Outcomes of early surgery for infective endocarditis with moderate cerebral complications

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Brain abscesses in infective endocarditis: contemporary profile and neuroradiological findings

BACKGROUND

Brain abscesses (BA) are severe lesions in the course of infective endocarditis (IE). We compare the bacteriological, clinical data, background, associated lesions, and outcome of IE patients with and without BAs, and assess the MRI characteristics of BAs.

METHODS

Retrospective study of 351 consecutive patients with definite IE (2005-2020) and at least one brain MRI. Patients with and without BAs were compared.

RESULTS

Twenty patients (5.7%) had BA (80% men; median age: 44.9 ± 11.5). They were younger (p = 0.035) and had a higher rate of predisposing factors (previous IE 20% vs 2.2%, p = 0.03), intravenous drug use [25% vs 2.2%; p < 0.0001]), underlying conditions (HIV infection, 20% vs 2.2%, p < 0.0001; alcohol abuse, 20% vs 2.2% p < 0.0001]; liver disease p = 0.04; hemodialysis, p = 0.001; type 2 diabetes, p = 0.001), bacterial meningitis (p = 0.0029), rare species involvement (35% vs 7%, p < 0.0006) and extra-cerebral abscesses (p = 0.0001) compared to patients without BA. Valve vegetations were larger in Group 1 (p = 0.046). Clinical presentation could suggest the diagnosis of BA in only 7/20 (35%) patients. MR identified 58 BAs (mean/patient 2.9; range 2-12): often multiple (80%), bilateral (55%) and ≤ 10 mm (72%). The presence of BA did not modify cardiac surgery indication and timing. Favorable outcome was observed in 85% of patients.

CONCLUSION

Rates of predisposing, underlying conditions, rare IE agents, meningitis and metastatic abscesses are significantly higher in BA-IE patients. As BAs can develop in asymptomatic IE patients, the impact of brain MRI on their management needs thoroughly to be further investigated.

Adding Fuel to the Fire: Infective Endocarditis and the Challenge of Cerebrovascular Complications

PURPOSE OF REVIEW

Infective endocarditis is a deadly disease and made more deadly by neurologic complications. We review the cerebrovascular complications of infective endocarditis and focus our discussion on medical and surgical management.

RECENT FINDINGS

While management of stroke in the setting of infective endocarditis differs from standard stroke treatment, mechanical thrombectomy has proven safe and successful. Optimal timing of cardiac surgery in the setting of stroke remains an area of debate, but additional observational studies continue to add more detail to the discussion. Cerebrovascular complications in the setting of infective endocarditis remain a high stakes clinical challenge. Timing of cardiac surgery in IE complicated by stroke exemplifies these dilemmas. While more studies have suggested that earlier cardiac surgery is likely safe for those with small ischemic infarcts, there remains a need for more data defining optimal timing of surgery in all forms of cerebrovascular involvement.

Does Quality of Life in Survivors of Surgery for Acute Left-Sided Infective Endocarditis Differ from Non-Endocarditis Patients?

Surgery for left-sided infective endocarditis (IE) has been demonstrated to improve patients' survival rates but information about quality of life (QoL) after surgery is scarce. The aim of this study was to assess the postoperative outcomes and QoL after surgery for IE patients compared to patients undergoing cardiac surgery for non-IE indications. Adult patients with definite acute left-sided IE were matched 1:1 to patients who underwent cardiac surgery for non-endocarditic purposes from 2014 to 2019. QoL was assessed using the SF-36 survey at the last follow-up. A total of 105 patients were matched. The IE group had higher rates of preoperative stroke (21% vs. 7.6%, p = 0.005) and higher stages of NYHA class (p < 0.001), EuroSCORE II (12.3 vs. 3.0, p < 0.001) and blood cell count abnormalities (p < 0.001). The IE group had higher incidence of low cardiac output syndrome (13.3% vs. 4.8%, p = 0.029), dialysis (10.5% vs 1.0%, p = 0.007) and prolonged mechanical ventilation (16.2% vs. 2.9%, p = 0.002) after surgery. At the last follow-up, subcomponents of the SF-36 QoL survey were not different between the groups. Patients who underwent cardiac surgery for IE demonstrated a higher risk profile with a higher rate of postoperative complications. Once recovered from the acute phase of the disease, the reported QoL at follow-up was comparable to that of matched cardiac patients operated for non-IE purposes.

Optimal Timing for Cardiac Surgery in Infective Endocarditis with Neurological Complications: A Narrative Review

In patients with infective endocarditis and neurological complications, the optimal timing for cardiac surgery is unclear due to the varied risk of clinical deterioration when early surgery is performed. The aim of this review is to summarize the best evidence on the optimal timing for cardiac surgery in the presence of each type of neurological complication. An English literature search was carried out from June 2018 through July 2022. The resulting selection, comprising observational studies, clinical trials, systematic reviews and society guidelines, was organized into four sections according to the four groups of neurological complications: ischemic, hemorrhagic, infectious, and asymptomatic complications. Cardiac surgery could be performed without delay in cases of ischemic vascular neurological complication (provided the absence of severe damage, which can be avoided with the performance of mechanical thrombectomy in cases of major stroke), as well as infectious or asymptomatic complications. In the presence of intracranial hemorrhage, a delay of four weeks is recommended for most cases, although recent studies have suggested that performing cardiac surgery within four weeks could be a suitable option for selected cases. The findings of this review are mostly in line with the recommendations of the current European and American infective endocarditis guidelines.

Anesthesia Considerations in Infective Endocarditis

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

Outcomes of surgically treated infective endocarditis in a Western Australian population

Background

Infective endocarditis is a disease that carries high morbidity and mortality. The primary endpoint of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary endpoint of this study is to assess the incidence of post-operative stroke, renal failure, complete heart block and recurrence.

Methods

Between the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital, Western Australia. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record. A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital morbidity and mortality.

Results

A total of 89 patients underwent surgery for infective endocarditis from 2015 to 2019, affecting a total of 101 valves. The mean age of patients was 53.7 ± 16.5. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 h of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass time and cross clamp time. Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 11 patients developed a complete heart block post operatively (12%) and endocarditis recurred in 10 patients (11%).

Conclusion

Prolonged cardiopulmonary bypass times were significantly associated with mortality. This study is novel to report a lower mortality rate than previously quoted in the literature. We also report our findings of organisms, preoperative embolic phenomena and surgery in a Western Australian population. We recommend that all patients with endocarditis are discussed in multidisciplinary forum.

Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

OBJECTIVES

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT.

METHODS

We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT.

RESULTS

Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08-8.30; P = 0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06-1.57; P = 0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49-8.70; P = 0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49-9.93; P = 0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12-0.22; P < 0.001) was a protective factor.

CONCLUSIONS

Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.

Optimal Timing of Surgery for Patients with Active Infective Endocarditis

Infective endocarditis (IE) is a rare but serious condition with a dismal prognosis. One of the keys to improving outcomes is the prompt identification of high-risk patients who have intracardiac and extracardiac (systemic and neurologic) complications. However, as cardiac and extracardiac complications indicating surgery add to the surgical risk for active IE, controversies surround the optimal indication and timing for surgery, especially in patients presenting neurologic complications. This article reviews the necessary evaluation for patients with suspected IE and proposes a state-of-the-art patient flow chart for evaluation of suspected IE.

Surgical outcomes of infective endocarditis in children: should we delay surgery for infective endocarditis?

OBJECTIVES

We compared the surgical outcomes of infective endocarditis (IE) between early surgery and non-early surgery groups in children.

METHODS

From January 2000 to April 2020, we retrospectively reviewed 50 patients <18years of age who underwent first surgery for IE. Early surgery was defined as that performed within 2 days for left-sided IE and 7 days for right-sided IE after diagnosis.

RESULTS

The median age and body weight at operation were 7.7 years [interquartile range (IQR), 2.3-13.2] and 23.7 kg (IQR, 10.3-40.7), respectively. The median follow-up duration was 9.5 years (IQR, 4.0-14.5). In 28 patients with native valve endocarditis, the native valve was preserved in 23 (82.1%). The most common causative microorganism was Streptococcus viridans (32.0%). The operative mortality was 2.0%, and 13 (26.0%) patients required reoperation most commonly for prosthesis failure (n = 7). There were no significant differences in patient characteristics and perioperative data between early surgery (n = 9) and non-early surgery (n = 36) groups, except for the interval between diagnosis and surgery (early surgery < non-early surgery, P < 0.001) and preoperative negative blood culture conversion (early surgery < non-early surgery, P = 0.025). There were no significant differences in overall survival, recurrent IE, and reoperation rate between the groups. Early surgery and preoperative negative blood culture conversion were not found as significant factors for surgical adverse outcomes.

CONCLUSIONS

Surgical outcomes for IE in children were acceptable irrespective of the time of surgery. Our results suggest that it may not be required to delay surgery for IE and the potential benefit of early surgery could be expected in children.

Guidelines on prosthetic heart valve management in infective endocarditis: a narrative review comparing American Heart Association/American College of Cardiology and European Society of Cardiology guidelines

Infective endocarditis (IE) represented over the last year a growing medical and surgical concern. The changes in etiology and demographic of the disease, which now includes also a large proportion of iatrogenic conditions, has prompted new studies and updates in the guideline for IE treatment. The increasing use of intravascular and intracardiac devices has introduced new challenges in terms of both antibiotic resistance and surgical treatment of prosthetic endocarditis. Also, patients with complex congenital heart diseases, intravenous drug abusers and patients with chronic renal failure under hemodialysis have been added to the list of high-risk subjects for IE. Important aspects concerning the establishment of the endocarditis team, the clinical management, the optimal medical therapy and the indication and timing for surgery are arguments of debate and controversy across the literature. In particular, the most adequate strategy to be adopted in the context of concomitant neurological complication remains greatly debated. Despite attempts to standardize the practice in IE, the lack of powered randomized clinical evidence prevented the achievement of a univocal consensus in several aspects of the management of IE. This situation reflects in some differences in the recommendation promoted by the European Society of Cardiology and American Heart Association/American College of Cardiology. In this review, we will compare the European Society of Cardiology and the American Heart Association guidelines and discuss important aspects related to clinical management and indications of for treatment.

The clinical features and prognosis of infective endocarditis in the elderly from 2007 to 2016 in a tertiary hospital in China

BACKGROUND

Infective endocarditis (IE) especially in the elderly is a serious disease, with a worse prognosis.

METHODS

A retrospective cohort study was conducted. A total of 405 patients with definite IE were divided into three groups: 205 patients under 50 years old, 141 patients between 50 and 64 years old and 59 patients over 65 years old.

RESULTS

For older patients, clinical symptoms such as fever, anemia, and heart murmur were as common as the younger patients. IE in old patients had more frequent nosocomial origin (P = 0.007) and tended to be more frequent with bad oral hygiene (p = 0.008). The most frequent isolated pathogens in the old groups was streptococci and coagulase-negative staphylococci. The old patients had a lower operation rate (40.7% vs 58.9% vs 62.4%, P = 0.012) and higher in-hospital mortality (20.3% vs 10.6% vs 8.8%, P = 0.044) compared with the younger patients. Surgical treatment was a significant predictor of one-year mortality even after adjusting for the confounders (HR = 2.45, 95% CI 1.027-10.598, P = 0.009). The one-year survival rate was higher for older patients with surgical intervention than those without (95.8% vs 68.6%, P = 0.007).

CONCLUSIONS

Older patients with IE presented with more comorbidities, bad oral hygiene, more nosocomial origin and a more severe prognosis than younger patients. Streptococci was the most frequent micro-organisms in this group. Surgery were underused in old patients and those with surgical treatment had better prognosis.

Infective endocarditis: trends, surgical outcomes, and controversies

The number of hospitalizations and surgical cases of infective endocarditis (IE) are increasing. The aim of this study was to review these trends, surgical outcomes, and controversies related to IE. A search of MEDLINE of studies published between 1960 and 2018 was conducted. Search terms included "infective endocarditis", "history of", "trend", "epidemiology", "outcome", "medical management", "surgery", "indication", and "re-operative surgery", or any combination thereof. The United States has the highest incidence of IE in the world at 15 per 100,000 people, with increases in incidence due to the aging population as well as increasing rates of intravenous drug use (IVDU). National guidelines support early surgical intervention in specific clinical settings in both left and right-sided IE. However, only 11% of the evidence used in formulating guidelines for surgical therapy in IE are based on level A evidence. Ongoing controversies include whether to perform surgery in the setting of continued or recurrent IVDU in a patient with a prior valve operation, timing of surgery after acute stroke due to IE, and general indications for surgery for tricuspid valve IE. IE has a surging incidence and increasing burden on the healthcare system in the United States. Multiple controversies exist, and formulating level A evidence and multidisciplinary collaboration will be essential components to effectively treating this complex patient population.

[Treatment of infectious endocarditis]

Antibiotic treatment of infective endocarditis is part of a multidisciplinary patient management that should be conducted within an "Endocarditis team". Initial antibiotic treatment of infective endocarditis should be parenteral and comply with current international guidelines. A switch to an oral antibiotic regimen may be considered after 2weeks of successful parenteral antibiotic treatment. Aminoglycosides should no longer be used for the initial treatment of native valve Staphylococcus aureus endocarditis. Valve surgery is required in almost half of the patients.