TREATMENT OF ENDOCARDITIS: Destruction and Reconstruction of the Fibrous Skeleton. Gösta B. Pettersson, M.D., Ph.D. No relationships to disclose!
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1 TREATMENT OF ENDOCARDITIS: Destruction and Reconstruction of the Fibrous Skeleton Gösta B. Pettersson, M.D., Ph.D. The Cleveland Clinic Foundation No relationships to disclose!
2 Adult Cardiac Surgery Symposium 93rd Annual Meeting of the AATS, Minneapolis, Minnesota Sunday, May 5, 2013 TREATMENT OF ENDOCARDITIS: Destruction and Reconstruction of the Fibrous Skeleton Gosta Pettersson, M.D., Ph.D. The Cleveland Clinic Foundation No relationships to disclose!
3 Surgical treatment of endocardtis is learning from experience!
4 200 Cleveland Clinic Endocarditis Surgery #
5 Lesson 1: Don t violate basic surgical principles
6 Lesson 2: Integrate Pathology and Anatomy ROSS for Endocarditis
7 This presentation is about Invasive Left-sided Endocarditis with Destruction beyond leaflets and cusps INVASIVE versus NON-INVASIVE
8 Focus: The Fibrous Skeleton
9 Endocarditis Prexcisting Valvular Disease Bacteremia Adherence Vegetations Release of Enzymes Tissue Disintegration Cusps and Leaflets Invasion & Destruction
10 Bacterial Invasion & Destruction: Enzymatic degradation of connective tissue / non-muscle tissue Enzyme specficity & aggressiveness Organism, e.g. staph. aureus
11 Surgical treatment of endocarditis Understanding destruction and pathology is key to debridement and reconstruction!
12 Native Valve Endocarditis versus Prosthetic Valve Endocarditis INVASIVE versus NON-INVASIVE Cause of A-V block
13 Native Valve Endocarditis
14 Prosthetic Valve Endocarditis
15 Prosthetic Valve Endocarditis
16 100 Survival % p=0.65 NVE PVE Years
17 Invasive Endocarditis Invasive Invasive 36% Invasive % 50 69% 69% 25 0 Noninvasive Aortic IE Noninvasive Mitral IE Noninvasive AV+MV IE
18 Survival Non-Invasive % Invasive p= Years
19 Cause of A-V Block?
20 RA Invasion and A-V node destruction!
21 RA Invasion and A-V node destruction!
22 RA Invasion and A-V node destruction! TV CS
23 RA Invasion and A-V node destruction! RCA LCA LT LVOT CFB
24 Aortic Valve Endocarditis
25 100 Survival: Aortic % AV Years
26 Survival: Aortic Non-Invasive % p=0.7 Invasive Years
27 Autologous Tissue LVOT P. PATCH
28 Aortic Allograft and minimal foreign material
29 Drainage to the pericardium
30 Aortic Valve Endocarditis versus Mitral Valve Endocarditis
31 100 Survival: Mitral % AV MV Years
32 Survival: Mitral Non-Invasive % Invasive p= Years
33 Why are we doing worse with Invasive MV Endocarditis?
34 Invasion is to the AV grove!
35 Surgical principles for Invasive Mitral Valve Endocarditis Expose dome incision / aortotomy / split the intervalvular fibrosa Debride = sterilize cavities Reconstruct anulus with autologous pericardium Anchor valve prosthesis to LV inlet myocardium
36 Radical Debridement still a MUST!
37 Autologus pericardium and Prosthesis
38 Double Valve Endocarditis Aortic and Mitral Valve Endocarditis
39 100 Survival: Double Valve % AV MV AV+MV 20 p= Years
40 100 Survival: Double Valve % Non-Invasive Invasive p= Years
41 Survival Non-Invasive AV % Invasive MV AV+MV Years
42 The Commando operation Intervalvular Fibrosa Reconstruction AV MV
43 Patients 1971 to 2008 n = 146 Double Valve Replacement for Endocarditis 51 (35%) Commando operations
44 % Overall Survival DVR Commando Years
45 Difference in Selection Factors 3 DVR % 2 1 Commando Propensity Score
46 Survival: Matched % DVR Commando Years
47 Double Valve PVE
48 Double Valve PVE
49 Commando operation Intervalvular Fibrosa Reconstruction
50
51
52
53
54 Prosthetic Valve Endocarditis: Subpulmonary Abscess LCA LT
55
56 A Commando Operation
57 Postop TEE
58 Many Roads may lead you to Rome! Condition: Radical debridement Krasopoulos, David and Armstrong 2008
59 Pitfalls
60 Pitfalls Too Late - Preoperative Stroke Too early - Hemorrhagic stroke Insensitive organism Incomplete debridement Missed lesions Misinterpretation of Anatomy and Pathology
61 Pitfalls cont.: Adverse events during reentry
62 Sometimes you need compromise: This prosthetic mitral valve was not infected! LCA RCA
63 Open Chest and Vacuum Dressing an option for Coagulopathy and Bleeding
64 Keys to success 1. See what you are doing 2. Know what you are doing 3. Radical debridement 4. Use less foreign material 5. Master alternative options for reconstruction 6. Adjust technique to tissue quality
65 Q46. Which factor is least important to success of surgery for endocarditis? a. Timing of surgery? b. Appropriate antibiotic treatment? c. Radical debridement? d. Choice of replacement valve?
66
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