dr pilar tornos endocarditis:changing guidelines for a changing disease. indications and optimal...
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Dr Pilar Tornos
Endocarditis:changing guidelines for a changing disease.
Indications and optimal time for surgery
Dr Pilar Tornos
Surgery in active Infective Endocarditis
PROS
To avoid progressive HF
To avoid irreversible structural dammage
To prevent systemic embolism
CONS
High surgical risk
Comorbidities
Possibility of relapses/prosthetic dysfunction
Very complex disease
No strong evidence-based data
Dr Pilar Tornos
Surgery in active Infective Endocarditis
The number of patients operated on during the active phase of infective endocarditis has increased and ranges from 30-60%
Hoen B et al JAMA 2002
Tornos P et al Heart 2005
Reasons:
Changes in epidemiology: more virulent organisms, more complications
Improvement in surgical techniques
The impact of surgery in the outcome is debatable
The effect of surgery is not uniform
There are uncertainties in indications and timing
Dr Pilar Tornos
Impact of surgery in the outcome of IE
No clinical trials, but most studies demonstrate a benefitial effect of surgery.
Assesment of outcome based in propensity score methods.
Do differences in methodological approaches explain conflicting results?
Bannay, A. et al. Eur Heart J 2009
Dr Pilar Tornos
Timing of surgery in the outcome of IE
No independent effect of time to surgery
Surgey performed very early (first week) may improve survival in the most complicated cases of IE.
.Thuny, F. et al. Eur Heart J 2009
Tleyeh IM et al Heart, 2008
The timing of surgery may influence mortality and morbidity
in adults with severe complicated infective endocarditis
Dr Pilar Tornos
New European IE Guidelines: Recommendations
Each case must be individualised and all factors associated with increased risk identified at the time of diagnosis
Early consultation with a cardiac surgeon is recomended in order to establish the surgical indication and its timing
In most cases the need for surgery will be determined by a combination of several high risk features.
Dr Pilar Tornos
New European IE Guidelines: Recommendations
MAIN INDICATIONS FOR SURGERY:
Heart failure: The most frequent and severe complication of IE due to acute regurgitation or more rarely to obstruction.
Uncontrolled infection: Persistent sepsis, increasing vegetation size, perivalvular extension(abscess, false aneurysms, fistulae), difficult organisms
Prevention of embolic events: Risk is highest during the first 2 weeks of AB and in pts with very large(>15 mm) and mobile vegetations
Dr Pilar Tornos
Timing of surgery. Definitions.
Surgery during the active phase: while the patient is still receiving AB
Emergency surgery (within 24 hours)
Urgent surgery (within a few days)
Elective (after weeks of AB)
New European IE Guidelines: Recommendations
Dr Pilar Tornos
Native valve Infective Endocarditis:Indications and timing for surgery
Dr Pilar Tornos
Dr Pilar Tornos
Native valve Infective Endocarditis:Indications and timing for surgery
Dr Pilar Tornos
Right sided Infective Endocarditis:Indications for surgery
Dr Pilar Tornos
Prosthetic valve Infective Endocarditis:Indications and timing for surgery
Dr Pilar Tornos
Dr Pilar Tornos
Prosthetic valve Infective Endocarditis:Indications and timing for surgery
Dr Pilar Tornos
Surgery in active IE. Final comments
Early identification of high risk patients
Early consultation with cardiac surgeon
Close follow up of medically treated patients, with immediate identification of complications that may require urgent surgery
Do not delay surgery if indicated