Outcomes after surgery for infective endocarditis

Abstract

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.

Keywords: Endocarditis; Infective endocarditis; Outcome; Surgery.

Fig. 1

A 41-year-old male patient was admitted with fever and pulmonary edema. Images showing extensive vegetation of mitral valve leaflet with severe mitral valve regurgitation (arrow). The patient underwent mitral valve replacement with a mechanical valve, however, succumbed to severe sepsis and multi-organ failure. Blood culture grew Klebsiella pneumonia

Fig. 2

A 44-year-old patient was admitted with a fever of 3-week duration. Echocardiogram showing a large 2-cm vegetation. The patient underwent urgent surgery and replacement of the valve as the valve was not suitable for repair. Blood culture grew Streptococcus viridans. Surgery was performed to prevent embolism as it carries significant morbidity and mortality

Fig. 3

A 58-year-old patient with aortic root abscess and severe paravalvar regurgitation(Arrow); 3 months after bio-prosthetic aortic valve replacement. Culture grew coagulase-negative Staphylococcus aureus. The patient underwent pericardial patch closure of the abscess cavity with redo-aortic valve replacement with a bio-prosthetic valve. This procedure can be associated with a high chance of recurrence; hence, aortic root replacement is a better option

Fig. 4

Mitral annular abscess and vegetation (arrow) which requires extensive debridement, annular reconstruction with bovine pericardial patch, and redo mechanical valve replacement. Culture grew Enterococcus faecalis. See supplemental video 1

Fig. 5

Posterior leaflet perforation (arrow) treated with debridement and closure of perforation with autologous pericardium and mitral valve annuloplasty

Fig. 6

A 22-year-old patient with infective endocarditis of Dacron patch to close ventricular septal defect (VSD) at the age of 2 years. He developed endocarditis of the aortic valve and Dacron patch and underwent bio-prosthetic valve replacement of the aortic valve and debridement of the VSD patch elsewhere. He developed recurrent infection 3 months after the procedure. Abscess in the interventricular septum was extending to the prosthetic aortic valve and tricuspid valve. The patient underwent removal of the patch, extensive debridement, redo-aortic valve replacement with a mechanical valve, ventricular septal defect closure with bovine pericardial patch, and tricuspid valve replacement with bio-prosthetic valve and permanent pacemaker implantation. The patient is doing well 2 years after surgery. All tissue cultures were negative. The arrow points to the interventricular septal abscess in the top panel and tricuspid valve vegetation in the bottom panel. See supplemental videos 2 and 3

Fig. 7

A 27-year-old patient status post aortic root replacement with 23-mm mechanical conduit for aorto-arteritis on 3 immunosuppressive drugs with aortic root abscess treated with redo aortic root replacement with Cabrol technique, 16 months after the index procedure. A 28-mm graft was sutured to the basal ring of the aortic root after debridement. A 23-mm mechanical valve was placed inside the graft with interrupted pledgetted sutures from outside. Coronary buttons were reimplanted with two separate 6-mm Dacron grafts (modified Cabrol technique). Abscess fluid grew coagulase-negative Staphylococcus aureus. The arrow points to the root abscess and flows into it. Computerized tomogram aortogram showing peri-aortic collection (arrow). See Supplemental Videos 2 and 3

Fig. 8

A 55-year-old woman who underwent perimembaranous ventricular septal defect closure 25 years ago; presented with vegetation in tricuspid valve (arrow) and on the dacron patch. Culture grew Staphylococcus aureus. The patient underwent removal of the prosthetic patch, debridement, pericardial patch closure of the septal defect, and tricuspid valve replacement with bio-prosthetic valve