Challenges in the Surgical Management of Aortic and Mitral Valve Endocarditis (IE) Oct 2016 Epworth P Skillington, CT surgeon

Challenges in the Surgical Management of Aortic and Mitral Valve Endocarditis valve repair vs replacement (mitral) choice of prosthesis (aortic and mitral) technical challenges – mainly relates to surgical management of annular abcess and its complications (eg intra cardiac fistula) management of pts with neurological Cx

Traditional Indications for early Surgery in Endocarditis (< 7 days) Uncontrolled Heart Failure Failure to control Sepsis with AB’s Large Vegetations, embolization (non cerebral) Certain specific responsible pathogens C/I Neurological Complications (cerebral emb)

Timing of Surgery – when to operate very early (<48hrs) virulent acute staph. Aureus, fungal infection prosthetic valve endocarditis with valve dehiscence demonstrated abcess or internal fistula (1 week) incipient acute respiratory or multi-system failure

Mitral Valve Repair or Replacement generally, repair gives better outcomes than replacement in non-infective degenerative mitral valve disease however feasability of repair in acute infective endocarditis depends on the extent of leaflet destruction, as complete resection of all involved tissues is required

Mitral v. Repair Anterior leaflet superfiscial defects without full thickness destruction full thickness defects not involving free edge full thickness defects – less than 1/3rd leaflet Posterior leaflet

Mitral Valve Repair posterior leaflet -quadrangular resection anterior leaflet - patch repair Commissural lesions managed by plication or patch prosthetic ring annuloplasty best avoided

Mitral Valve Repair operative mortality for valve repair in “active endocarditis” depends on definitions of acuity, time delay till surgery reported mortality of 0 –11.8% in significant series reported over past 20 years low re-infection rates - < 3% re- operation rates 0 –14% at 5 – 10 yrs ( higher than valve replacement)

Presenting on a recently published paper on Surgical Management of Endocarditis: The Society of Thoracic Surgeons Clinical Practice Guideline Report form STS Workforce on Evidenced-based Surgery. Published in June Annals of Thoracic Surgery 9

Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE) MITRAL VALVE – STS 2011 Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE) technically feasible Yes Repair (Class I, LOE B) No Replacement (Class IIa, LOE B) Redo-surgery Replacement (Class IIb, LOE C) Mechanical Bioprosthesis

STS – Mitral Valve Repair vs Replacement for Endocarditis * For active endocarditis, only 16% repair rate – mortality rate was 10.6% for repair, 15% for MVR

Mitral Valve Repair or Replacement whilst there are some groups that claim high repair rates, generally the best valves for repair are those cases caused by low grade virulent organism (eg strept.viridans), with little in the way of valve leaflet destruction, operated on often 1-2 weeks after onset of Rx

Mitral Valve Repair or Replacement “as patients undergoing valve replacement often have more severely damaged valves as a result of IE, simple retrospective comparison between outcome of valve repair and those of valve replacement may be misleading” repair should always be considered Yamaguchi, Annals Thorac Cardiovasc Surg Vol 13, no. 3 (2007) - Review

Mitral Valve Replacement No difference in re – infection rates between bioprosthetic valves and mechanical valves shown generally bioprosthetic valves reserved for older (> 70yrs) patients because of poor durability in younger patients (10 – 12yrs)

Prosthetic Valve Endocarditis

Aortic Valve Endocarditis high early surgical mortality of 4 –20% ( mean 15%)

Aortic Valve Endocarditis greater destruction of valve leaflet tissue aortic regurgitation gives a greater haemodynamic burden to heart, thus increased heart failure Abcess formation more likely Complications of abcess increased - fistula

Aortic Valve Endocarditis surgical intervention more likely more often required in the early stages of active infection acute AR not well tolerated left ventricular function suffers, and may take years to recover valve repair rarely possible

Choice of prostheses greater for AVR mechanical valve bioprosthetic (xenograft) aortic allograft (homograft) ross procedure (pul. Autograft)

Aortic Allograft( homograft) resistance to early re-infection permeated by antibiotics in the blood mitral leaflet can be used to reconstruct defects caused by tissue destruction in the aortic root excellent durability in young patients Caution : requires expertise in allograft insertion techniques; in short supply, which limits use

Aortic Allograft –tailoring for use trim off segments not required

Insertion of Allograft using Root Replacement technique reimplantation of coronary arteries previously considered valve of choice for AVR for acute IE

O’Brien et al,2001 Aortic Homograft Durability vs Age: Freedom from Re-op

Ross Procedure best durability of any tissue valve double valve operation 2 valves require f/up lengthy procedure associated with increased mortality whe used for acute IE

Anatomy of Aortic Root infection confined to aortic valve leaflets– easy location of annular abcess (50 –70%) dictates risk of heart block, type of reconstruction required also likelihood of fistula, and possible rupture in to pericardium

Localized Abcess in non – coronary annulus management by excision of all infected tissue and autologous pericardial patch repair

Abcess can drain in to pericardial cavity after patching

Aorto – ventricular separation

Choice between Mechanical valve,Tissue valve vs Aortic Allograft in aortic valve endocarditis 1990’s – aortic allograft shown in some studies – lower reinfection since 2000, now shown that there is little difference between various prostheses, providing all infective tissue is excised

Abcess can drain in to pericardial cavity after patching

Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE) AORTIC VALVE – STS 2011 Native Valve Endocarditis (NVE) Prosthetic Valve Endocarditis (PVE) Confined to valve / annulus Mechanical or Bioprosthesis ± Homograft (Class IIb, LOE B) Extensive Disease 1. Periannular Abscess 2. Annular / Ao Wall Destruction Homograft (Class IIb, LOE B) Confined to valve / annulus Mechanical or Bioprosthesis ± Homograft (Class IIa, LOE B) Extensive Disease 1. Periannular Abscess 2. Annular / Ao Wall Destruction Homograft (Class IIa, LOE B)

Neurological Complications (affects 15 –30% cases of IE) Traditionally, for cases presenting with a neurological deficit, with proven brain imaging, or if this develops during medical treatment, surgery was deferred for 4-6 weeks, because of the perceived risk of worsening the deficit Problem is that further cerebral emboli can occur whilst waiting

Primary Endpoint a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization N Engl J Med, 2012 Jun 28; 366(26): 2466-73

N Engl J Med, 2012 Jun 28; 366(26): 2466-73

Guidelines for Surgical Management of IE STS guidelines 2011 out of date AHA/ACC 2014 guidelines for Valvular Heart Disease do not really address timing of intervention except to say that Early intervention (during hospitalization) should be performed for the usual indications 2015 European Society of Cardiology ESC have made some new recommendations in this area

2015 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis: 9.Neurological complications

2015 European Society of Cardiology (ESC) guidelines for the management of IE: (Neurological complications –affects 15-30%) For a patient presenting with neurological complications of IE, providing the usual indications for early surgical intervention are present, and providing the patient doesn’t have either of: Intracranial Haemorrhage Coma CVA with severe neurological deficit Should proceed with “early” surgery

2015 ESC guidelines for the management of infective endocarditis

This paper addresses whether or not proceeding to early surgery (< or = 7days) leads to increased mortality, or worsens neurological outcomes

Oh et al, Asian Cardiovasc Thorac Ann 2016 ….brain imaging for a clinically diagnosed preoperative neurological event. Patients were categorized as early surgery (< or = 7days of clinical or cerebral imaging diagnosis of stroke) or delayed surgery (>7 days after diagnosis)

Conclusion IE of aortic and mitral valves requiring surgery has a high mortality mitral valve repair should be performed where possible, although in reality, if tissue destruction too great , replacement may be required aortic valve IE causes Acute AR, leads to early heart failure, and thus surgery common

Conclusion (cont.) annular abcesses common in aortic valve IE these patients need excision of all infected tissue, to minimize recurrent infection reconstruction of aortic annulus with autologous pericardium before valve replaced aortic allografts have theoretical advantages including resistance to early reinfection, and very good durability

Conclusion (cont.) aortic allografts require increased surgical expertise, and are in short supply – limits use No difference in reinfection rates between any of the prostheses providing all infected cardiac tissue excised Ross procedure good for elective surgery for healed IE, in patients with chronic AR, higher mortality in acute IE in patients presenting with heart failure

Conclusion (cont.) Patients with cerebral embolization complicating IE, providing haemorrhage is excluded, coma is not present, and the resultant stroke is not too severe, should proceed to early surgical intervention, if otherwise indicated If intracranial haemorrhage is present, surgery should be delayed 4 weeks Intracranial mycotic aneurysms should be managed in conjunction with neuro interventionalist

Aortic Root Enlargement

Prostheses lower profile and better haemodynamic function

STS – Mechanical vs Tissue AVR for Endocarditis