Surgical Challenges in Infective Endocarditis: State of the Art

Abstract

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Keywords: Commando procedure; aortic mitral curtain; infective endocarditis; mitral valve repair; native valve endocarditis; prosthetic valve endocarditis; tricuspid valve repair.

Figure 1

Intraoperative picture of native mitral valve infective endocarditis. Through left atriotomy, exposure of mitral valve. (1) Large vegetation involving anterior and posterior leaflet of mitral valve suspended and resected; (2) leaflet reconstruction with a pericardial patch (Cardiovascular Department, UO of Cardiac Surgery of IRCCS Humanitas Research Hospital).

Figure 2

Intraoperative picture of native tricuspid valve infective endocarditis. Through right atriotomy, exposure of tricuspid valve. (1,2) Large vegetation is detected and resected on the anterior leaflet; (3,4) reconstruction of the leaflet is obtained through a pericardial patch; (5) neochordal apparatus is sutured on the free margin of the new anterior leaflet, and in order to optimize coaptation and competence, an incomplete tricuspid annular ring is positioned; (6) final result (Cardiovascular Department, UO of Cardiac Surgery of IRCCS Humanitas Research Hospital).

Figure 3

Intraoperative picture of mechanical prosthetic aortic valve endocarditis and aortic annular erosion and abscess, detected during the prosthesis removal (Cardiovascular Department, UO of Cardiac Surgery of IRCCS Humanitas Research Hospital).

Figure 4

Aortomitral curtain disjunction in double mechanical prosthesis infective endocarditis. (1,2) Transesophageal echocardiogram imaging showing communication and jet from the ascending aorta to the left atrium; (3) intraoperative founding of aortomitral curtain disjunction detected through the aortotomy (black hole) (Cardiovascular Department, UO of Cardiac Surgery of IRCCS Humanitas Research Hospital).