Andersons pediatric cardiology 1495

This is defined as: emergency within 24 hours, urgent within a few days, and early elective surgery after 1 to 2 weeks of diagnosis and before completion of the full course of antibiotic

Timing of the operation is likely crucial for the outcome It differs significantly between centers throughout the world The benefit of early surgery has become well established during the past decade This is defined as: emergency (within 24 hours), urgent (within a few days), and early elective surgery (after 1 to 2 weeks

of diagnosis and before completion of the full course of antibiotics)

The indications for emergency and urgent surgery are well outlined in the currently used guidelines Intractable, severe, and complicated heart failure is an emergency indication It is usually caused by acute or increasing valvar

regurgitation The addition of ventricular dysfunction is an unfavorable

prognostic sign The presence of risk factors for systemic embolism is another group of indications: it seems that large vegetations (>10 mm), especially on the anterior mitral leaflet, are the best described risk factor

An adapted summary of the indications for early surgery in left-sided IE is shown in Table 56.10

Table 56.10

Indications for Early Surgery in Left-Sided Infective Endocarditis

HEART FAILURE

Aortic or mitral IE with severe acute regurgitation or valve obstruction causing refractory

pulmonary edema or cardiogenic shock

Emergency a

Aortic or mitral IE with fistula into a cardiac chamber or pericardium causing refractory

pulmonary edema or shock

Emergency Aortic or mitral IE with severe acute regurgitation or valve obstruction and persisting heart

failure or poor hemodynamic tolerance (early mitral closure, pulmonary hypertension)

Urgent a

Aortic or mitral IE with severe regurgitation and no HF Elective a

UNCONTROLLED INFECTION

Locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) Urgent

Persisting fever and positive blood cultures >10 days on appropriate antibiotic Urgent

Infection caused by fungi or multiresistant organisms Urgent/elective

PREVENTION OF EMBOLISM

Aortic or mitral IE with large vegetations (>10 mm) following one or more embolic episodes

despite appropriate antibiotic therapy

Urgent Aortic or mitral IE with large vegetations (>10 mm) and other predictors of complicated course

(HF, persistent infection, abscess)

Urgent

a Emergency <24 hours; Urgent <few days; Elective >1–2 weeks of antibiotic therapy.

IE, Infective endocarditis; HF, heart failure.

Modified from Habib G, Lancellotti P, Antunes MJ, et al 2015 ESC Guidelines for the

management of infective endocarditis: The Task Force for the Management of Infective

Endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM).

Eur Heart J 2015;36(44):3075–3128.

The benefit of early surgery in adults has become well established during the past decade The benefits of early surgery have previously been reported in

adults in smaller studies,122 including in prospective studies123,124 and the first controlled randomized study in adults.125 Some studies could not show benefit of early surgery for PVE in adult IE.126,127 There is a recent comprehensive review

on the topic128 and meta-analysis.129 This evolution of understanding is also based on the following:

■ Improved outcomes after surgery.

■ Growing evidence that the negative side for

operating on patients with active infection is minimal.

■ Substantial data that duration of preoperative

antibiotic treatment has no or little effect on

■ The fact that in the case of BC-negative IE, surgery also can help to identify the causative microorganism thanks to microbiologic examination of the operative specimen, including molecular testing with PCR.

Early surgery for pediatric IE results are addressed in a 2013 paper of a single center 15-year analysis.130 It reports the possibility of early surgery in more than 60%, native valve-preserving surgery in 50%, low recurrence risk of 2%,

mortality rate of 6.5% (compared with 10% in the nonsurgical group), and a survival rate at 1, 5, and 10 years of 98%, 90%, and 81%, respectively, in the surgical group (compared with 96%, 89%, and 81% in the nonsurgical group) There is a general understanding that early surgery is safe, although it might be technically challenging for a valve-preserving surgery because of the

characteristics of the infected and necrotic tissue

Infective Endocarditis Surgery in Cerebral Complications.

Mycotic aneurysms may occur in any systemic artery or the pulmonary arteries but are particularly dangerous in the cerebral circulation; surgical therapy may

The ESC 2015 guidelines advise urgent surgery for IE complicated by

cerebral embolism or transient ischemic events Recent data suggest that the risk

of neurologic exacerbation is lower than previously thought There are recent recommendations on surgery in patients with embolic stroke.12 It is difficult to extrapolate these recommendations to the pediatric IE because even now the decisions in IE with neurologic complications are more often in favor of an operation

The decision for a cardiopulmonary bypass surgery is more difficult in cases

of intracranial hemorrhage An operative delay of 3 weeks or more has been advised as reasonable among patients with recent intracranial hemorrhage.7 However, this might not be possible to be adhered to in case of lifesaving

indications

Aortic Root Abscess Surgery.

The aortic root abscess surgery continues to be a challenge The destruction of the aortic annulus usually does not allow for mere aortic valve replacement and requires aortic root replacement It is believed that the radical resection of the abscess is very important Management of aortic root abscess in adults has been discussed in multiple papers131–134; the pediatric series are scarce

The type of aortic root replacement is of significance Aortic homografts have been used with reported excellence,135–139 and our teams have personal

preference for this approach More recently, in view of the deficit of homografts, there has been a search for alternative methods Pulmonary autograft aortic root replacement (Ross procedure) has been reported to have excellent results in pediatric IE with aortic root abscess.140 There have been previous reports of the use of autopericardial replacement of the left ventricular outflow tract,141,142 as well as equine and Dacron grafts for closure of the abscess The graft selection was thought to be of significance with recommended avoidance of prosthetic material.143 However, there are recent reports of the use of flanged composite graft (artificial tube with implanted valve) where the subprosthetic part of the synthetic graft can be used to patch all kinds of defects created by resection of the abscess and the prosthesis can be produced in different sizes and easily

shaped.144 Aortic valve repair with neocuspidization (Ozaki repair) might also become possible after patching of the defects created by the infected wall

resection.145,146