Vegetectomy: An alternative surgical treatment for infective endocarditis of the atrioventricular valves in drug addicts

Isolated tricuspid valve endocarditis - A rare entity and a surgeon’s dilemma

Isolated tricuspid valve endocarditis accounts for only 5 to 10 percent of infective endocarditis cases globally. Numerous surgical procedures ranging from simple vegetectomy, creation of neoleaflets or complete replacement by a prosthetic valve have been described. We aimed to evaluate our experience in surgical management of this entity and to formulate an approach for timing, appropriateness and extent of surgery. Patients operated on semi elective/emergency basis had adverse outcome with residual regurgitation and had longer ICU stay. Also, patients who required excision of leaflet and creation of neoleaflets had a higher incidence of regurgitation. This suggests that maximal preservation of native valve lessens the incidence of residual regurgitation. Simple vegetectomy and patch repair of the residual defect offers the best outcome.

Excision of Aortic Vegetation in Brucella Endocarditis

A 19-year-old man with brucella endocarditis was treated by antimicrobial therapy and surgical excision of vegetation with preservation of the native aortic valve.

Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association

BACKGROUND

Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances.

METHODS AND RESULTS

This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations.

CONCLUSIONS

Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.

Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America

BACKGROUND

Despite advances in medical, surgical, and critical care interventions, infective endocarditis remains a disease that is associated with considerable morbidity and mortality. The continuing evolution of antimicrobial resistance among common pathogens that cause infective endocarditis creates additional therapeutic issues for physicians to manage in this potentially life-threatening illness.

METHODS AND RESULTS

This work represents the third iteration of an infective endocarditis "treatment" document developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It updates recommendations for diagnosis, treatment, and management of complications of infective endocarditis. A multidisciplinary committee of experts drafted this document to assist physicians in the evolving care of patients with infective endocarditis in the new millennium. This extensive document is accompanied by an executive summary that covers the key points of the diagnosis, antimicrobial therapy, and management of infective endocarditis. For the first time, an evidence-based scoring system that is used by the American College of Cardiology and the American Heart Association was applied to treatment recommendations. Tables also have been included that provide input on the use of echocardiography during diagnosis and treatment of infective endocarditis, evaluation and treatment of culture-negative endocarditis, and short-term and long-term management of patients during and after completion of antimicrobial treatment. To assist physicians who care for children, pediatric dosing was added to each treatment regimen.

CONCLUSIONS

The recommendations outlined in this update should assist physicians in all aspects of patient care in the diagnosis, medical and surgical treatment, and follow-up of infective endocarditis, as well as management of associated complications. Clinical variability and complexity in infective endocarditis, however, dictate that these guidelines be used to support and not supplant physician-directed decisions in individual patient management.

Infective Endocarditis in Intravenous Drug Abusers

Infective endocarditis (IE) is one of the most severe complications in intravenous drug abusers (IVDA). IE usually involves the tricuspid valve, Staphylococcus aureus is the most common etiologic agent, and it has a relatively good prognosis. Currently, between 40% and 90% of IVDA with IE are HIV infected, and the HIV epidemic has caused a decrease in the incidence of this disease, probably due to changes in drug administration habits undertaken by addicts in order to avoid HIV transmission. This review focuses on progress made over the past few years in some aspects of IE in IVDA. The pathogenesis of tricuspid endocarditis is still unknown more than 60 years after the first series. The most important advance in antibiotic therapy is that noncomplicated S. aureus right-sided endocarditis can be successfully treated with an intravenous 2-week course of nafcillin or cloxacillin plus an aminoglycoside, although probably the aminoglycoside administration could be stopped after the first 3 to 5 days. Surgery in HIV-infected IVDA with IE does not worsen the prognosis. Considering the possibility of reinfection in IVDA, prosthetic material is usually avoided. Tricuspid valvulectomy or valve repair should be considered the technique of choice in IVDA with right-sided IE. Replacement of the tricuspid valve by a cryopreserved mitral homograft is the latest introduction into clinical practice. It provides atrioventricular competence, thereby avoiding late right heart failure. Reinfections can be treated medically with a negligible reoperation rate. Overall mortality for HIV-infected or non-HIV-infected IVDA with IE is similar. However, among HIV-infected IVDA, mortality is significantly higher in those who are most severely immunosuppressed, with CD4(+) cell counts below 200/L or with AIDS criteria.

Infective endocarditis in the injection drug user

Although infective endocarditis is certainly not the most common infection seen in injecting drug users, it is the infection that clinicians most commonly think of when they consider infectious complications of injected drug use. The microbiology of infective endocarditis in injection drug users has remained relatively stable over the last several decades. Tricuspid valve endocarditis has been associated most frequently with injection drug use, but recent reports have suggested that involvement of left-sided valves is seen more often now than in the past. The use of transesophageal echocardiography has greatly advanced the ability to diagnose infective endocarditis and the cardiac complications of valvular infection.

Biofilms: survival mechanisms of clinically relevant microorganisms

Though biofilms were first described by Antonie van Leeuwenhoek, the theory describing the biofilm process was not developed until 1978. We now understand that biofilms are universal, occurring in aquatic and industrial water systems as well as a large number of environments and medical devices relevant for public health. Using tools such as the scanning electron microscope and, more recently, the confocal laser scanning microscope, biofilm researchers now understand that biofilms are not unstructured, homogeneous deposits of cells and accumulated slime, but complex communities of surface-associated cells enclosed in a polymer matrix containing open water channels. Further studies have shown that the biofilm phenotype can be described in terms of the genes expressed by biofilm-associated cells. Microorganisms growing in a biofilm are highly resistant to antimicrobial agents by one or more mechanisms. Biofilm-associated microorganisms have been shown to be associated with several human diseases, such as native valve endocarditis and cystic fibrosis, and to colonize a wide variety of medical devices. Though epidemiologic evidence points to biofilms as a source of several infectious diseases, the exact mechanisms by which biofilm-associated microorganisms elicit disease are poorly understood. Detachment of cells or cell aggregates, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are all biofilm processes which could initiate the disease process. Effective strategies to prevent or control biofilms on medical devices must take into consideration the unique and tenacious nature of biofilms. Current intervention strategies are designed to prevent initial device colonization, minimize microbial cell attachment to the device, penetrate the biofilm matrix and kill the associated cells, or remove the device from the patient. In the future, treatments may be based on inhibition of genes involved in cell attachment and biofilm formation.

Surgery for tricuspid valve endocarditis: a selective approach

The authors report their 18-year experience in the surgical treatment of infective tricuspid endocarditis. Between January 1981 and January 1999, 238 cases of infective endocarditis were seen. with a tricuspid involvement in 21 cases (8.8%). Tricuspid valve repair was performed in 9 patients with infective lesions involving one single leaflet. The surgical principle of the repair was to avoid any prosthetic material implantation. Posterior leaflet vegetectomy was performed in another 2 patients with infected intracavitary leads. Tricuspid valve replacement was performed in 10 patients with involvement of the whole valvular apparatus. One patient died of septic shock 3 days postoperatively. All the other patients had a good postoperative recovery. Follow-up ranged between 12 and 155 months (mean 68.9 +/- 55 months). Five cases of late mortality were observed: 3 for cardiac reasons and 2 of cancer. All the other patients are alive. Late postoperative echocardiography in the patients with tricuspid repair showed tricuspid regurgitation to be absent in 6 patients, mild in 2, moderate in 1, and severe in 1. No recurrent infections were observed either in patients with valve repair or in those with valve replacement. Good early and long-term results can be achieved in the surgical treatment of tricuspid endocarditis as long as complete excision of the infected tissue is performed and risk factors are controlled.

Pulmonic valve endocarditis after orthotopic liver transplantation

Infective endocarditis is a rare complication affecting solid-organ transplant recipients. Isolated pulmonic valve endocarditis is also rare. A case of persistent bacteremia secondary to an isolated pulmonic valve vegetation occurred in a woman 10 days after liver transplantation. A pulmonary vegetectomy was performed as an alternative to valve replacement in addition to long-term antibiotic therapy.

Tricuspid valve disease. Clinical evaluation, physiopathology, and management

The tricuspid and mitral valves are homologous whose function depends on coordination among components. Isolated tricuspid valve abnormalities are relatively uncommon. Rheumatic disease, chemicals, immunologic and degenerative disorders alter leaflet anatomy and may result in either stenosis, insufficiency or a combination. More often, tricuspid disorders present as a component of congenital syndromes or secondary to pulmonary vascular or let heart disease which alter geometry and function of nonleaflet components.

Surgical treatment of endocarditis

Since early investigators first suggested that the treatment of endocarditis should include valve replacement for infections not readily controlled with medical therapy alone, the role of surgery has become expanded, yet refined, to improve the outcome of patients with this potentially fatal disease. Innovative surgical techniques have also been developed in an effort to improve the results of surgical treatment for complex sequelae of invasive infections. This article examines the current indications for surgical intervention, compares the various surgical options, and assesses the expected short-and long-term outcome after valve replacement for patients with native valve or prosthetic valve endocarditis.

Valve repair in acute endocarditis

Forty patients were operated on in the early phase of active endocarditis between 1980 and 1988. Indications for operation were heart failure (30 patients), severe valvular regurgitation (4), uncontrolled sepsis (2), septic emboli (3), and other (1 patient). Time between onset of endocarditis symptoms and operation ranged from 12 to 45 days (mean, 30 days). The aortic valve was involved in 3 patients; the mitral valve, in 28; both valves, in 7; and the tricuspid valve, in 2. There was no previous underlying valve pathology in 40%. Lesions found were cusp perforation (17 patients), annular abscess (4), vegetation (13), and chordal rupture (22). Positive blood cultures were found in 30 patients (75%). Bacterial findings were Streptococcus in 12 patients (30%), Staphylococcus in 15 (37.5%), gram-negative in 3 (7.5%), and unknown in 10 (25%). Criteria to perform valve repair were adequate antibiotic therapy for at least 1 week and large excision of all macroscopically involved tissues. In all cases, Carpentier's reconstructive techniques were used. Perioperative mortality was 2.5% (1 patient). Reoperation was necessary in 1 patient. Late mortality was 2.5% (1 patient). Repair was assessed either by angiography or by Doppler echocardiography before hospital discharge: 32 patients showed no regurgitation, whereas 7 had mild regurgitation (3 aortic, 4 mitral). Mean follow-up of 30 months was achieved in all survivors. There was no recurrence of endocarditis and no reoperation for valvular insufficiency. We conclude that valve repair in acute endocarditis is possible and effective in most instances.

Tricuspid valve Candida endocarditis cured by valve-sparing debridement

This report describes the case of a patient in whom Candida albicans tricuspid valve endocarditis was treated by excision of a large vegetation and partial tricuspid valvectomy without prosthetic valve replacement. In select patients, valve-sparing debridement may allow a long-term cure and may be the procedure of choice in the treatment of Candida tricuspid valve endocarditis.