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Aortic Valve Endocarditis
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weeks from diagnosis, while others define “early surgery” as surgery performed during the
first hospitalization for IE [62-64].
Treatment in the acute phase with active or uncontrolled sepsis may lead to higher
operative mortality and morbidity and risk of relapse [65] and the surgical operation could be
more demanding due to the need to intervene on inflamed and infected tissue.
Although there are no prospectively randomized studies (excluding the one already
mentioned, which however has several limitations), the advantages of early surgery have been
highlighted by several observational studies, often enhanced by the propensity score
technique [62-64]. Lalani et al. [64] studied the issue on a large multinational cohort of
patients with definite IE. Effects of early surgery was assessed by propensity-based matching
incorporating 25 clinically relevant covariates and 3 interaction terms. In subgroup analysis,
surgery was found to confer a survival benefit compared with medical therapy among patients
with a higher propensity for surgery (absolute risk reduction 10.9%) and those with
paravalvular complications (17.3%), systemic embolization (12.9%), Staphylococcus aureus
NVE (20.1%), and stroke (13%). Authors concluded that early surgery for NVE is associated
with a significantly lower in-hospital mortality rate than medical therapy.
A recent meta-analisys analyzing 16 studies with 8141 patients [66] confirmed the
connection between early surgery and better results in term of early and long-term results for
NVE while the effectiveness of the “early surgery” approach in PVE was less clear.
While surgical therapy, especially early on, seems to give good results, there are cases in
which it is believed that early intervention is impossible: patients with recent brain damage.
In these cases, surgery can give a worsening of the neurological lesion with different
mechanisms: heparinization, hypercoagulability and hypotension during extracorporeal
circulation may contribute to further cerebral infarction into hamorrhagic or favor its
extension.
This issue is particularly important because recently, using magnetic resonance imaging
(MRI), it has been observed that there are many more patients with brain injuries than
previously believed [34, 67] reaching up to 62%.
This group of patients has high mortality: in patients undergoing surgery with left side IE
with pre-existing neurologic damage, mortality was 45% compared with 24% of those
without [68, 69].
The STS guideline [3] suggests delaying operation for almost 4 weeks following
neurologic damage.
However, in patients with complicated endocarditis, waiting 4 weeks may be impossible
due to the presence of heart failure or other conditions that require urgent or emergency
intervention. Furthermore, postponing the procedure exposes these patients to the risk of
further cerebral embolic episodes.
Some studies have recently shown that surgery, even performed in the presence of
ischemic brain damage, may not be as risky as expected [70-72].
In a retrospective study using magnetic resonance imaging as a tool to detect neurological
damage, Yoshioka et al. [67] studied 64 patients with preoperative neurological damage. 34
were operated on within 14 days of neurological diagnosis (early group) and 30 after 14 days
(late group). Worsening of the brain injury occurred in one patient from each group, while
hemorrhagic transformation occurred only in one patient from the late group. The authors
concluded that there are no benefits in delaying surgery beyond 14 days. However, the
number and retrospective nature of the study do not allow generalizations.
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A meta-analysis [68] including 27 studies found higher mortality in early surgery in the
presence of ischemic or hemorrhagic brain damage (pooled relative risk 1.74, confidence
interval 1.34-2.25) and a higher occurrence of worsening of the neurological damage.
However, in the analysis of the subgroups, patients with ischemic stroke operated within 7
days did not worsen compared to those operated within 14 days; patients with hemorrhagic
damage operated on within 21 days had an increase in mortality compared to those operated
within the 28th day (pooled relative risk 1.77 vs 0.63) and a higher incidence of worsening of
neurological damage (pooled relative risk 2.02 vs 0.44). The conclusion was that intervention
in the presence of ischemic damage should be delayed by 7-14 days if possible and in the
presence of hemorrhagic damage it should be delayed beyond 21 days.
It would be desirable, regarding this specific topic, to carry out randomized prospective
studies that would allow a better definition of the optimal time for intervention while avoiding
potential biases..
Techniques
Aims of IE surgery include: removal of all infected tissue and reconstruction of cardiac
morphology and function.
In the achievement of these goals, we have to distinguish aortic valve IE in two principal
groups:
Infection limited to leaflet
Infection extending beyond leaflet (or complex aortic valve endocarditis)
When only leaflets are involved, with both vegetation and perforation, the aortic valve
surgery doesn’t differ from the aortic valve replacement for non-infective aortic disease with
valve replacement using mechanical or biological prostheses.
If abscess formations are detected upon removal of the cusps (or already known by means
of preoperative diagnostic imaging), these must be debrided and the stitches, with pledgets,
are placed to obliterate the cavity. When this is not possible due to extension of the disrupted
tissue, an autologous or heterologous pericardium patch is sutured around the abscess cavity
with the stitches passed on the healthy myocardial tissue and the aorta. The surface of the
patch can be used as a hook for the sutures of the valve prosthesis.
Pericardial or Dacron patches are used also for the closure of structural defect in aorto-
mitral continuity, left ventricle, atrium, mitral valve or ventricular septal defects.
When the infection extends beyond the annulus with paravalvular abscess formation and
root destruction, the surgical treatment includes the resection of the infected tissue and
reconstruction of the left ventricular outflow tract with coronary ostia reimplanted as buttons.
In these cases, use of cryopreserved homografts was historically considered as the gold
standard [73]. Advantages in the homografts’ use were the low recurrence of infection, good
hemodynamic behavior with low gradient and low morbidity and mortality. The
disadvantages were the demanding surgical techniques, the tendency to calcify and the
limited availability [74, 75]. Recurrence of infection in the homograft has also been reported.
Aortic Valve Endocarditis
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They were progressively substituted by stent less aortic valve, easier to implant and with
similar characteristics [75-78]; furthermore stentless aortic valve are always available. They
can be implanted in subcoronary position or be utilized for complete root replacement [79,
80].
Composite grafts using stented mechanical or biological valves were alternative to
homograft and stentless valves.
Results
Early results of surgery for IE are inferior to elective non-infective valve surgery, ranging
in recent series between 5 to 14%. Long term result are also inferior with a 10-year survival
rate ranging between 40 to 60%. These results are partly due to patients’ selection, as those
operated frequently suffer from heart failure, uncontrolled infection, recurrent embolism,
cardiac and systemic dysfunction and the potential presence of other infection’s localization
and persistence of microorganism in the biofilm complex.
Leontyev et coll. [81] retrospectively analyzed 172 patients operated for aortic valve IE
with aortic root abscess at Herzzentrum, Universitat of Leipzig in Germany between 1996 and
2009. They had a 30 days mortality of 25% (35.5% in NVE vs 16.7% in NVE) and 1 and 5
years mortality were 55% and 50% respectively. Interestingly, they found a recurrence rate of
8.7% occurring mainly in the first 12-months following surgery.
In a recent single center report on 168 patients with aortic valve IE operated at Leuven
University Hospital in Belgium between 2000 and 2013 [82] the operative mortality was
10.7%; there were no differences between treatment groups (stented graft, stented graft with
patch, stentless valve, allograft and composite graft). During the 13-years follow up, there
were other 47 deaths with survival at 10 years ranging from 55% to 75% in groups.
Reinfection occurred in 23 patients and was significantly higher in patients treated with
composite graft (33.3%) and lower in the patients treated with stentless valve (0%). Predictors
of mortality were cardiogenic shock, septic shock, ejection fraction and concomitant mitral
valve surgery while predictors of reinfection were mitral valve endocarditis and aortic root
abscess.
The stented valves had an earlier re-infection peak compared to allographs in the group
analyzed by Knosalla et coll. [83] while stentelss valve have a constant rate of reinfection
without the initial risk increase [81, 82].
PROSTHETIC VALVE ENDOCARDITIS
PVE accounts for 25% of the cases of IE and occurs in 1 to 6% of patients with valvular
prostheses with high mortality rates ranging between 20 to 40% [84, 85].
PVE are traditionally divided in early and late on the basis of the interval between the
valve implantation and the infection onset. Early PVE (within 12 months of the first surgery)
accounts for the 43% of PVE while 57% has late PVE. The aortic valve is involved in 66.5%
of cases [86].
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This difference is important because the first form is directly linked to the surgical act
and the perioperative period while the second has the same etiology as the NVE.
The time interval that defines the early from and late form is still object of debate to this
day.
The guidelines indicate this time interval as 1 year [3, 4], but many reports indicate
shorter intervals with almost 77% of cases occurring within 120 days. Lee et al. [87] found
that the diagnosis of PVE occur in 46.4% in the first two months. The median time between
surgery and infection ranged from 53 days and 129 days [88].
Moreover, after 120 days, a shift in causative microorganisms was observed: the most
common agent causing early PVE is the Staphilocoloccus aureus (36%) and CoNS while late
PVEs are more frequently caused by Enterococci and Streptococcus viridans. Staphylococcus
aureus early PVE represent a subgroup with high risk of mortality and complication [89].
Some retrospective studies [90, 91] and a meta-analysis [92] have shown a greater risk of
PVE for biological valves compared with mechanic ones, but this has not been confirmed in
other studies.
In early PVE microorganisms invade prosthesis during valve replacement operation or
via hamatogenic dissemination. In biological prostheses, PVE involves mainly leaflets with
vegetation development and leaflet perforation. In mechanical prosthesis, the ring invasion is
aided by the slow process of ring endothelization. From the ring, pathogens initially invade
the perivalvular tissue causing abscess, pseudoaneurism, fistulas and valve dehiscence with
extensive disruption [93, 94]. Periannular extension is present in 56-100% of PVE.
Symptoms of PVE don’t differ from those of NVE and are frequently initially
disregarded.
Diagnosis relies mainly on TEE while TTE is made difficult by artifacts caused by the
prostheses.
Sensitivity of TEE in diagnosis of PVE ranges between 86% to 96% while TTE has a
sensitivity of 17-36% [95]. CT/PET and CT-SPECT are useful in uncertain cases [46-49].
Antibiotic therapy is regarded as base treatment for PVE, but it frequently evolves into
more complex forms requiring surgery.
Mortality decreased in recent years due the advancements in diagnostic and treatments,
but still remains high. Surgery of PVE has high mortality 24-35% and frequently requires
complex aortic root reconstruction.
In a large analysis involving 1313 patients operated on for IE at Deutsches Herzzentrum
in Berlin [96], 349 were PVE (26,6%). The aortic valve prostheses endocarditis occurred in
215 cases (61.6%), 202 of which with abscess formation. The major causative agent was
Staphilococcus aureus. The operative mortality within the whole group was of 28,4% and the
30-day, 1-, 5- and 10 year survival were 71,4 ± 2,4%, 58,7 ± 2,7%, 44,5 ± 3%, 31,7 ± 3,5%.
Predictors of early mortality were: mechanical support, emergency operation, catecholamine
support, mitral valve surgery and age. The main intervention performed on the aortic valve
was aortic root replacement with homograft.
Habib et al. [97] identified the following mortality risk: severe heart failure,
staphylococcal infection and PVE complications. Therefore, they suggested to aggressively
treat patients with these three conditions. Luciani et al. [86] identified as mortality risk
factors: female gender, shock status, surgical procedures within 3 months, multi valvular
involvement and urgent surgery.
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Moreover, many studies report high late mortality rate with 10 years survival of about
30% [96].
A new chapter in the field of prosthetic endocarditis has been opened with the spread of
transcatheter valve implantation (TAVI) procedures: the incidence of endocarditis after TAVI
is around 1% [19].
While some authors have indicated CoNS, Staphilococcus aureo, enterococci and
streptococci as main causative agents [20], others have noted a higher incidence of bacteria
normally present in the genitourinary and intestinal tract such as enterococci in trans femoral
TAVI and a higher incidence of staphilococci in valve implanted using trans apical access
[98]. In TAVI, the infection is mainly localized to the leaflet and less on the stent or the
surrounding structures [19].
The majority of patients with TAVI IE are medically treated also if complications are
present. In fact, rates of operative mortality within this subgroup of patients reaches 34% [99]
as they had already been considered at high or very high operative risk when scheduled for
TAVI.
OUR EXPERIENCE AT THE LANCISI CARDIOVASCULAR CENTER
We retrospectively analyzed the profile and outcome of surgically treated patients with
aortic valve IE over a 4 years period, between January 2016 and December 2019.
One-hundred-seventeen endocarditis patients were operated upon. Of these, 76 (65%)
patients (n = 53 men, median age 63 years) had aortic valve IE with 34 (44.7%) of them
showing prosthetic endocarditis (PVE).
13 (17.1%) patients had mitral involvement and 2 (2.6%) tricuspid insufficiency
requiring correction.
Periannular abscess was found in 21 (27.6%) patients and 9 (11.8%) of them developed
pseudoaneurysms. Among patients with PVE, 24 (70.5%) had prostheses dehiscence.
Cultures were negatives in 42 (55.3%) patients. The most frequent causative
microorganisms were streptococcus (15 patients), followed by staphylococci (11) and
enterococci (6). Almost all patients underwent maximal antibiotic therapy immediately after
the diagnosis of endocarditis was suspected and strict clinical followup with the cooperation
of infective disease specialists and cardiologists. This likely justifies the high percentage of
cases with negative cultures.
Emergency operation was performed in 11 (14.5%); 3 patients were in cardiogenic shock
and 26 had severe cardiac failure at time of operation. Euroscore II was 7.2 (range 0.5 – 52).
Procedures performed included 58 aortic valve replacements (76.3%), 2 aortic root
replacement with composite graft and 16 (21%) root replacement with stentless valved
pericardial conduit implanted using a subannular suturing line (Biointegral) (Di Eusanio et al.
2019).
Associate procedures were mitral valve replacement or repair (n = 14), tricuspid valve
repair (n = 2), pace-maker implantation (n = 9), abscess closure with pericardial or autologous
patch (n = 6) and myocardial revascularization (n = 2).
Overall in-hospital mortality was 2.6% (n = 2): both patients had PVE and previous aortic
root replacements. One had undergone aortic valve replacement with stented prostheses and
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root replacement with stentless valved conduit. The second patient was operated on in
emergency due to cardiogenic shock and had a recent cerebral embolism. Both deaths
occurred in the ICU, following multi-organ failure.
Despite its retrospective nature and the relatively limited number of patients taken into
account, our case study shows that the mortality of patients with IE of the aortic valve can be
significantly lowered with a combination of aggressive pre-operative antibiotic therapy, early
surgery and by involving a diversified team of specialists in the handling of the patient.
CONCLUSION
Aortic valve IE is a complex disease with high mortality rate and its management
presents many challenges.
Nowadays, there is an increasingly incidence of acute forms affecting elderly patients and
with many comorbidities. The germs involved often exhibit antibiotic resistance and are more
aggressive, also due to the emergence of health-care associated forms.
On the other hand, there are many fields in which innovations are being sought to
improve treatments: new diagnostic techniques, new antibiotics and molecules to fight the
biofilm and the shift toward early surgery.
New antibiotics could lead to better eradication of infections and new delivery strategies
could incentivize hospitals let patients continue therapies at home. Molecules are tested to
fight the biofilm. Surgical therapy, thanks to technical and anesthesiology improvements,
moves towards early intervention in order to avoid the rise of complicated forms.
In any case, the various phases of the management of patients with endocarditis involve
different medical professionals with diverse skills who must interface and cooperate in order
to identify the best approach and timing for diagnosis and therapy.
The creation of multidisciplinary teams has been proposed in tertiary hospitals.
Endocarditis teams should be trained by cardiologists, cardiac surgeons, infectious disease
specialists and radiologists, pharmacologists and neurologists as needed. The team members
should regularly meet in order to discuss their progress with endocarditis patients.
The implementation of these teams has been associated with a reduction in mortality
[100, 101] and are strongly recommended in guidelines [4, 97].
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