Valve Endocarditis Indications and Timing of Surgery

Transcription

1 Valve Endocarditis Indications and Timing of Surgery Michele Di Mauro, MD, PhD Cardiac Surgeon and Cardiologist Heart Department,SS Annunziata H, Chieti, Italy

2 What do the guidelines say?

3 Heart Failure American Heart Association Native valve IE with valve dysfunction causing HF Prosthesis valve IE with dehiscence, fistula, dysfunction cau sing HF EARLY during initial hospitalization and before completion of a full course of antibiotics ESC/EACTS Aortic or mitral NVE or PVE with severe acute regurgitation, obstruction, or fistula causing refractory pulmonary edema or cardiogenic shock EMERGENT (within 24h) Aortic or mitral NVE or PVE with severe acute regurgitation, obstruction, or fistula causing HF or poor hemodynamics URGENT (within few days)

4 Uncontrolled infection Elective surgery? American Heart Association Heart block Annular or aortic abscess, destructive penetrating lesions Relapsing PVE Persistent infection (Persistent bacteremia or fever lasting >5 7 d after the start of appropriate antimicrobial therapy) EARLY ESC/EACTS Elective/Urgent Fungi or multiresistant organisms PVE caused by staphylococci or gram-negative bacteria Urgent Locally uncontrolled infection (abscess, false aneurysm, fist ula, enlarging vegetation) Persisting positive blood cultures despite appropriate antibio tic therapy

5 Prevention of embolism American Heart Association Recurrent emboli and persistent or enlarging vegetations despite appropriate antibiotic therapy Severe valve regurgitation Mobile vegetations >10 mm, particularly when involving the anterior leaflet of the mitral valve EARLY ESC/EACTS Aortic or mitral NVE, or PVE with persistent vegetations >10 mm after embolic episode despite appropriate antibiotic therapy Aortic or mitral NVE with vegetations >10 mm, associated with s evere valve stenosis or regurgitation, and low operative risk Aortic or mitral NVE, or PVE with isolated very large vegetations (>15 mm) URGENT (within few days)

6 55% Concerns from Guidelines Early during initial hospitalization and before completion of a full course of antibiotics 25% Elective (delayed) >1-2 weeks Fungi or multiresistant organisms PVE caused by staphylococci or gram-negative bacteria AHA 35% ESC/EACTS AHA gives a too variable range for timing with the term early ESC suggests to delay surgery after 1 or 2 week of antibiotics BUT in presence of particularly aggressive germs such as fungi and staphylococci and in multiresistant germs where antibiotics are more prone to fail

7 H A V R Take Home Message 1

8 Why should we wait?

9 What does literature say? High Level of evidence Low RCT Meta-analysis Propensity Score Observational studies Kang et al 2012 Liang et al 2016 Lalani et al Many others Left-sided IE Early surgery vs Conventional treatment 16 studies 8141 patients All studies but 1 (early vs delayed) Early surgery vs medical therapy International Collabora tion on Endocarditis Prospective Cohort Study (ICE-PCS) database 619 matched patients

10 Randomized Control Trial

11 Randomized Control Trial Primary end-point A composite of in-hospital death or clinic al embolic events that occurred within 6 weeks after randomization Secondary end-point Death from any cause, embolic events, recurrence of infective endocarditis, and repeat hospitalizatio n due to the development of congestive HF Kang et al. Early Surgery versus Conventional Treatment for Infective Endocarditis. NEJM 2012;366:

12 In hospital mortality long-term mortality Optimal timing for early surgery in infective endocarditis: a meta-analysis Liang et al ICVTS 2016;22: We concluded that early surgery was associat ed with lower in-hospital and long-term mortali ty compared with non-early surgical treatment for IE

13 Propensity Score Study Lalani et al. Analysis of the Impact of Early Surgery on In-hospital Mortality of Native Valve Endocarditis: Use of Propensity Score and Instrumental Variable Methods to Adjust for Treatment Selection Bias. Circulation March 2; 121(8): ICE-PCS Data from Overall The ICE-PCS cohort consisted of 2760 Patients; 1552 NVIE Early vs Medical Therapy 720 Early surgery vs 832 MT Matched cohorts 619 matched patients for each group using PS

14 Cerebral Complications Patients with stroke Better delayed surgery Patients with c. hemorrhage Better delayed surgery STROKE HEMORRHAGE

15 ISCHEMIC STROKE This text can be replaced with your own text EARLY LATE 584 DELAYED 317 EARLY

16 HEMORRHAGIC STROKE This text can be replaced with your own text EARLY LATE 110 DELAYED 31 EARLY

17 MIXED C.E. This text can be replaced with your own text EARLY LATE DELAYED EARLY

18 Moderate Cerebral Complications This text can be replaced with your own text NIHSS 10 Moderate CC

19 Our Experience The Italian Registry of Heart Valve and Prosthesis Infective Endocarditis Surgically Treated The Italian Registry of Valve and Prosthesis Infective Endocarditis Sur gically Treated has been developed since 2013, starting from an idea of Dr. Guglielmo Actis Dato, with the aid of Dr. Michele Di Mauro It was developed on behalf of GIROC (The Italian Group of Research for Outcome in Cardiac Surgery) In 2015, The Italian Society For Cardiac Surgery (SICCH) endorsed GIR OC and this registry

20 Our Experience Vicenza Napoli - II Università-Monaldi 822 Torino - Ospedale Mauriziano 342 Bergamo - Ospedale Papa Giovanni XXIII 305 Genova - Ospedale San Martino-Università 265 Varese - Ospedale Universitario 249 San Donato M.se - IRCCS San Donato M.se 240 Torino - Ospedale Universitario Molinette 228 Milano - IRCCS San Raffaele 224 Bologna - Ospedale Malpighi Sant'Orsola 223 Parma - Ospedale Maggiore 216 Milano- Ospedale Sacco 216 Udine - Ospedale Universitario 165 Verona - Borgo Trento 128 Pisa - Ospedale Universitario 119 Brescia - Spedali Civili 76 Ome (BS) - Fondazione Poliambulanza 71 Lecce - Ospedale V Fazi 66 Roma - Ospedale San Camillo Forlanini 65 Vincenza - Ospedale San Bortolo 32 Catanzaro - Clinica Sant'Anna 21 Bari - Clinica Santa Maria 11 To the last update (February 2018), 21 Italian Centers joined the registry: 4084 patients from 1979 to 2018

21 Low and High Risk! data from the Italian Experience (GIROC) Your Text Here You can simply impress your audience and add a unique zing and appeal to your Presentations. Endoscore 10% High risk Sensitivity 79% Specificity 72% Early mortality Low risk High Risk

22 Let s summarize!

23 Timing Summary small sized stroke Add Text Simple PowerPoint Cerebral hemorrhage Large sized stroke

24 Thank you for your attention! Coming together is a beginning! Keeping together is progress! Working together is SUCCESS. Henry Ford