surgical outcome of surgical outcome of native valve infective native valve infective

endocarditis in endocarditis in srinagarind hospitalsrinagarind hospital

2004-20052004-2005

Worawit Intanoo MD. Worawit Intanoo MD.

Sompop pratanee MD.Sompop pratanee MD.

Cardiovascular- thoracic unit, Cardiovascular- thoracic unit, Department of surgery, Department of surgery, Khonkaen universityKhonkaen university

Background Background

Native valve infective endocarditis Native valve infective endocarditis (NVE) is associated with a myriad of (NVE) is associated with a myriad of complications.complications.

Khonkaen prevalence was 4 patients Khonkaen prevalence was 4 patients per 1,000 hospital admissions.per 1,000 hospital admissions.

InIn--hospital mortality was 25 per centhospital mortality was 25 per cent . . During the first month after admission, During the first month after admission,

45 per cent of the patients underwent 45 per cent of the patients underwent surgerysurgery . .Pachirat O et al . Infective endocarditis : prevalence,

characteristics and mortality in Khon Kaen, 1990-1999 . J Med Assoc Thai. 2002 Jan;85(1):1-10.

During the last three decades, valve During the last three decades, valve replacement and even valve repair replacement and even valve repair have become commonplace in the have become commonplace in the management of selected management of selected complications of NVE.complications of NVE.

Valve surgery was associated with Valve surgery was associated with reduced mortality.reduced mortality.

Background Background

Vikram HR et al. Impact of valve surgery on 6 month mortality in adult with complicated, left sided native valve endocarditis. JAMA 2003 Dec 24;290(24):3207-14

Indication for surgeryIndication for surgery

valve dysfunction leading to heart valve dysfunction leading to heart failure (1B)failure (1B)

infection with difficult to treat infection with difficult to treat pathogens (1C)pathogens (1C)

valve destruction resulting in severe valve destruction resulting in severe regurgitation with hemodynamic regurgitation with hemodynamic evidence of elevated left ventricular evidence of elevated left ventricular end-diastolic or left atrial pressures end-diastolic or left atrial pressures (1C)(1C)the 2006 American College of Cardiology/American Heart the 2006 American College of Cardiology/American Heart

Association (ACC/AHA) guidelinesAssociation (ACC/AHA) guidelines

Indication for surgeryIndication for surgery

persistent infection, including persistent infection, including paravalvular abscess (1C)paravalvular abscess (1C)

embolic events while on an embolic events while on an appropriate antibiotic regimen OR appropriate antibiotic regimen OR associated with a large vegetation associated with a large vegetation (2C)(2C)

mobile, large (>10 mm) left sided mobile, large (>10 mm) left sided vegetations with or without emboli vegetations with or without emboli (IIC)(IIC)the 2006 American College of Cardiology/American Heart the 2006 American College of Cardiology/American Heart

Association (ACC/AHA) guidelinesAssociation (ACC/AHA) guidelines

MethodologyMethodology

Retrospective Descriptive studyRetrospective Descriptive study January 2004 – December 2005January 2004 – December 2005 23 NVE patients23 NVE patients

Demographic dataDemographic data

Age : year (mean)Age : year (mean) 39.439.4

Sex (male: female)Sex (male: female) 2 : 12 : 1

Comorbidity, risk Comorbidity, risk factorfactor

DM : n%DM : n% 4 (17.4)4 (17.4)

CKD : n%CKD : n% 1(4.3)1(4.3)

HIV : n%HIV : n% 1(4.3)1(4.3)

Liver cirrhosis ; n%Liver cirrhosis ; n% 1(4.3)1(4.3)

Marfan’s syndrome : nMarfan’s syndrome : n%%

1(4.3)1(4.3)

Demographic dataDemographic data

NYHA I : n%NYHA I : n%

NYHA II : n%NYHA II : n% 55 (22)(22)

NYHA III : nNYHA III : n%%

66 (26)(26)

NYHA IV : n%NYHA IV : n% 12 (52)12 (52)

Dyspnea statusDyspnea status

Diagnostic toolDiagnostic tool

Hemoculture positiveHemoculture positive : n%: n% 5(21.7)5(21.7)

echocardiogramechocardiogram

Annular abscessAnnular abscess : n%: n% 11(48)11(48)

Vegetation : n%Vegetation : n% 15(65.3)15(65.3)

Interventricular abscessInterventricular abscess : : n%n%

1(4.2)1(4.2)

organismorganism

S. Viridan : n% 4(14.7)

S. epidermidis :n% 1(4.2)

operationoperationInterval between diagnosis Interval between diagnosis and surgery : hours (mean)and surgery : hours (mean)

54.654.6

procedureprocedure

MVRMVR : n%: n% 3(13)3(13)

AVRAVR : n%: n% 18(78)18(78)

Aortic root replacementAortic root replacement : n%: n% 1(4.2)1(4.2)

MV repairMV repair : n%: n% 1(4.2)1(4.2)

CPB time : min(mean)CPB time : min(mean) 9797

Aortic cross clamp timeAortic cross clamp time : : min(mean)min(mean)

53.453.4

outcomeoutcomeICU stayICU stay : day (mean): day (mean) 8.28.2

Hospital stayHospital stay : day (mean): day (mean) 27.327.3

Hospital mortalityHospital mortality : n%: n% 6(26)6(26)

complicationcomplication

Heart failure : n%Heart failure : n% 15(65)15(65)

Re-operation (bleeding)Re-operation (bleeding) : n%: n% 2(8.6)2(8.6)

Complete heart blockComplete heart block : n%: n% 2(8.6)2(8.6)

Acute renal failureAcute renal failure : n%: n% 4(17.24(17.2))

Paravalvular leakageParavalvular leakage : n%: n% 4(17.24(17.2))

summarysummary

NVE is not uncommon condition in NVE is not uncommon condition in srinagarind hospital.srinagarind hospital.

Hospital mortality rate is still high.Hospital mortality rate is still high.

discussiondiscussion Consideration for surgery in patients Consideration for surgery in patients

with native valve endocarditis must with native valve endocarditis must involve a decision analysis that balances involve a decision analysis that balances the risks of medical treatment with those the risks of medical treatment with those of surgical intervention, including of surgical intervention, including operative mortality and morbidity, operative mortality and morbidity, recurrent embolization, recurrent embolization, co-morbidities, co-morbidities, the long-term complications of valvular the long-term complications of valvular

prostheses and anticoagulation. prostheses and anticoagulation.

Surgery should not be delayed to Surgery should not be delayed to complete antimicrobial therapy in complete antimicrobial therapy in patients with progressive HF or patients with progressive HF or evidence of other complications. evidence of other complications.

discussiondiscussion