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

Value of Time-Resolved Cardiac CT in Children and Young Adults with Congenital Heart Disease and Infective Endocarditis

BACKGROUND

Diagnosis of infective endocarditis (IE) can be challenging due to negative blood cultures and diagnostic limitations of various imaging modalities. Transesophageal echocardiography (TEE) is the gold standard imaging modality for visualization of valvular vegetations. However, due to the anterior location of the pulmonary valve, post-surgical changes, and sedation requirement, TEE can be challenging in the pediatric population. The aim of this study was to assess the value of Cardiac CT (CCT) for diagnosis of IE in children and young adults with congenital heart disease (CHD).

METHODS

This is a single-center retrospective study of pediatric patients with CHD and diagnosis of IE who underwent CCT from 2018 to 2022. Data collected included age, gender, cardiac diagnosis, clinical presentation, echocardiographic/CCT findings, and blood culture results. In addition, modified Duke criteria (MDC) for the diagnosis of IE were applied with and without CCT findings as the diagnostic imaging criterion.

RESULTS

Fourteen patients were included in this study with a median age of 11 years old. Nine patients were female. Ten patients had IE of the RV-PA conduit and four patients had IE of the aortic valve. Using MDC, 4 patients had definite IE. After including CCT findings, 11 patients (79%) met MDC for definite IE. Blood cultures were positive in 12 patients. CCT revealed the following complications: thromboembolic findings/pseudoaneurysms in 5 patients each and prosthetic valve perforation/prosthetic valve leak in one patient each.

CONCLUSIONS

This study reinforces the complimentary role of CCT to echocardiography in the work-up and diagnosis of IE in patients with CHD. With further improvement in lowering radiation exposure, CCT may have a key role in the diagnostic work-up of endocarditis and could be implemented in the diagnostic criteria of IE.

Outcomes after surgery for infective endocarditis

The role of surgery in infective endocarditis is becoming established the world over. In spite of all recent advances, endocarditis remains a lethal disease following surgery. With the emergence of more difficult-to-treat microorganisms, sicker and older patients with multiple co-morbidities, and an increase in healthcare-associated infections, the need for surgery in the management of infective endocarditis is only bound to increase. Data on the use of surgery in endocarditis till date is largely from observational data due to the relative rarity of the disease and variable practice patterns around the world. Hopefully, with increasing awareness and more inter-institutional and international collaborations, more robust data will emerge to further establish the role of surgery. For the time being, individual patient management will require the active multi-disciplinary approach of an endocarditis team to provide the best possible outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01647-9.

Swiss Evaluation Registry for Pediatric Infective Endocarditis (SERPIE) - Risk factors for complications in children and adolescents with infective endocarditis

BACKGROUND

Infective endocarditis (IE) in pediatric patients is a severe cardiac disease and its actual epidemiology and clinical outcome in Switzerland is scarcely studied.

METHODS

Retrospective nationwide multicenter data analysis of pediatric IE in children (<18 years) between 2011 and 2020.

RESULTS

69 patients were treated for definite (40/69;58%) or possible IE (29/69;42%). 61% (42/69) were male. Diagnosis was made at median 6.4 years (IQR 0.8-12.6) of age with 19 patients (28%) during the first year of life. 84% (58/69) had congenital heart defects. IE was located on pulmonary (25/69;35%), mitral (10/69;14%), tricuspid (8/69;12%) and aortic valve (6/69;9%), and rarely on ventricular septal defect (VSD;4/69;6%) and atrial septal defect (ASD;1/69;1%). In 22% (16/69) localization was unknown. 70% (48/69) had postoperative IE, with prosthetic material involved in 60% (29/48; right ventricular to pulmonary artery conduit (24), VSD (4), ASD (1)). Causative organisms were mostly Staphylococci spp. (25;36%) including Staphylococcus aureus (19;28%), and Streptococci spp. (13;19%). 51% (35/69) suffered from severe complications including congestive heart failure (16;23%), sepsis (17;25%) and embolism (19;28%). Staphylococcus aureus was found as a predictor of severe complications in univariate and multivariate analysis (p = 0.02 and p = 0.033). In 46% (32/69) cardiac surgery was performed. 7% (5/69) died.

CONCLUSIONS

IE in childhood remains a severe cardiac disease with relevant mortality. The high morbidity and high rate of complications is associated with Staphylococcus aureus infections. Congenital heart defects act as a risk factor for IE, in particular the high number of cases associated with prosthetic pulmonary valve needs further evaluation and therapeutic alternatives.