ENDOCARDITE AIGUE INFECTIEUSE TRAITEMENT...
Transcript of ENDOCARDITE AIGUE INFECTIEUSE TRAITEMENT...
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NOM Intitulé du topo Date ….
ENDOCARDITE AIGUE INFECTIEUSETRAITEMENT CHIRURGICAL
Pr Fadi FARHAT
Service de Chirurgie Cardiovasculaire Adulte et Transplantation
Hôpital Louis Pradel, Bron, FRANCE
2ème Journée Scientifique de la Réunion de Concertation Pluridisciplinaire sur l’Endocardite Infectieuse du
CHU de Lyon
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Résultats
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
• Quand doit-on opérer ?
• Quel geste peut-on / doit-on
réaliser ?
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Résultats
Timing?
Quand doit-on opérer ?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Problématique :
− Plus l’intervention chirurgicale est réalisée précocement,
plus le risque de récidive infectieuse est important.
− Plus elle est tardive, plus le risque de complications
augmente.
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Résultats
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Quand doit-on opérer ?
Indications "anatomiques" :
− Abcès annulaire volumineux, évoluant, compliqué d’un
BAV
− Communications aortocardiaques (Aorte-OG, Aorte-
OD) et CIV
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
Quel geste peut-on réaliser ?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Principes du traitement chirurgical :
− Analyse des lésions : valve, anneau, culot aortique, septum inter-ventriculaire, trigone mitro-aortique…
− Excision complète et extensive des tissus infectés
− Reconstruction anatomique des structures lésées
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Reconstructions valvulaires
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Reconstruction de l’anneau mitral
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Reconstruction de l’anneau mitral postérieur
d'Udekem, David, et al. Ann Thorac Surg 1996
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Continuité mitro- aortique
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Continuité mitro- aortique
d'Udekem, David, et al. Ann Thorac Surg 1996
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Continuité mitro- aortique
d'Udekem, David, et al. Ann Thorac Surg 1996
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Bloc mitro aortique mécanique pour endocardite sur prothèse (2ème récidive en 2008, survie à 7 ans)
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Farhat, Interactive Cardiovasc Thorac Surg 2007
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Farhat, Interactive Cardiovasc Thorac Surg 2007
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Farhat, Interactive Cardiovasc Thorac Surg 2007
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Farhat, Interactive Cardiovasc Thorac Surg 2007
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Byrne, Ann Thorac Surg 2011
- Revue de la littérature de 2000 à 2010
- Visant à établir des bonnes pratiques chirurgicales sur l’approche technique ainsi que le type de prothèse à implanter
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Byrne, Ann Thorac Surg 2011
Endocardite aortique sur valve native
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Byrne, Ann Thorac Surg 2011
Endocardite aortique sur valve native avec
abcès périvalvulaire
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Endocardite aortique sur prothèse valvulaire
Byrne, Ann Thorac Surg 2011
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Endocardite aortique sur prothèse valvulaire
avec abcès périvalvulaire
Byrne, Ann Thorac Surg 2011
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Endocardite mitrale sur valve native
Byrne, Ann Thorac Surg 2011
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Endocardite mitrale sur prothèse valvulaire
Byrne, Ann Thorac Surg 2011
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Endocardite valvulaire tricuspide
Byrne, Ann Thorac Surg 2011
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NOM Intitulé du topo Date ….
Conclusion
Discussion
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
Byrne, Ann Thorac Surg 2011
Endocardite valvulaire multiple
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
David, Eur J Cardiothorac Surg 2006
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
BACKGROUND:Nearly half of patients require cardiac surgery during the acute phase of infective endocarditis (IE). We describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and examine whether the type of prosthesis was associated with in-hospital and 1-year mortality.METHODS AND RESULTS:Among 5591 patients included in the International Collaboration on Endocarditis Prospective Cohort Study, 1467 patients with definite IE were operated on during the active phase and had a biological (37%) or mechanical (63%) valve replacement. Patients who received bioprostheses were older (62 vs 54years), more often had a history of cancer (9% vs 6%), and had moderate or severe renal disease (9% vs 4%); proportion of health care-associated IE was higher (26% vs 17%); intracardiacabscesses were more frequent (30% vs 23%). In-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p=0.0009) and 25.3% vs 16.6% (p<.0001), respectively. In multivariable analysis, mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10years), and in patients with a history of cancer (0.72), but were more commonly implanted in mitral position (1.60). Bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298).CONCLUSIONS:Patients with IE who receive a biological valve replacement have significant differences in clinical characteristics compared topatients who receive a mechanical prosthesis. Biological valve replacement is independently associated with a higher in-hospitaland 1-year mortality, a result which is possibly related to patient characteristics rather than valve dysfunction.
Delahaye, Int J Cardiol 2015
One-year outcome following biological or mechanical valve replacement for infective endocarditis
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
BACKGROUND:Acute bacterial endocarditis may be extremely destructive for cardiac valves and their periannular structures. It has been suggested that complex reconstruction procedures require the use of homografts because of their versatility and potency to resist repeated infection.METHODS:We studied the long-term results of 69 patients with complex endocarditis who received homografts in the aortic position.RESULTS:The results after a mean follow-up of 8.1 ± 5.1 years (median, 8.0 years) showed that the recurrence of endocarditis even in these complex cases is low (7%), but the incidence of structural valve degeneration (SVD) is high. Freedom from SVD at 10 years is only 60.0%. When aortic homografts degenerate, they predominantly calcify.CONCLUSIONS:The use of homografts to reconstruct endocarditis-related aortic valve destruction is associated with a low recurrence of endocarditis but a high incidence of SVD in the long run.
Durability of homografts used to treat complex aortic valve endocarditis
Flameng, Ann Thorac Surg 2015
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NOM Intitulé du topo Date ….
Conclusion
Résultats
Quel geste chirurgical?
Timing?
INTRO
TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES
− Analyse des lésions pour traitement adapté
− Excision complète et extensive des tissus infectés
− Reconstruction anatomique des structures lésées
− Pas de matériau prothétique préférentiel : attitude au cas par cas
Conclusion