INFECTIVE ENDOCARDITIS: AN UPDATE · 2019-05-22 · 1Chu VH, Park LP, Athan E, et al. International...

INFECTIVE ENDOCARDITIS: AN UPDATE

David D. Yuh, MD FACS FACCChair, Department of Surgery, Stamford HospitalMedical Student Clerkship Director (Stamford Affiliation)Columbia University College of Physicians and Surgeons

OVERVIEW

Ò Current SignificanceÒ Management Updates

É Antibiotic ProphylaxisÉ DiagnosticsÉ Antibiotic TreatmentÉ Indications for SurgeryÉ Timing of Surgery

Ò Endocarditis after TAVRÒ Surgical Techniques

SIGNIFICANCE

Ò Infective endocarditis (IE) affects 3-10 individuals/100,000 per year

Ò Average cost $120,000 per patient

Ò One-year mortality has not improved in over 2 decades

Ò Incidence risingÉ 40,000 to 50,000 new

cases/yearStanford University, autoprac.com.

CHANGING DEMOGRAPHIC

Ò In 21st century, IE healthcare-acquired in > 25% of cases

Selton-Suty C, Celard M, Le Moing V, et al. Preeminence of Staphylococcus aureus in infective endocarditis:A 1-year population-based survey. Clin Infec Dis 2012; 54:1230-1239.

ANTIBIOTIC PROPHYLAXIS

Cahill TJ, Baddour LM, Habib G, et al. Challenges in infective endocarditis. JACC 2017; 69:325-344.

DIAGNOSIS

Ò Timely diagnosis tied to improve outcomes

Ò Variegated clinical presentations

Ò Limitations of modified Duke criteria

crutchfielddermatology.com

DIAGNOSIS: DUKE CRITERIA

Perez-Vazquez A, Farinas C, Garcia-Palomo, et al. Evaluation of the Duke criteria in 93 episodes of prostheticValve endocarditis: Could sensitivity be improved? Arch Intern Med 2000; 160:1185-1191

DIAGNOSIS: IMAGING

Ò Transthoracic Echocardiography (TTE)É Native valve endocarditis

Ð 50-90% sensitivity, 90% specificity

É Prosthetic valve endocarditisÐ 40-70% sensitivity

É Can be better than TEE for visualizing anterior prosthetic aortic valve abcesses

step2medbullets.com

DIAGNOSIS: IMAGING

Ò TransesophagealEchocardiography (TEE)É Indicated when TTE is positive or

non-diagnosticÉ Native valve endocarditis

Ð 90-100% sensitivity, 90% specificity

É Prosthetic valve endocarditisÐ 86% sensitivity

É Superior to TTE for detection of complicationsÐ PerforationsÐ AbscessesÐ Fistulae

pubs.sciepub.com

http://pubs.sciepub.com/ajmcr/3/5/1/

DIAGNOSIS: IMAGING WHAT’S NEW?

Ò Computed TomographyÉ Key adjunctive imaging modality when echocardiography unclearÉ Possibly superior in detecting paravalvular complicationsÉ Less subject to prosthetic valve artifactsÉ Concurrent coronary angiography

Cahill TJ, Baddour LM, Habib G, et al. Challenges in infective endocarditis. JACC 2017; 69:325-344.


Ò Combining CT with metabolic imaging (i.e., 18FDG-PET, SPECT) may enhance diagnosis in “possible” IE or device infectionÉ 18FDG-PET plus CT had 73%

sensitivity and 80% specificityÉ Adding “abnormal prosthetic valve

18FDG-PET signal” as a diagnostic criterion increased sensitivity of modified Duke criteria from 70% to 95%

É Reduced the frequency of “possible IE” from 56% to 32%.

Amraoui S et al. Contribution of PET imaging to the diagnosis of septic embolism in patients with pacing lead endocarditis. JACC: Cardiovascular Imaging; 2016; 9:283-290.


Cahill TJ, Baddour LM, HabibG, et al. Challenges in infective endocarditis. JACC 2017; 69:325-344.


Ò Combining CT with metabolic imaging (i.e., 18FDG-PET, SPECT) may enhance diagnosis in “possible” IE or device infectionÉ 18FDG-PET plus CT had 73%

sensitivity and 80% specificityÉ Adding “abnormal prosthetic valve

18FDG-PET signal” as a diagnostic criterion increased sensitivity of modified Duke criteria from 70% to 95%

É Reduced the frequency of “possible IE” from 56% to 32%.

Ò Limitations/DrawbacksÉ Metabolic imaging cannot

accurately discriminate between sterile inflammation and infection

É False-positives for PET/CT reported after cardiac surgery

É Access to advanced imaging is limited

É Identifying which patients stand to benefit remains to be determined

DIAGNOSIS: MICROBIOLOGY WHAT’S NEW?

Ò Staphylococcus aureus now most common pathogen in IE (30% of cases)É Aggressive diseaseÉ Increased risk of embolism, stroke,

persistent bacteremia, deathÉ Most common cause of PVE

Ð ReoperationsÐ Mortality rates approaching 50%

Ò 10% to 20% have negative blood cultures rigorous testingÉ Serologic testingÉ Blood PCRÉ Causative organism can be identified

in 2/3 of culture negative patients

incolors.club

slideplayer.com

TREATMENT: ANTIBIOTICS WHAT’S NEW?Ò Organism-specific antibiotic protocols

(AHA Guidelines1)Ò Traditional requirement for 4-6 weeks

of intravenous antibioticsÒ Balancing treatment efficacy versus

toxicityÉ New evidence supporting short-

course/stepped-down antibiotic treatment in selected groups (e.g., uncomplicated oral Streptococci)

Ð Post-surgical patients with negative valve culture findings

Ð Earlier transition to oral antibiotics

É Increasing data suggesting that aminoglycosides may cause harm without clear benefit

Ð Aminoglycosides removed or reduced in current treatment guidelines

1Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation 2015; 132:1435-1486.

TREATMENT: ANTIBIOTICS WHAT’S NEW?

Ò Novel strategies to prevent and treat biofilm-forming strains of multidrug-resistant organisms (e.g., S.aureus)É Inhibition of bacterial adhesionÉ Disruption of biofilm architecture

Elgharably H, Hussain ST, Srestha NK, et al. Current hypotheses in cardiac surgery: biofilm in infective endocarditis. Sem Thorac Cardiovasc Surg 2016; 28:56-59

TREATMENT: ANTIBIOTICS WHAT’S NEW?

Ò Association of nontuberculous mycobacterial infections in cardiac surgical patients

Ò Pathogen identified in heater-cooler devices used in extracorporeal circulation

Ò Chronic colonization despite adherence to manufacturer cleaning recommendations

Ò Attributed to biofilm formation

Elgharably H, Hussain ST, Srestha NK, et al. Current hypotheses in cardiac surgery: biofilm in infective endocarditis. Sem Thorac Cardiovasc Surg 2016; 28:56-59

Ann Thorac Surg 2017; 104:1237-1242

SURGERY

Ò Performed in 50% to 60% of patientsÒ 6-month survival rates > 80%

SURGERY: CURRENT INDICATIONS

Cahill TJ, Baddour LM, HabibG, et al. Challenges in infective endocarditis. JACC 2017; 69:325-344.

SURGERY

Ò Predictors of Surgical Treatment among patients with Indications for Surgery1

1Chu VH, Park LP, Athan E, et al. International collaboration on endocarditis investigators. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation 2015; 131:131-140.

SURGERY

Ò In the “real-world” many patients with a guideline indication for intervention do not undergo surgery1

1Chu VH, Park LP, Athan E, et al. International collaboration on endocarditis investigators. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation 2015; 131:131-140.

Ò The perceived operative risk dictates the threshold for surgery (overall in-hospital mortality of 20% or higher)

SURGERY

Chu VH, Park LP, Athan E, et al. International collaboration on endocarditis investigators. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis. Circulation 2015; 131:131-140.

SURGERY: OPTIMAL TIMING

Ò Balancing ActÉ Delay allows increased antibiotic course and

“stabilization”, but runs risk of disease progression (e.g., abscess, heart block, embolism)

Ò Recent trend towards “Early Surgery”Ò Still controversial; more RCTs neededÒ No proven benefit in delaying surgery once an

indication has been established

Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. NEJM 2012; 366:2466-2473

SURGERY: STROKE

Ò Endocarditis complicated by stroke in 20% to 40% of cases

Ò Independent risk factor for postoperative mortality in IE patients

Ò Risk of stroke highest at diagnosis and decreases rapidly after initiation of antibiotic therapy

Ò Risk factors for embolismÉ Vegetation size (> 10 to 15 mm)É Mitral valve involvementÉ Vegetation mobilityÉ Staphylococcus aureus

Ò Timing of surgery after stroke controversial

jamanetwork.com

SURGERY: STROKE

Ò Early studies identified high mortality rates among patients who underwent surgery soon after stroke, but they were small and not risk-adjusted

Ò Still, there is a reluctance to perform surgery immediately after stroke

Ò No definitive studies have confirmed that it is safe to perform surgery within 7 days after stroke or if it is better to postpone.

hkuelcn.med.hku.hk

SURGERY:Ò More recent studies suggest better

outcomes for endocarditis patients presenting with ischemic stroke when they undergo early cardiac surgery

Ò Time elapsed between the stroke and cardiac surgery does not impact rates of perioperative neurologic complications or neurologic recovery1,2

Ò Mortality was higher when surgery was performed within 4 weeks of hemorrhagic stroke compared with delayed surgery (75% versus 40%)3 1. Ruttmann E, Willeit J, Ulmer H,

Chevtchik O, et al. Neurological outcome of septic cardioembolicstroke after infective endocarditis. Stroke. 2006;37:2094–2099.

2. Barsic B, Dickerman S, Krajinovic V, et al., International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Influence of the timing of cardiac surgery on the outcome of patients with infective endocarditis and stroke. Clin Infect Dis 2013;56:209–17.

3. García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013;127:2272–2284.

SURGERY: STROKE

Ò Current AHA Recommendations

1Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation 2015; 132:1435-1486.

SURGERY: TAVR - ENDOCARDITIS

Ò 1 year incidence 0.1% to 3.0%Ò Causative antecedent procedure identified in about 50%Ò Enterococcus, StaphylococcusÒ < 20% underwent open heart surgery or transcatheter valve-in-

valve procedureÒ Antibiotic therapy with poor results

É In-hospital mortality from 47% to 64%É 1-year mortality from 66% to 75%

researchgate.net

NATIVE MITRAL ENDOCARDITIS

Erik Beyer; youtube.com

bjcardio.co.uk.com

cardiologyres.org

SURGICAL TECHNIQUES: MITRAL VALVE

Ò Lends itself more often to reparative procedures

Ò Severe mitral insufficiency, especially with congestive signs and symptoms, dictates surgical intervention

Ò Look out for ventriculoatrialdiscontinuity

Ò Annular abscess: all infected tissue must be removed and annulus reconstructed with pericardium

Doty JR, Caine WT. Surgical treatment of endocarditis. From: The Johns Hopkins Textbook of Cardiothoracic Surgery 2/e. Eds. Yuh DD, Vricella LA, Yang S, Doty JR. 2007, McGraw-Hill, New York

SURGICAL TECHNIQUES: MITRAL VALVE

Murashita et al. West Virginia Univ, CTSNet

Cleveland Clinic Foundation, 1998

NATIVE AORTIC ENDOCARDITIS

bjcardio.co.uk.com

Internalmedicinerevie.weebly.com

escardio.org

SURGICAL TECHNIQUES: AORTIC VALVE

Ò Leaflet destructionÒ Generally requires aortic valve

replacementÒ No conclusive evidence favoring

tissue over mechanical prosthesisÒ Inspect aortic root for abscessÒ Inspect mitral valve anterior leaflet

for “drop lesions”Ò Involvement of anterior mitral

leaflet and intravalvular fibrous body may require homograft reconstruction

meduweb.com

heartsurgeons.com


Ò Sometimes aortic endocarditis extends onto aortomitral continuity requiring more complicated reconstruction

Ò Homograft reconstruction of intravalvular fibrous body using attached aortomitral continuity, ascending aorta, and left atrial dome

Ò Reimplantation of coronary buttonsÒ Mitral annuloplasty



Jose Navia, MD, Cleveland Clinic

AORTIC ROOT ABSCESS

jscimedcentral.com

Doty JR, Caine WT. Surgical treatment of endocarditis. From: The Johns Hopkins Textbook of Cardiothoracic Surgery 2/e. Eds. Yuh DD, Vricella LA, Yang S, Doty JR. 2007, McGraw-Hill, New York

SURGICAL TECHNIQUES: AORTIC ROOT

Ò Generally requires aortic root replacement

Ò Biologic conduit preferredÒ Occasionally, can get by with

debridement patch repair


columbiasurgery.org heart-valve-surgery.com


Ò Patch Repair


Arie Blitz, MD Case Western Reserve University


Ò Infected Sinus of Valsalva Aneurysm

PROSTHETIC VALVE ENDOCARDITIS

Ò Best assessed by TEE; much higher sensitivity than TTE

Ò Suggestive findings:É “Rocking” valve indicating

dehiscenceÉ Moderate to severe perivalvular

leakÉ Abnormal leaflet motionÉ Perivalvular abscessÉ Vegetation(s)

Ò Staphylococci, Streptococci, and Enterococci are frequent isolated species

Ò Fungal species also seen, especially in immunocompromised

Tuna IC, Harrison MR. NEJM 2001:344:275

PROSTHETIC VALVE ENDOCARDITIS

Jose Navia, MD, Cleveland Clinic

KEY TAKEAWAYS

Ò Incidence of infective endocarditis (IE) rising, affecting a wider demographic with new antibiotic resistances and new cardiac devices

Ò Multimodality diagnostic approaches may improve diagnostic accuracy of IEÒ Antibiotic IE prophylaxis has been revised, focusing on highest risk patientsÒ Shorter-course antibiotic treatment regimens for selected patientsÒ Earlier, more aggressive surgical treatment of IE, with proper indications,

associated with better outcomesÒ Earlier surgical treatment of IE after non-hemorrhagic stroke may be

associated with improved clinical outcomes. Ò Reasonable to defer surgery in patients suffering from hemorrhagic stroke

for four weeksÒ Cornerstone of surgical therapy of IE is to remove all infected tissue, even if

it results in a more extensive operationÒ Homografts generally preferred for aortic root replacement for IE

INFECTIVE ENDOCARDITIS: AN UPDATE · 2019-05-22 · 1Chu VH, Park LP, Athan E, et al. International...

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