Open Transcatheter Multivalve Replacement in Degenerated Valve Prostheses in High-Risk Patients with Endocarditis

Abstract Multivalve redo procedures carry a high surgical risk. We describe an alternative surgical treatment for patients presenting with severely degenerated aortic and mitral valve prostheses who have to undergo open surgery due to endocarditis. Open transcatheter multivalve implantation is a feasible bailout strategy in high-risk patients to save cross-clamp and procedural times to reduce morbidity and mortality.

Massa Valvar Mitral em Paciente com Suspeita de Lúpus Sistêmico: Tumor, Endocardite ou Ambos? / Mitral Valve Mass in a Patient Suspected of Systemic Lupus: Tumor, Endocarditis or Both?

Resumo Apresentamos o relato de caso de uma paciente com mixoma valvar mitral infectado e uma revisão da literatura sobre o assunto. Uma mulher de 33 anos apresentou histórico de febre e dispneia com evolução de alguns dias. Na hospitalização, ela apresentava uma síndrome semelhante ao lúpus, com hemoculturas positivas para Haemophilus spp . O ecocardiograma revelou uma massa gigante envolvendo ambos os folhetos mitrais associada à regurgitação grave, necessitando de troca valvar mitral biológica. A microscopia revelou mixoma infectado e a paciente recebeu alta assintomática após o término da antibioticoterapia. Ela apresentou bons resultados no seguimento. Este é o sexto caso de mixoma valvar mitral infectado relatado na literatura e o terceiro caso de mixoma cardíaco infectado pelo grupo HACEK. Devido à alta incidência de eventos embólicos, a antibioticoterapia precoce aliada à pronta intervenção cirúrgica são decisivos para a redução da morbimortalidade. O tempo para o diagnóstico foi muito mais breve do que o geralmente relatado em casos de endocardite por HACEK. A troca valvar foi a intervenção mais comum e todos os pacientes em relatos de caso anteriores apresentaram bons resultados no seguimento.

Abstract We present a case report of a patient with an infected mitral valve myxoma and a literature review on the subject. A 33-year-old female presented with a history of fever and dyspnea evolving over a few days. On admission, she had a lupus-like syndrome with positive blood cultures for Haemophilus species . Echocardiogram revealed a giant mass involving both mitral leaflets causing severe regurgitation, requiring biological mitral valve replacement. Microscopy showed an infected myxoma and the patient was discharged asymptomatic upon completion of antibiotics. She did well on follow-up. This is the sixth case of an infected mitral valve myxoma reported in the literature and the third case of a cardiac myxoma infected by the HACEK group. Exceedingly high incidence of embolic events makes prompt imaging, antibiotic therapy and surgery crucial for better outcomes. Time to diagnosis was much briefer than usually reported in other cases of HACEK endocarditis. Valve replacement was the most common surgical procedure and all patients from previous reports did well on follow-up.

Análise de Escores de Risco para Predição de Mortalidade em Pacientes Submetidos à Cirurgia Cardíaca por Endocardite / Analysis of Risk Scores to Predict Mortality in Patients Undergoing Cardiac Surgery for Endocarditis

Resumo Fundamento Escores de risco estão disponíveis para uso na prática clínica diária, mas saber qual deles escolher é ainda incerto. Objetivos Avaliar o EuroSCORE logístico, o EuroSCORE II e os escores específicos para endocardite infecciosa STS-IE, PALSUSE, AEPEI, EndoSCORE e RISK-E na predição de mortalidade hospitalar de pacientes submetidos à cirurgia cardíaca por endocardite ativa em um hospital terciário de ensino do sul do Brasil. Métodos Estudo de coorte retrospectivo incluindo todos os pacientes com idade ≥ 18 anos submetidos à cirurgia cardíaca por endocardite ativa no centro do estudo entre 2007 e 2016. Foram realizadas análises de calibração (razão de mortalidade observada/esperada, O/E) e de discriminação (área sob a curva ROC, ASC), sendo a comparação das ASC realizada pelo teste de DeLong. P < 0,05 foi considerado estatisticamente significativo Resultados Foram incluídos 107 pacientes, sendo a mortalidade hospitalar de 29,0% (IC95%: 20.4-37.6%). A melhor razão de mortalidade O/E foi obtida pelo escore PALSUSE (1,01, IC95%: 0,70-1,42), seguido pelo EuroSCORE logístico (1,3, IC95%: 0,92-1,87). O EuroSCORE logístico apresentou o maior poder discriminatório (ASC 0,77), significativamente superior ao EuroSCORE II (p = 0,03), STS-IE (p = 0,03), PALSUSE (p = 0,03), AEPEI (p = 0,03) e RISK-E (p = 0,02). Conclusões Apesar da disponibilidade dos recentes escores específicos, o EuroSCORE logístico foi o melhor preditor de mortalidade em nossa coorte, considerando-se análise de calibração (mortalidade O/E: 1,3) e de discriminação (ASC 0,77). A validação local dos escores específicos é necessária para uma melhor avaliação do risco cirúrgico. (Arq Bras Cardiol. 2020; 114(3):518-524)

Abstract Background Risk scores are available for use in daily clinical practice, but knowing which one to choose is still fraught with uncertainty. Objectives To assess the logistic EuroSCORE, EuroSCORE II, and the infective endocarditis (IE)-specific scores STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E, as predictors of hospital mortality in patients undergoing cardiac surgery for active IE at a tertiary teaching hospital in Southern Brazil. Methods Retrospective cohort study including all patients aged ≥ 18 years who underwent cardiac surgery for active IE at the study facility from 2007-2016. The scores were assessed by calibration evaluation (observed/expected [O/E] mortality ratio) and discrimination (area under the ROC curve [AUC]). Comparison of AUC was performed by the DeLong test. A p < 0.05 was considered statistically significant. Results A total of 107 patients were included. Overall hospital mortality was 29.0% (95%CI: 20.4-37.6%). The best O/E mortality ratio was achieved by the PALSUSE score (1.01, 95%CI: 0.70-1.42), followed by the logistic EuroSCORE (1.3, 95%CI: 0.92-1.87). The logistic EuroSCORE had the highest discriminatory power (AUC 0.77), which was significantly superior to EuroSCORE II (p = 0.03), STS-IE (p = 0.03), PALSUSE (p = 0.03), AEPEI (p = 0.03), and RISK-E (p = 0.02). Conclusions Despite the availability of recent IE-specific scores, and considering the trade-off between the indexes, the logistic EuroSCORE seemed to be the best predictor of mortality risk in our cohort, taking calibration (O/E mortality ratio: 1.3) and discrimination (AUC 0.77) into account. Local validation of IE-specific scores is needed to better assess preoperative surgical risk. (Arq Bras Cardiol. 2020; 114(3):518-524)

Mortality predictors in the surgical treatment of active infective endocarditis

Abstract Introduction: Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated. Objective: To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up. Methods: This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes. Results: The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003). Conclusion: A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.

Aporte de la ecocardiografía tridimensional en el diagnóstico y manejo de la endocarditis infecciosa: experiencia clínica / Added value of three-dimensional echocardiography in the diagnosis and management of infective endocarditis: clinical experience

Resumen: El diagnóstico ecocardiográfico (eco) de la endocarditis infecciosa ha tenido una evolución vertiginosa, destacando el desarrollo de la ecocardiografía transesofágica (ETE), la imagen armónica y la ecocardiografía tridimensional (Eco 3D), tecnologías que han incrementado su capacidad diagnóstica. Presentamos una serie de endocarditis donde el Eco 3D tuvo un rol importante. CASO 1: Hombre de 18 años, antecedente remoto de artritis séptica y deterioro de capacidad funcional asociado a soplo de insuficiencia mitral. La ecocardiografía transtorácica (ETT) objetivó leve dilatación ventricular izquierda e insuficiencia mitral severa, el Eco 3D identificó una perforación circular en el velo anterior mitral, logrando la reparación valvular con un parche de pericardio. CASO 2. Hombre de 29 años, con absceso dental reciente, se presenta en shock séptico, el ETT y ETE mostraron una válvula aórtica bicúspide (VAB) con insuficiencia severa y un absceso del velo anterior mitral. El Eco 3D identificó una perforación del velo no rafial, se realizó un doble recambio valvular. CASO 3: Hombre de 61 años, con antecedente previo de endocarditis y VAB. Consulta por estado infeccioso. El ETT y ETE informaron insuficiencia aórtica moderada asociado a insuficiencia mitral severa, el eco 3D identificó prolapso del segmento P3 de la válvula mitral, ayudando a programar su reparación. CASO 4. Mujer de 78 años, con diagnóstico de endocarditis mitral protésica, el Eco 3D objetivó un absceso periprotésico posterior de 16 mm, siendo referida a cirugía. El Eco 3D aporta información complementaria en diversos escenarios de la endocarditis, tales como: perforaciones valvulares, compromiso perianular, endocarditis protésica, optimizando su manejo.

Abstracts: The echocardiographic diagnosis of infective endocarditis has evolved in a vertiginous manner. Among its main hallmarks are; the development of transesophageal echocardiography (TEE), harmonics imaging and three-dimensional echocardiography (3D Echo), thereby enhancing its diagnosis capability. The following endocarditis cases revealed the usefulness of 3D Echo. CASE 1. 18 year-old male, past history of septic arthritis, refers decline in functional capacity associated with a mitral regurgitation murmur. Transthoracic echocardiography (TTE) pictured a mildly dilated left ventricle and severe mitral regurgitation. 3D Echo identified a circular perforation of the anterior mitral leaflet; successful mitral valve repair was accomplished. CASE 2. 29 year-old male, with recent dental abscess, presents in septic shock. TTE and TEE portrayed a bicuspid aortic valve (BAV) with severe regurgitation along with an abscess of the anterior mitral valve leaflet. 3D Echo showed a perforation of the nonfused aortic leaflet; double valve replacement was uneventfully performed. CASE 3. 61 year-old male, with remote history of endocarditis and BAV, evaluated with TTE and TEE due to sepsis, depicting moderate aortic regurgitation and P3 prolapse with rupture chordae and severe mitral regurgitation. Based on the 3D Echo data the mitral valve was repaired and the aortic valve replaced. CASE 4. 78 year-old woman with prosthetic mitral valve endocarditis, 3D Echo allowed complete visualization of a 16 mm diameter posterior abscess, being referred to surgery. Thus, 3D Echo has added value in several endocarditis scenarios such as; leaflet perforations, periannular involvement, prosthetic valve endocarditis, improving its management.

Endocarditis fúngica, una causa infrecuente de lesión en válvula cardiaca nativa / Fungal endocarditis, an uncommon cause of native cardiac valve disease

Introducción: La endocarditis fúngica (EF) es una forma grave de endocarditis infecciosa (EI), asociada a una alta morbimortalidad. Su incidencia es baja y se puede presentar después de una cirugía cardiaca, uso de válvula cardiaca protésica, catéteres endovenosos centrales (CVC), etc. Presentación del caso: Hombre de 17 años con antecedente de enfermedad renal crónica en hemodiálisis y múltiples hospitalizaciones por septicemia asociada a CVC, presentó cuadro febril el cual fue tratado con antibióticos y cambio de CVC. Estudio con hemocultivos resultó positivo para Candida parapsilosis. Se decidió hospitalización domiciliaria y tratamiento con Fluconazol. Persistió febril por lo que se decidió hospitalización por sepsis fúngica persistente y continuar tratamiento antimicótico. Estudio con ecocardiograma mostró endocarditis mitral con vegetación móvil en velo anterior e insuficiencia moderada. Se decidió tratamiento quirúrgico, realizándose reemplazo de válvula mitral con prótesis cardiaca biológica. En el intraoperatorio se observó vegetación verrugosa y móvil. Cultivos y estudio histopatológico confirmó EF. Evolucionó con candidemia persistente, pero sin hallazgos ecográficos de endocarditis. Control con tomografía computada demostró hallazgos sugerentes de candidiasis crónica diseminada (CCD), modificándose el tratamiento con Caspofungina y Voriconazol. Al cuarto mes postoperatorio fue dado de alta con tratamiento antifúngico crónico. Discusión: La EF es un tipo infrecuente de endocarditis infecciosa constituyendo un 6% de los casos. Se asocia a una alta mortalidad a pesar de tratamiento médico y quirúrgico combinado. La CCD es una forma infrecuente de candidemia, casi exclusiva de pacientes oncohematológicos. El antecedente de factores de riesgo obliga a sospecharlo.

Introduction: Fungal endocarditis (EF) is a severe form of infectious endocarditis (IE) associated with high morbidity and mortality. Its incidence is low and may be related to heart surgery using prosthetic heart valve, central intravenous catheters (CVC), etc. Case report: Man aged 17 with a history of chronic kidney disease on hemodialysis, and multiple hospitalizations for sepsis associated to CVC, presented febrile illness, which was treated with antibiotics and CVC change. Blood culture study was positive for Candida parapsilosis. Home hospitalization and treatment with Fluconazole was decided. He persisted febrile so hospitalization it was decided by persistent fungal sepsis and to continue antifungal therapy. Echocardiogram study showed mitral endocarditis with mobile vegetation anterior leaflet and mitral insufficiency. Surgical treatment was decided. Mitral valve replacement surgery with biological cardiac prosthesis is performed. A warty and mobile vegetation was observed in the surgery. Cultures and histopathology confirmed EF. He evolved with persistent candidemia, but without sonographic findings of endocarditis. Control with computed tomography showed suggestive findings of chronic disseminated candidiasis (CCD), modifying treatment with Caspofungin and Voriconazole. The fourth postoperative month was discharged with chronic antifungal treatment. Discussion: EF is a rare type of EI constitutes 6% of cases. It is associated with high mortality despite combined medical and surgical treatment. The CCD is an almost exclusive rare form of candidemia in oncohematological patients. The history of risk factors forcing suspect.

Healthcare-Associated Infective Endocarditis: a Case Series in a Referral Hospital from 2006 to 2011 / Endocardite Infecciosa Associada aos Cuidados de Saúde: Série de Casos em Hospital de Referência entre 2006 e 2011

Background: Healthcare-associated infective endocarditis (HCA-IE), a severe complication of medical care, shows a growing incidence in literature. Objective: To evaluate epidemiology, etiology, risk factors for acquisition, complications, surgical treatment, and outcome of HCA-IE. Methods: Observational prospective case series study (2006-2011) in a public hospital in Rio de Janeiro. Results: Fifty-three patients with HCA-IE from a total of 151 cases of infective endocarditis (IE) were included. There were 26 (49%) males (mean age of 47 ± 18.7 years), 27 (51%) females (mean age of 42 ± 20.1 years). IE was acute in 37 (70%) cases and subacute in 16 (30%) cases. The mitral valve was affected in 19 (36%) patients and the aortic valve in 12 (36%); prosthetic valves were affected in 23 (43%) patients and native valves in 30 (57%). Deep intravenous access was used in 43 (81%) cases. Negative blood cultures were observed in 11 (21%) patients, Enterococcus faecalis in 10 (19%), Staphylococcus aureus in 9 (17%), and Candida sp. in 7 (13%). Fever was present in 49 (92%) patients, splenomegaly in 12 (23%), new regurgitation murmur in 31 (58%), and elevated C-reactive protein in 44/53 (83%). Echocardiograms showed major criteria in 46 (87%) patients, and 34 (64%) patients were submitted to cardiac surgery. Overall mortality was 17/53 (32%). Conclusion: In Brazil HCA-IE affected young subjects. Patients with prosthetic and native valves were affected in a similar proportion, and non-cardiac surgery was an infrequent predisposing factor, whereas intravenous access was a common one. S. aureus was significantly frequent in native valve HCA-IE, and overall mortality was high. .

Fundamento: A endocardite infecciosa associada aos cuidados de saúde (EI-ACS) é uma complicação grave associada aos cuidados médico-hospitalares, com uma incidência crescente na população. Objetivo: Avaliar a EI-ACS com relação à sua epidemiologia, etiologia, fatores de risco de aquisição, complicações, tratamento cirúrgico e quadro clínico. Métodos: Este estudo de caráter observacional e prospectivo avaliou uma série de casos reportados entre 2006 e 2011 em um hospital público no Rio de Janeiro. Resultados: Cinquenta e três pacientes com EI-ACS de um total de 151 casos de endocardite infecciosa (EI) foram incluídos no estudo, dos quais 26 (49%) eram do sexo masculino (idade média de 47 ± 18,7 anos), e 27 (51%) eram sexo feminino (idade média de 42 ± 20,1 anos). Quadros clínicos agudos de EI ocorreram em 37 casos (70%) e quadros subagudos em 16 casos (30%). A válvula mitral foi afetada em 19 casos (36%), e a valva aórtica em 12 casos (36%). As válvulas cardíacas protéticas foram afetadas em 23 casos (43%), e as válvulas cardíacas nativas em 30 casos (57%). O acesso venoso profundo foi usado em 43 pacientes (81%). Hemoculturas negativas foram observadas em amostras de 11 pacientes (21%). Nas hemoculturas positivas, Enterococcus faecalis foi identificado em 10 casos (19%), Staphylococcus aureus em 9 casos (17%) e Candida sp. em 7 casos (13%). Febre ocorreu em 49 pacientes (92%), esplenomegalia em 12 pacientes (23%), novo sopro de regurgitação valvar em 31 pacientes (58%) e proteína C reativa elevada em 44 pacientes (83%). O ecocardiograma apresentou critérios principais em 46 casos (87%). Trinta e quatro pacientes (64%) foram submetidos à cirurgia cardíaca. A mortalidade ocorreu em 17 casos (32%). Conclusão: EI-ACS afeta ...

Tricuspid Valve Replacement in an Adult with Destroyed Tricuspid Valve and Refractory Right Heart Failure.

22 year old woman with no previous heart disease history, presented with progressive worsening of right heart failure symptoms due to severe tricuspid valve regurgitation which had become refractory to medical management. Echocardiogram revealed probable rare case of dysplastic tricuspid valve with large calcified mobile masses attached to leaflets. Calcified masses were thought to be due to healed vegetations from silent infective endocarditis of abnormal tricuspid valve which she had suffered in the past. There were no known acquired causes of tricuspid valve endocarditis. She had successfully undergone tricuspid valve replacement with bio-prosthetic valve along with a right atrial reduction surgery after which her heart failure symptoms improved markedly.

Surgical treatment of aortic valve endocarditis: a 26-year experience / Tratamento cirúrgico da endocardite da válvula aórtica: 26 anos de experiência

Objective: We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years. Methods: From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years. Results: Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up. Conclusion: Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low. .

Objetivo: Analisamos, retrospectivamente, os resultados das operações realizadas para endocardite valvar aórtica em um único centro em 26 anos. Métodos: De junho de 1985 a janeiro de 2011, 174 pacientes foram operados por endocardite da válvula aórtica. Cento e trinta e oito (79,3%) pacientes eram do sexo masculino e a média de idade foi de 39,3 ± 14,4 (9-77) anos. Vinte e sete (15,5%) pacientes apresentavam endocardite na prótese valvar. O tempo médio de acompanhamento foi de 7,3 ± 4,2 anos (0,1- 18,2) totalizando 1.030,8 paciente/ano . Resultados: Duzentos e oitenta e dois procedimentos foram realizados. O procedimento mais realizado foi a substituição da valva aórtica por prótese mecânica (81,6 %). A mortalidade intra-hospitalar ocorreu em 27 (15,5%) casos. No pósoperatório, 25 (14,4% ) pacientes apresentaram baixo débito cardíaco e 17 (9,8%) bloqueio cardíaco . As taxas de sobrevida atuarial para 10 e 15 anos foram 74,6±3,7% e 61,1±10,3%, respectivamente. A mortalidade intra-hospitalar foi encontrada esteve associada com o sexo feminino, operação de emergência, insuficiência renal pós-operatória e baixo débito cardíaco. A mortalidade a longo prazo foi significativamente associada com o envolvimento da válvula mitral. O sexo masculino encontrado mostrou-se um fator de risco para a recorrência no seguimento. Conclusão: A cirurgia para tratamento da endocardite da válvula aórtica apresenta mortalidade. Operação de emergência, o sexo feminino, insuficiência renal pós-operatória e baixo débito cardíaco são fatores de risco significativos. O risco de recorrência e necessidade de reoperação são baixos. .

Surgical Experience with Infective Endocarditis and Aortic Root Abscess

PURPOSE: This study was conducted to evaluate the surgical outcomes of active infective endocarditis with aortic root abscess formation. MATERIALS AND METHODS: Between February 1999 and June 2012, 49 patients underwent surgery for active endocarditis with aortic root abscess. The infected valve was native in 29 patients and prosthetic in 20 patients. The patients' mean age was 50+/-14 years, and 36 patients were male. Surgery was urgent/emergent in 15 patients (31%). The abscess involved the aortic annulus (11), left ventricular outflow tract (18), fibrous trigone (16), and mitral annulus (4). In all patients, wide debridement of abscess and aortic valve replacement with or without patch reconstruction of aortic root or annulus was performed. RESULTS: There were 6 (12%) operative deaths. Causes of early mortality were sepsis (2) and multi-organ failure (4). On postoperative echocardiogram, there was significant improvement of left ventricular dimension (LVEDD, from 58.8+/-11.8 mm to 52.6+/-8.2 mm, p<0.001); however, LV ejection fraction was significantly decreased (from 61.4+/-12.0% to 49.8+/-16.5%, p<0.001). The mean follow-up duration was 68.7+/-40.4 months. There was no late death or recurrent endocarditis during follow up. New York Heart Association functional class significantly improved from 3.2+/-0.7 to 1.2+/-0.4 (p<0.001). Kaplan-Meier estimated survival at 10 years was 87.2%. CONCLUSION: Surgical treatment for active endocarditis with aortic root abscess is still challenging, and was associated with high operative mortality. Nevertheless, long-term survival was excellent with good functional capacity after recovery from the early postoperative period.

Surgical treatment for infective endocarditis and hospital mortality in a Brazilian single-center / Tratamento cirúrgico para endocardite infecciosa e mortalidade hospitalar em centro único brasileiro

OBJECTIVE: We evaluated patients underwent cardiac valve surgery in the presence of infective endocarditis in an attempt to identify independent predictors of 30-day mortality. METHODS: We evaluated 837 consecutive patients underwent cardiac valve surgery from January 2003 to May 2010 in a tertiary hospital in São José do Rio Preto, São Paulo (SP), Brazil. The study group comprised patients who underwent intervention in the presence of infective endocarditis and was compared to the control group (without infective endocarditis), evaluating perioperative clinical outcomes and 30-day all cause mortality. RESULTS: In our series, 64 patients (8%) underwent cardiac valve surgery in the presence of infective endocarditis, and 37.5% of them had surgical intervention in multiple valves. The study group had prolonged ICU length of stay (16%), greater need for dialysis (9%) and higher 30-day mortality (17%) compared to the control group (7%, P=0.020; 2%, P=0.002 and 9%, P=0.038; respectively). In a Cox regression analysis, age (P = 0.007), acute kidney injury (P = 0.004), dialysis (P = 0.026), redo surgery (P = 0.026), re-exploration for bleeding (P = 0.013), tracheal reintubation (P <0.001) and type I neurological injury (P <0.001) were identified as independent predictors for death. Although the manifestation of infective endocarditis influenced on mortality in univariate analysis, multivariate Cox regression analysis did not confirm such variable as an independent predictor of death. CONCLUSION: Age and perioperative complications stand out as predictors of hospital mortality in Brazilian population. Cardiac valve surgery in the presence of active infective endocarditis was not confirmed itself as an independent predictor of 30-day mortality.

OBJETIVO: Avaliamos pacientes submetidos à cirurgia valvar em vigência de endocardite infecciosa na tentativa de identificar preditores independentes de mortalidade intrahospitalar em 30 dias. MÉTODOS: Foram avaliados 837 pacientes consecutivamente submetidos à cirurgia valvar, no período de janeiro de 2003 a maio de 2010, em um hospital terciário de São José do Rio Preto, SP, Brasil. O Grupo de Estudo compreendeu indivíduos submetidos à intervenção em vigência de endocardite infecciosa e foi comparado ao Grupo Controle, considerando complicações clínicas perioperatórias e óbito por todas as causas em 30 dias. RESULTADOS: Em nossa casuística, 64 (8%) pacientes foram submetidos à cirurgia valvar em vigência de endocardite infecciosa, sendo 37,5% deles com indicação de intervenção cirúrgica em múltiplas valvas. O Grupo de Estudo apresentou maior permanência em Unidade de Terapia Intensiva (16%), necessidade de diálise (9%) e maior mortalidade em 30 dias (17%) comparado ao Grupo Controle (7%, P=0,020; 2%, P=0,002 e 9%, P=0,038; respectivamente). A análise de regressão de Cox confirmou idade (P=0,007), lesão renal aguda (P=0,004), diálise (P=0,026), reoperação (P=0,026), reintervenção por sangramento (P=0,013), reintubação orotraqueal (P<0,001) e lesão neurológica tipo I (P<0,001) como preditores independentes para óbito. Embora a manifestação de endocardite infecciosa influencie na mortalidade na análise univariada, a regressão de Cox não confirmou tal variável como preditor independente de óbito em nossa casuística. CONCLUSÃO: Idade e complicações perioperatórias destacam-se como preditores de mortalidade hospitalar em população brasileira. Cirurgia valvar em vigência de infecção ativa não se confirma como preditor independente de óbito nesta casuística.

Successful surgical intervention in an unusual case of Aspergillus endocarditis with acute myeloid leukemia

Endocarditis due to Aspergillus infection is a rare complication in patients with hematological malignancies. Here, we present a case of aspergillus endocarditis in a patient with acute myeloid leukemia [AML] successfully treated with antifungal therapy and surgical treatment. The patient was a 51 years old male, a known case of AML who was admitted to our medical center for evacuating his valvular vegetations and repairing his atrial septal defect. He underwent an open heart surgery to relinquish his thromboses and also received an antifungal regimen. The patient tolerated the procedure well and eight months after his surgery, the patient remains asymptomatic. Successful treatment of this severe case of aspergillus endocarditis justifies a multidisciplinary method to be as a safe and effective approach to manage these patients

Challenge in the management of infective endocarditis with multiple valvular involvement / Desafio no manejo clínico da endocardite infecciosa com acometimento multivalvar

We describe the case of a 41-year-old man with congenital heart disease and infective endocarditis (IE), who presented multiple vegetations attached to the pulmonary, mitral, and aortic valves. Three valve replacements were performed, but the patient developed an abscess at the mitral-aortic intervalvular fibrosa and died due to sepsis. We briefly discuss the indications for surgery in IE, emphasizing its role in the treatment of uncontrolled infection.

Paciente do sexo masculino, 41 anos, portador de cardiopatia congênita apresentando-se com endocardite infecciosa (EI) e vegetações nas valvas pulmonar, aórtica e mitral. Três trocas valvares foram realizadas, mas o paciente evoluiu com recidiva da infecção, desenvolvendo abscesso na região da fibrosa intervalvar mitro-aórtica progredindo para sépsis e óbito. Nesse relato, discutimos brevemente as indicações para a cirurgia na EI, destacando sua indicação no tratamento da infecção não controlada.

Endocarditis infecciosa: experiencia quirúrgica en el Cardiocentro de Santiago de Cuba / Infectious endocarditis: surgical experience at the Cardiology Center of Santiago de Cuba

Se realizó un estudio epidemiológico, descriptivo y transversal, de 104 pacientes intervenidos en el Cardiocentro del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba, desde enero de 1988 hasta diciembre del 2008, por presentar endocarditis infecciosa. Entre los hallazgos sobresalió el predominio del grupo etario de 15-45 años, del sexo masculino, de la cardiopatía reumática como factor predisponerte, de la forma de presentación séptico-infecciosa, de los estafilococos como gérmenes y de los hemocultivos negativos. La disfunción valvular fue la principal indicación quirúrgica, seguida de la insuficiencia cardíaca. La mortalidad representó 16,3 por ciento, atribuible fundamentalmente al fallo multiorgánico por sepsis y al bajo gasto cardiaco. Los resultados de estas operaciones son buenos en la mencionada institución.

A descriptive cross-sectional and epidemiological study was carried out in 104 patients operated due to infectious endocarditis at the Cardiology Center of the Saturnino Lora Provincial Teaching Clinical Surgical Hospital in Santiago de Cuba from January 1988 to December 2008. Among the findings was the prevalence of the 15-45 year-old patients, male sex, rheumatic heart disease as predisposing factor, and septic and infectious presentation, staphylococci as pathogens and negative blood cultures. Valve disease was the main surgical indication followed by heart failure. The mortality was 16,3 percent attributable mainly to multiorgan failure due to sepsis and to the low cardiac output. The results of these interventions are favorable in that institution.

Tratamiento quirúrgico de la endocarditis infecciosa / Surgical treatment of infective endocarditis

La cirugía constituye un ataque vigoroso a la incompetencia valvular que ocasiona las graves complicaciones hemodinámicas que se observan en la endocarditis infecciosa. Se presenta una breve revisión de las diferentes técnicas quirúrgicas que se emplean para el tratamiento de la endocarditis infecciosa de la válvula mitral nativa, utilización de homoinjertos mitrales, tratamiento quirúrgico de la endocarditis infecciosa de la válvula aórtica y de la endocarditis infecciosa de prótesis valvular aórtica, homoinjertos criopreservados, prótesis sin soporte valvular y otros tipos de prótesis, así como de otras técnicas que se pueden emplear en caso de no contar con homoinjertos. Se revisan las técnicas que se utilizan en la endocarditis infecciosa de la válvula tricúspide y la conducta quirúrgica en la endocarditis por cables de marcapasos o desfibriladores automáticos implantables(AU)

Surgery is a strong attack to valvular incompetence causing the severe hemodynamic complications seen in infective endocarditis. This is a brief review of the different surgical techniques used in the treatment of infective endocarditis of native mitral valve, utilization of mitral homografts, surgical treatment of the infective endocarditis of the aortic valve and the infective endocarditis of the aortic valvular prosthesis, cryopreservation of the homografts, prosthesis without valvular support and other types of prostheses, as well as of other techniques that could be used if the homografts are not available. Techniques used in the infective endocarditis of tricuspid valve are reviewed and the surgical behavior in the endocarditis provoked by the pacemakers cables or implanted automated defibrillators(AU)

Evolução pós-operatória de pacientes com refluxo protético valvar / Evolución postoperatoria de pacientes con reflujo protésico valvular / Postoperative outcome of patients with prosthetic valve leak

FUNDAMENTO: O refluxo de prótese valvar é uma possível complicação da cirurgia de troca valvar. Embora raro, suas consequências podem ser graves. Há poucos estudos que correlacionam o grau do refluxo de prótese valvar com os eventos clínicos dos pacientes. OBJETIVO: Comparar a evolução pós-operatória de pacientes com refluxo de prótese valvar discreto/moderado (D/M) ou importante (Imp). MÉTODOS: Dentre 1.350 pacientes submetidos a cirurgia valvar entre 1999 e 2001, foram selecionados 185 pacientes com refluxo de prótese valvar. Desses pacientes, foram avaliados retrospectivamente dados clínicos, laboratoriais e ecocardiográficos de uma amostra de 58 pacientes (37 homens) com refluxo de prótese valvar no pré e/ou no pós-operatório de troca valvar com dados completos em prontuários, sendo 36 com refluxo D/M versus 22 com refluxo Imp. RESULTADOS: A incidência de reoperação foi de 11,1 por cento no Grupo D/M versus 22,7 por cento no Grupo Imp (odds ratio = 2,35 [IC95 por cento 0,56-9,94]). Endocardite foi a causa de reoperação em 75 por cento dos pacientes do Grupo D/M e em 60 por cento do Grupo Imp. As biopróteses aórticas foram as mais acometidas por refluxo (55,8 por cento no Grupo D/M e 57,7 por cento no Grupo Imp). Evoluíram sem refluxo de prótese valvar no segundo pós-operatório 40 por cento dos pacientes com refluxo prévio D/M versus 21,4 por cento dos pacientes com refluxo de prótese valvar Imp. Não houve diferenças significantes nas variáveis laboratoriais. CONCLUSÕES: (1) Os portadores de refluxo importante têm maior probabilidade de reoperação. (2) Endocardite foi a causa mais frequente de reoperação para qualquer grau de refluxo. (3) O refluxo de prótese valvar importante é de mais difícil resolução completa após tratamento cirúrgico.

BACKGROUND: Prosthetic valve leak is a possible complication of surgical valve replacement. Although uncommon, its consequences may be serious. Few studies correlate the degree of prosthetic valve leak with clinical events. OBJECTIVE: To compare the postoperative outcome of patients with mild/moderate (Mi/Mo) or severe (Sev) prosthetic valve leak METHODS: A total of 185 patients with prosthetic valve leak were selected among 1350 patients undergoing heart valve surgery between 1999 and 2001. Of these, a sample of 58 patients (37 men) with prosthetic valve leak (36 with Mi/Mo versus 22 with Sev leak) in the pre and/or postoperative period of heart valve replacement had complete medical record data, so their clinical, laboratory and echocardiographic data could be retrospectively assessed. RESULTS: The incidence of reoperation was 11.1 percent in the Mi/Mo group, versus 22.7 percent in the Sev group (odds ratio = 2.35 [95 percent CI 0.56-9.94]). Endocarditis was the cause of reoperation in 75 percent of the patients of the Mi/Mo group and in 60 percent of the Sev group. Aortic bioprostheses were those most frequently related to leak (55.8 percent in the Mi/Mo group and 57.7 percent in the Sev group). Forty percent of the patients with previous Mi/Mo leak did not present prosthetic valve leak on postoperative day 2 versus 21.4 percent of the patients with Sev prosthetic valve leak. No significant differences were found regarding laboratory variables. CONCLUSIONS: (1) Patients with severe leak are more likely to undergo reoperation. (2) Endocarditis was the most frequent cause of reoperation for any leak degree. (3) Severe prosthetic valve leak is more difficult to fully resolve after surgical treatment.

FUNDAMENTO: El reflujo de prótesis valvular es una posible complicación de la cirugía de reemplazo valvular. Aunque raras, sus consecuencias pueden resultar severas. Hay pocos estudios que correlacionan el grado del reflujo de prótesis valvular con los eventos clínicos de los pacientes. OBJETIVO: Comparar la evolución postoperatoria de pacientes con reflujo de prótesis valvular leve/moderado (L/M) o severo (S). MÉTODOS: Teniendo en cuenta a los 1.350 pacientes sometidos a la cirugía valvular entre el 1999 y el 2001, se seleccionaron a 185 pacientes con reflujo de prótesis valvular. De ellos, se evaluaron retrospectivamente datos clínicos, laboratoriales y ecocardiográficos de una muestra de 58 pacientes (37 varones) con reflujo de prótesis valvular en el pre y/o en el postoperatorio de reemplazo valvular con datos completos en prontuarios, con 36 presentado reflujo L/M versus 22 con reflujo S. RESULTADOS: La incidencia de reoperación fue del 11,1 por ciento en el Grupo L/M versus el 22,7 por ciento en el Grupo S (odds ratio = 2,35 [IC95 por ciento 0,56-9,94]). La Endocarditis fue la causa de reoperación en el 75 por ciento de los pacientes del Grupo L/M y en el 60 por ciento del Grupo S. Las bioprótesis aórticas fueron las más afectadas por reflujo (el 55,8 por ciento en el Grupo L/M y el 57,7 por ciento en el Grupo S). Evolucionaron sin reflujo de prótesis valvular en el segundo postoperatorio el 40 por ciento de los pacientes con reflujo previo L/M versus el 21,4 por ciento de los pacientes con reflujo de prótesis valvular S. No hubo diferencia significantes en las variables laboratoriales. CONCLUSIÓN: 1) Los portadores de reflujo severo tienen mayor probabilidad de reoperación. 2) Endocarditis fue la causa más frecuente de reoperación para cualquier grado de reflujo. 3) El reflujo de prótesis valvular severo es de más difícil resolución completa tras tratamiento quirúrgico.