICE
International Collaboration on Endocarditis
International Collaboration on Endocarditis
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Specific indications
Mechanical valveYoung, “good” ring, cured IE
BioprosthesisElderly (?), “good” ring, cured IE
HomograftComplicated IE, abscess, annular destruction
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The complicated root
1. Root abscess2. Aorto-cavitary fistula
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Aorto-cavitary fistulae
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
L770 - AORTO-CAVITARY FISTULIZATION IN COMPLICATED ENDOCARDITIS. CLINICAL AND
ECHOCARDIOGRAPHIC FEATURES OF 76 CASES (1992-2001) AND PROGNOSTIC FACTORS OF MORTALITY
The Spanish Aorto-cavitary Fistula Endocarditis Working Group
42nd ICAAC. San Diego, CA. September 27-30, 2002
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
No clinical infective endocarditis (IE) series have been performed studying the development of aorto-cavitary fistulas (ACF) as a result of spread of infection from valvular tissue towards perivalvular structures. Our aims were to investigate the clinical, echocardiographic and microbiologic features and prognostic factors of in-hospital mortality in patients with IE and ACF.
Retrospective and multicentre study at 11 Spanish and 1 North-american Hospitals in patients with IE and ACF.
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Spread of infection in infective endocarditis (IE) from valvular structures to the surrounding perivalvular tissue results in periannular complications.
Rupture of abscesses and pseudoaneurysms in the sinuses of Valsalva result in the development of aorto-cavitary fistulas and intracardiac shunts.
Aorto-cavitary fistula formation is an unusual complication of IE. An incidence of 1% of all cases of IE has been estimated. Fistulization of perivalvular abscesses occurs in 6-9% of cases.
Basic considerations
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
* Multicenter, international, retrospective, descriptive study performed between 1992 and 2001* Infective endocarditis diagnosed according to Duke criteria* Aorto-cavitary fistulization documented by TTE/TEE* Univariate analysis of prognostic factors of mortality
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
General populationNative valve
AorticMitralOther
PVEAorticMitralOther
PacemakerIV Drug abusers
OVERALL
693838----3131------7
76
314721051056 930 119 872 536 326 10 1701534
4681
2.21.83.6------3.55.8---------0.4
1.6
ACF n Cases IE n Incidence %
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Mean age (y)Male genderPrevious valve diseaseComorbidityMechanical ventilationIV drug abuseDuration of symptoms (d)Duration to Dx of ACF (d)CHFNeuro eventsRenal failurePeripheral emboliComplete AV block
50.9±18.7*36 (80%)13 (28%)18 (40%) 6 (13%) 7 (16%)24.5±18.736.2±31.631 (69%) 8 (18%)20 (44%) 8 (18%) 5 (11%)
60.2±13.4*20 (65%)31 (100%) 9 (29%) 1 (3%) 029.8±37.744.1±55.516 (52%) 4 (13%) 8 (26%) 7 (23%) 6 (19%)
54.7±17.256 (74%)44 (59%)27 (36%) 7 (9%) 7 (9%)26.7±27.939.4±42.847 (62%)12 (16%)28 (37%)15 (20%)11 (14%)
NVE=45 PVE=31 All=76Clinical characteristics
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Staphylococcus sppS.aureusCNS
Streptococcus sppVGSS.bovisOther streptococci
Enterococcus sppCulture negativeOther (HACEK)
17 (38%)*13 (29%)* 4 (9%)*16 (35%)10 (22%) 2 (4%) 4 (9%) 2 (4%) 5 (11%) 7 (15%)
18 (58%)* 3 (10%)*15 (48%)* 9 (29%) 5 (16%) -- 4 (13%) 2 (6%) -- 2 (6%)
35 (46%)16 (21%)19 (25%)25 (33%)15 (20%) 2 (3%) 8 (10%) 4 (5%) 5 (6%) 9 (12%)
NVE=45 PVE=31 All=76
Pathogens
NVE vs PVE groups (p<0.05)
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Echocardiography
Diagnostic yield of TTE and TEE
TTE n (%) TEE n (%)
Native valve 26/44 (59%) 31/33 (94%)
PVE 15/31 (48%) 28/28 (100%)
Overall 40/75 (53%) 59/61 (97%)
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Patients with vegetations Mean maximal veg. size (mm)Vegetations > 10 mmPatients with abscess Mean maximal abscess
diameterAbscess > 10 mmVentricular septal defect Mean EF (%)
Mean LVEDD (mm) Multivalvular infection
83 %11.7
56 %78 %
12 mm
54 %20 %61.754.9
30 %
96 %*11.5
49 %71 %
10 mm
44 %21 %62.555.2
33 %
65 %*12.170 %87 %
15 mm
67 %19 %60.554.426%
TotalN=76
NativeN=45
ProstheticN=31
*Native vs prosthetic, p < 0.05
Echo findings
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Fistulized sinus of Valsalva (SV)
Right SV
Left SV
Non coronary SV
Fistulized cardiac chamber (%)
Right atrium
Right ventricle
Left atrium
Left ventricle
Multiple
Moderate/severe regurgitation
37%38%25%
17%25%26%16%12%49%
44% 35%20%
18%31%22%13%11%
64%*
26%42%32%
16%16%32%19%
13%*26%*
TotalN=76
NativeN=45
ProstheticN=31
* Native vs prosthetic, p < 0.05
Echo findings
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Surgical treatmentTime to surgery
< 24 hours2 - 7 days> 7 days
Closure of fistula (%)SimplePericardial patchGore-tex patch
Valve replacementBioprosthesisMechanicalHomograft
87%
24%42%34%
41%48%11%92%24%50%18%
87%
33%36%31%
41%46% 13%95%28%49% 18%
87%
11%52% 37%
41%52% 7%89% 19%52%19%
TotalN=76
NativeN=45
ProstheticN=31
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
In-hospital mortality- Surgical group (N=66)- Medical group (N=10)
31 (41%)28 (42%)3 (30%)
16 (36%)13/39 (33%)
3/6 (50%)
15 (48%)15/27 (55%)
0/4 (-)
TotalN=76
NativeN=45
ProstheticN=31
Cause of death- Multiorgan failure- Sudden death- Septic shock- Cardiogenic shock- Hemorrhage
MedicalN=3
SurgicalN=28
23%10%26%19%23%
33%33%
-33%
-
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Lost for follow-up
Follow-up (mo., mean, range)
Residual fistula
Late CHF
Late valvular replacement
Late death
2 4
Medical *N=7
SurgicalN=38
36 (1-96)*
-
3
0
1
29 (1-144)*
5 (11%)
7 (16%)
5 (11%)
3 ( 7%)
* The 3 patients who died w/o surgery had fatal co-morbid conditions. The remaining 7 patients did not undergo surgery because they did not have cardiac failure,
severe valvular regurgitation and echocardiographical abscess.
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Age > 65yearsMale genderProsthetic endocarditisSymtoms duration >30 d.Moderate or severe CHFRenal failureNeurologic symptomsS.aureus infectionVegetation >10 mmPatients with periannular abscessPeriannular abscess > 10 mmModerate or severe ARFistulized sinus of ValsalvaFistulized cardiac chamberEF <65%Urgent or emergency surgery
2.8 (1.0-7.9)0.8 (0.2-2.4)2.5 (0.9-6.8)0.8 (0.2-2.6)2.2 (0.7-5.1)1.8 (0.7-5.1)0.6 (0.1-2.8)1.2 (0.4-3.6)1.2 (0.4-3.6)1.6 (0.5-5.5)2.3 (0.7-7.3)0.8 (0.3-2.1)
--
1.1 (0.4-3.1)2.7 (0.9-7.8)
0.050.6
0.070.7
0.150.20.50.80.70.4
0.140.70.90.20.8
0.06
OR – 95%CI p
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Limitations
* Ascertainment bias – multicenter nature* Severity of CHF higher – low-grade shunts underdiagnosed* High-risk profles of surgical candidate* Not comparable to medically treated* Not comparing medical and surgical patients
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Abscesses vs fistulae
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Kaplan-Meier estimation of survival from time of diagnosis of periannular complication.
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Actuarial freedom from death, heart failure requiring hospital admission and repeat surgery in patients with periannular complications surviving the index hospitalization. A. patients referred to surgical therapy
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
B. patients medically-managed
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
* Aorto-cavitary fistulization in IE is an unfrequent event and occurs in patients with aortic endocarditis with high grade of local tissue destruction.
* It was associated with staphylococci and streptococci native-valve IE and with coagulase-negative staphylococci prosthetic valve IE.
* In-hospital mortality was high even when most patients were referred to surgical treatment.
* Congestive heart failure identified the subgroup of patients with the worst prognosis.
Conclusions
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Prosthetic valve endocarditis
- What?- When?- Who?- Why?
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Methods
* International Collaboration on Endocarditis Merged Database* Large, multicenter, international registry of patients with definiteendocarditis by Duke criteria* Clinical, microbiological, echocardiographic variables to determine* Those factors associated with the use of surgery in PVIE* Logistic regression analysis* Propensity score to match surgery vs medical therapy
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
PVIE – Patient characteristics
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Complications and outcomes of patients with PVIE
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Propensity analysis of surgical treatment of PVIE
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Logistic regression analysis of variables independentlyassociated with in-hospital mortality in patients with PVIE
and matched propensity for surgical treatment
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Conclusions
* Despite the frequent use of surgery for the treatment of PVIEthis condition continues to be associated with high in-hospitalmortality* After adjustment for factors related to surgical intervention,brain embolism and S. aureus infection were independentlyassociated with in-hospital mortality and a trend toward asurvival benefit of surgery was evident
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Echocardiographic (TTE) Follow-up
Year Patient TTE TTE FU Last TTE NYHABefore After (Yrs)
1991 AMG Veg 28 mm Mild TR 13 Severe TR IILarge RV
1991 RPO Veg 22 mm Severe TR 13 Severe TR IISevere TR Large RV Large RVLarge RV
1992 PER Veg 30 mm Severe TR 5 Severe TR ISevere TR Ruptured Large RV
chordae1994 JLF Veg 22 mm Mild TR 1 Mild TR I
1996 JFG Veg 28 mm Mild TR 1 Severe TR ISevere TR
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Echocardiographic (TTE) Follow-up
Year Patient TTE TTE FU Last TTE NYHABefore After (Yrs)
2001 ERA Severe TR Trivial TR pod Po Death
2002 LML Veg 20 mm Trivial TR pod Po DeathSevere TR Large RVLarge RV
2002 JGR Veg 30 mm Mild TR 2.5 Mild TR ISevere TR
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Year Patient FU Drug addiction Recurrent HIV Outcome(Yrs) relapse endocarditis stage
1991 AMG 6 Yes 14 mos B3 Alive(Corynebacterium spp) Late Reop
1991 RPO 6 Yes 48, 58, 63 mos B2 Alive(MSSA all cases) No Reop
1992 PER 5 No No A2 AliveLate Reop
1994 JLF 2.5 Yes No A3 DeathOverdose
1996 JFG 8.5 Yes 7, 12 mos A2 Alive(MSSA) No reop
Outcomes
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Year Patient FU Drug addiction Recurrent HIV Outcome(Yrs) relapse endocarditis stage
2001 ERA PO N N C3 Death
2002 LML PO N N B2 Death
2002 JGR 2.5 N No A1 Alive
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The most complex situation
Fibrous Skeletal destruction
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Acute pectoralis major myositis in an otherwise healthy young male
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
• 25-year-old male
• Smoker ½ pack/day
Occasional recreational drugs. NO iv abuse
• Job: Waiter. Physically fit. Contact sports (judo, full-contact…)
• In the past 2 years 4 episodes of abscess requiring surgical drainage (hand, foot, knee, axilla)
• No other personal nor familiar medical history of interest
• 5-day left upper limb and upper left chest pain accompanied by high-degree fever (39°C), chills and malaise
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
• Aortic root replacement with a 20-22 mm cryopreserved aortic homograft
• Intraoperative findings: Massive AR due to perforation of the right coronary cusp on a morphologically normal aortic valve. Full root subaortic abscess extending towards the left atrial roof
• Aortic cross-clamp 73 min – CPB 189 min• Left ventricular failure and myocardial edema
after CPB. Sternum open. Intraaortic ballon pump support
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Outcome - I
• Postop unstable hemodynamics. Urgent TTE showed anterior-septoapical hypokinesia
• Urgent coronary angiogram showed 70% LMCA stenosis with remaining normal coronaries
• August 12, 2004: Off-pump LIMA-LAD bypass graft and delayed sternal closure
• August 12, 2004 2/2 + blood cultures (ORSA)
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Outcome - II
• Early favourable postop. Improved condition, no congestive heart failure
• August 14, 2004, 2/2 negative blood cultures. Trasnsferred to ward August 22, 2004. Good condition with low-degree fever (37°C)
• August 24, 2004 new control TTE
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Surgery - II
• September 1, 2004 – Homograft replacement with a 21 mm SJM Toronto-Root porcine heterograft
• Surgical findings: Subaortic circumferential detachment of the normal functioning homograft. Extensive lesions of the entire fibrous body. Left atrial fistula
• Post-repair severe mitral regurgitation• Profound left ventricular failure. LVAD Abiomed BVS-
5000 implanted• All samples to Microbiology
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Outcome - IV
• September 2, 2004 – Unstable under maximal intropic support and LVAD. No further conventional surgery indicated. Decision to include in emergency WL for heart transplantation
• September 3, 2004 – Orthotopic heart transplantation
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Final diagnosis
1. Community-acquired ORSA myositis
2. Acute aortic root ORSA infective endocarditis
3. Heart transplantation
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Endocarditis and Heart Transplantation• 1: Galbraith AJ et al. Cardiac transplantation for
prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999; 18:805-806
• 2: Blanche C et al. Heart transplantation for Q fever endocarditis. Ann Thorac Surg. 1994; 58:1768-1769
• 3: Pulpon LA et al. Recalcitrant endocarditis successfully treated by heart transplantation. Am Heart J 1994; 127:958-960
• 4: Park SJ et al. Heart transplantation for complicated and recurrent early prosthetic valve endocarditis. J Heart Lung Transplant. 1993; 12:802-803.
• 5: DiSesa VJ et al. Heart transplantation for intractable prosthetic valve endocarditis. J Heart Transplant. 1990; 9:142-143
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Endocarditis and Heart Transplantation
• “Heart transplantation could be an alternative, not a contraindication, when in Infective Endocarditis all other measures have failed” (1)
Galbraith AJ Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart. J Heart Lung Transplant. 1999 Aug;18(8):805-6
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Case Age Pathogen Valve Position Timing for HTx Conditions
1 25 M. hominis Tissue Aortic 2 months SLE
2 30 S viridans Mechanical Aortic 1 month PreTX + cultures
3 58 S viridans Native Mitral 2 years 3 VR’s
4 32 C burnetti Native Mi + Ao 14 months Persistent fever
5 54 MRSA Mechanical Mitral 17 days Previous HTx
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Conclusions
* IE is a very serious pathology* It is not popular* Highly demanding* Suboptimal results* Team approach* Risk takers
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Parsonnet score
Single centre – Subjective factors – Overestimates risk
Cleveland score
Single centre – Excludes non CABG – Leads to gaming
EuroScore
Large multicentre database – Fit for all adult cardiacsurgical patients – Even correlates with STS
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
EuroSCORE
0 – 23 – 56 – 89 – 1112>
0.88 – 1.512.62 – 3.516.51 – 8.3714.02 – 19.1231.00 – 42.32
Additive
Score % mortality
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
EuroSCORE
Its predictive accuracy has been establishedOnly the additive model has been validated
Inconsistencies among the additive and logisticmodels when applied to the high-risk patients
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Cross-over point
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Reasons to predict mortality in Cardiac Surgery
1. Helping to determine indications for surgery2. Quality monitoring
Additive EuroScore works well for most purposes
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Considerations
The relationship between risk factors is not additive
Combined impact of two or more factors on operativerisk may be more than simple sum
Logistic score more realistic
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The reality
* Infective endocarditis is a high-risk situation
* There is lack of data regarding risk assessment before valve surgery
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Aim of the study
To validate the EuroSCORE preoperative stratification risk model in infective endocarditis
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Population
Period Jan 95 – Jan 04Patients 147Mean age 56.33 ± 15.95Male gender 69.4%
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Native valve IE
N %
Aortic 64 43.5
Mitral 25 17
Tricuspid 2 1.4
Pulmonary 1 0.7
A + M 12 8.2
M + T 1 0.7
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Prosthetic valve IE
N %
PVE Aortic 17 11.6
Homograft Ao 2 1.4
PVE Mitral 11 7.5
PVE Ao + M 1 0.7
PVE Ao + PVE Mi 2 1.4
A + PVE Mi 1 0.7
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Intravascular leads
N %
DDD 3 2
AICD 1 0.7
VVI R 1 0.7
VVI 2 1.4
Mitral + DDD 2 1.4
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Characteristics
Active endocarditis 91.2%IV Drug addicts 10.9%HIV+ 5.4%ESR – HD 3.4%Reoperation 27.2%
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Pathogens
N %
Culture negative 10 6.8
Staphylococcus 55 37.4
Streptococcus 43 29.3
Enterococcus 14 9.5
Polimicrobial 8 5.4
Candida 1 0.7
Other 14 9.5
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Type of operation
Emergency 29.9%Urgent 21.8%Elective 46.9%
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
EuroSCORE
Additive
RangeMeanMedian
2 – 1910.15 ±3.8110
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
EuroSCORE
Logistic
RangeMeanMedian
1.51 – 94.17% EM25.59 ± 20.8118.95
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Overall in-hospital mortality 32.7%
- Intraoperative death- 30 days po- Regardless the length of stay
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower bound
Upper bound
Sig.
All patients .826 .036 .756 .896 .000
Asymptotic 95% confidence interval
Receiver operating characteristics (ROC) curves
Area > 0.7 Good correlationArea > 0.8 Very good correlationArea > 0.9 Excellent correlation
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower Bound
Upper Bound
Sig.
Native valve IE .814 .045 .727 .902 .000
Prosthetic IE .779 .088 .607 .952 .000
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower Bound
Upper Bound
Sig.
Aortic position .778 .064 .652 .904 .001
Mitral position .937 .051 .836 1.037 .001
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower Bound
Upper Bound
Sig.
Aortic prostheses .729 .125 .484 .980 .112
Mitral prostheses .833 .152 .535 1.132 .068
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower Bound
Upper Bound
Sig.
Gram + .819 .041 .739 .899 .000
Gram - .833 .204 .433 1.233 .248
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Results
Area SE Lower Bound
Upper Bound
Sig.
Staphylococci .834 .054 .727 .940 .000
Streptococci .856 .087 .686 1.026 .002
Enterococci .500 .163 .181 .829 1.000
Polymicrobial .800 .165 .476 1.124 .180
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
ROC Curve
VÁLVULA: A
Diagonal segments are produced by ties.
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
ROC Curve
VÁLVULA: A
Diagonal segments are produced by ties.
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00Case Processing Summaryb
16
46
2
Exitus poPositivea
Negative
Missing
Valid N(listwise)
Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.
The positive actual state is S.a.
VÁLVULA = Ab.
Area Under the Curvec
Test Result Variable(s): Logístico (%)
,778 ,064 ,001 ,652 ,904Area Std. Error
aAsymptotic
Sig.b
Lower Bound Upper Bound
Asymptotic 95% ConfidenceInterval
The test result variable(s): Logístico (%) has at least one tie between thepositive actual state group and the negative actual state group. Statisticsmay be biased.
Under the nonparametric assumptiona.
Null hypothesis: true area = 0.5b.
VÁLVULA = Ac.
Aortic valve
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
ROC Curve
VÁLVULA: HA
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
ROC Curve
VÁLVULA: HA
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00Case Processing Summaryb
1
1
Exitus poPositivea
Negative
Valid N(listwise)
Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.
The positive actual state is S.a.
VÁLVULA = HAb.
Area Under the Curvec
Test Result Variable(s): Logístico (%)
1,000 ,000 ,317 1,000 1,000Area Std. Error
aAsymptotic
Sig.b
Lower Bound Upper Bound
Asymptotic 95% ConfidenceInterval
Under the nonparametric assumptiona.
Null hypothesis: true area = 0.5b.
VÁLVULA = HAc.
Homograft aortic
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
ROC Curve
VÁLVULA: M
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
ROC Curve
VÁLVULA: M
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00Case Processing Summaryb
7
18
Exitus poPositivea
Negative
Valid N(listwise)
Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.
The positive actual state is S.a.
VÁLVULA = Mb.
Area Under the Curvec
Test Result Variable(s): Logístico (%)
,937 ,051 ,001 ,836 1,037Area Std. Error
aAsymptotic
Sig.b
Lower Bound Upper Bound
Asymptotic 95% ConfidenceInterval
Under the nonparametric assumptiona.
Null hypothesis: true area = 0.5b.
VÁLVULA = Mc.
Mitral valve
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
ROC Curve
VÁLVULA: PA
Diagonal segments are produced by ties.
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
ROC Curve
VÁLVULA: PA
Diagonal segments are produced by ties.
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
Case Processing Summaryb
9
8
Exitus poPositivea
Negative
Valid N(listwise)
Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.
The positive actual state is S.a.
VÁLVULA = PAb.
Area Under the Curvec
Test Result Variable(s): Logístico (%)
,729 ,125 ,112 ,484 ,975Area Std. Error
aAsymptotic
Sig.b
Lower Bound Upper Bound
Asymptotic 95% ConfidenceInterval
The test result variable(s): Logístico (%) has at least one tie between thepositive actual state group and the negative actual state group. Statisticsmay be biased.
Under the nonparametric assumptiona.
Null hypothesis: true area = 0.5b.
VÁLVULA = PAc.
Aortic prosthesis
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
ROC Curve
VÁLVULA: PM
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00
ROC Curve
VÁLVULA: PM
1 - Specificity
1,00,75,50,250,00
Se
nsi
tivity
1,00
,75
,50
,25
0,00Case Processing Summaryc
6
5
Exitus pob
Positivea
Negative
Valid N(listwise)
Larger values of the test result variable(s) indicatestronger evidence for a positive actual state.
The positive actual state is S.a.
The test result variable(s): Logístico (%) has atleast one tie between the positive actual stategroup and the negative actual state group.
b.
VÁLVULA = PMc.
Area Under the Curvec
Test Result Variable(s): Logístico (%)
,833 ,152 ,068 ,535 1,132Area Std. Error
aAsymptotic
Sig.b
Lower Bound Upper Bound
Asymptotic 95% ConfidenceInterval
Under the nonparametric assumptiona.
Null hypothesis: true area = 0.5b.
VÁLVULA = PMc.
Mitral prosthesis
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Comments
There is a very good correlation between logisticEuroSCORE and mortality for the entire group
Division in subgroups yields a decrease in statisticalpower but correlation is almost the same in all subgroups
The area is good in the prosthetic valve IE although nonsignificant by position
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Comments
The area is very good for Gram – and polymicrobialalthough with low statistical power
There is statistical power for significance in theStaphylococci and Streptococci groups
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Limitations
Small sample size
Statistical power decreases when analyzing subgroups
Just preliminary results
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
When to use Logistic EuroScore?
-To calculate a precise and realistic risk prediction for a very high-risk patient, particularly when the indication for surgery may not be clear
- To monitor quality of care in institutions where a substantial proportion of patients are of very high-risk
- To help in the further study of risk modelling by groups and institutions with a scientific interest in the subject
- To carry out normal stratification in institutions with easy availability of accesible information technology, especially where high-risk surgery forms a substantial part of the workload
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
The Future of risk stratification
* Larger sample size
* More institutions involved
* Subgroup analysis (Pathogens, abscess…)
* Team approach
* The role of ICE
* Changing our approach to patients?
* Quality assurance
Infective endocarditis and surgery
C.A.Mestres for the HC Endocarditis Study Group ESCMID – Santander - 2006
Conclusions
* IE is a very serious pathology* It is not popular* Highly demanding* Suboptimal results* Team approach* Risk takers