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ORIGINAL ARTICLE

Surgical treatment of active infectious endocarditis: a study of 361 surgical cases

Altamiro Ribeiro Dias0; Pablo M. Pomerantzeff0; Carlos Manoel A. Brandão0; Ricardo Ribeiro Dias0; Max Grinberg0; Eliecer Villamizer de Lahoz0; Sérgio Almeida de Oliveira0

DOI: 10.1590/S0102-76382003000200010

INTRODUCTION

Wallace et al. [1] published in 1965 a report of a patient with active infectious endocarditis (AIE), who, due to the persistent fever and progressive aortic failure, was submitted to surgical treatment with the replacement of the aortic valve and successful removal of the focus of the infection.

In 1986, we presented [2] the experience of the Heart Institute, Hospital das Clinicas of the Medical school in São Paulo (InCor) and from then until the present time, the number of patients operated on for AIE in our institution has increased greatly.

In this work we analyzed some aspects of this disease, as well as the results of the surgical treatment of AIE of a total of 361 operated patients.

METHOD

The results of a total of 361 patients operated on for AIE in InCor over a period of 19 years were evaluated.

The diagnosis of endocarditis was based on the clinical history of the patient, blood cultures and echocardiographic studies. The cultures were positive in 311 (86.20%) of the patients. The identified agents are shown in Table 1.


Table 1. Active infectious endocarditis: surgical treatment Identified etiological agents

The ages of the patients varied from 3 to 81 years with a mean of 38 ± 83 years, where 230 patients were male and 131 were female.

Two hundred and 5 patients presented with compromise of native valves, which included 136 aortic valves, 107 mitral valves and 16 tricuspid valves. Several of these patients presented with multiple valve impairment. One hundred and forty-two patients presented with compromise of bioprostheses and 14 of mechanical prostheses (Table 2).


Table 2. Active infectious endocarditis: surgical treatment. Affected valves grouped by patient

The patients with endocarditis in native valves presented with severe regurgitation in about 80% of the cases.

Figure 1 shows the functional class (NYHA) of the patients in the pre-operative period.


Fig. 1 - Active infectious endocarditis: surgical treatment. Functional class - pre-operative period

Ninety patients suffered from annular abscesses and 11 presented with fistulae.

The surgical indications of the 205 patients with native valve compromise were severe heart failure in 104 (50.73%) individuals; failure of the etiologic treatment in 87 (42.44%); embolic phenomenon in 7 (3.41%); a fungal etiology in 5 (2.44%); and other etiologies in 2 (0.98%).

In the patients with artificial valves, the surgical indications obeyed the same criteria, with the artificial valve introducing an additional element in the indication of surgical treatment.

The surgical procedures complied with the basic methodological principles of complete eradication of all the growths, as well as the infected tissue surrounding the focus of the infection [3-6].

There was a necessity to replace the native aortic valves in 136 patients. The mitral valves were replaced in 94 individuals, with resection of the vegetation in isolation possible with another 13 mitral valves. Of the 16 infected tricuspid valves it was possible to partially resect the septal and/or posterior cuspids in 8 individuals, thus preserving the anterior cuspids. Bioprostheses were employed in 203 (99%) of the patients.

Annular abscesses were found during surgery in 90 patients, where 66 (73.34%) of these abscesses were equal to or less than 10 mm in diameter. In all these 66 abscesses it was possible to completely remove the purulent material with the resulting wounds treated with ethanolic iodine and occluded with a direct suturing after the implantation of the corresponding valvar prosthesis. In 43 patients these abscesses were on the aortic annuli and in 23 they were located in the mitral annuli.

In 24 (26.66%) of the patients, the abscesses presented with diameters greater than 10 mm, making the treatment more complex; 18 of these abscesses were found on aortic annuli and 6 on mitral annuli.

With wounds of greater than 10 mm, after cleaning and treatment with ethanolic iodine, occlusion was achieved with a bovine pericardial membrane patch fixed in glutaraldehyde which was sutured onto the abscess cavity in all our cases, although other materials can be used for this purpose [7-9]. The corresponding valvar prostheses were sutured on the previously fixed bovine pericardial patches.

Ten of these abscesses with diameters greater than 10 mm were located on aortic annuli and 6 in mitral annuli.

In 2 patients with large abscesses there was a discontinuity between the left ventricle and the aorta, which obliged the use of valved tubular grafts and re-implantation of the coronary arteries, the so-called valvar translocation, which was necessary given the intensity of the annular damage observed [10-14].

In 6 patients, of the group with large abscesses, there was severe compromise of the transition between the aortic and mitral valves. In these patients the surgical methodological principles as proposed by David et al. [5] and Ergin et al. [6] were followed, which can be summarized as follows:

a) Complete removal of the compromised structures, including the fibrous trigones, transforming the mitral-aortic region into a single orifice.

b) Reconstruction using a double triangular bovine pericardial membrane patches; one of these sheets is used to close the aortic root and the other to close the left atrium, suturing laterally to the remaining tissue of the fibrous trigones.

c) On the transition line created between the mitral and aortic annuli, segments corresponding to the aortic and mitral prostheses are sutured, thus restoring the mitral and aortic orifices.

In 11 patients fistulae were evidenced, with 6 from the aorta to the right atrium, 3 from the aorta to the right ventricle and 2 cases from the aorta to the left atrium.

All the courses of the fistulae were rigorously cleaned and closed with bovine pericardial patches sutured over the two orifices.

RESULTS

Table 3 reports the main complications that occurred in the immediate post-operative period.


Table 3. Active infectious endocarditis: surgical treatment. Complications in the post-operative period

There were 75 (20.78%) deaths in the immediate post-operative period, the causes of which are shown in Table 4, but were predominantly related to cardiogenic problems.


Table 4. Active infectious endocarditis: surgical treatment. Causes of hospital deaths

Of the 286 patients who were released from hospital, 225 (78.67%) were accompanied for periods ranging from 18 to 200 months.

The patients presented with a considerable improvement in their functional class, as can be observed in Figure 2. In fact 222 (77.62%) of the patients were functional class I after surgical treatment.


Fig. 2 - Active infectious endocarditis: surgical treatment. Surgical treatment - functional class

Thirty-six late complications occurred, of which 15 were relapsed endocarditis. Ten of these patients required reoperations (Table 5).

Table 5. Active infectious endocarditis: surgical treatment. Late complications


There were 26 late deaths, the majority of which (73.07%) were due to heart failure (Table 6).

Table 6. Active infectious endocarditis: surgical treatment. Causes of late deaths


The global survival rate was 67.3 ± 5.1% at 160 months (Figure 3) and the AIE-free survival rate was 92.3 ± 2.8% (Figure 4).



Fig. 3 - Actuarial curve free of endocarditis


Fig. 4 - Survival curve free of endocarditis


COMMENTS

Surgical treatment of AIE constitutes a great challenge as, not always, the post-operative examinations, in particular the echocardiographic studies, precisely demonstrate the total extension of the annulo-valvar infectious process, especially in patients with valvar prostheses, fistulae and multiple valve lesions.

Another factor that greatly aggravates the situation is the duration of the process. It is common for patients to arrive at InCor after months of suffering from symptoms and sometimes after inadequate antibiotic treatment.

There is a consensus in the literature that surgical treatment must be radical in the sense of removing all infected tissue, thus the surgeon can not concern himself with the extension of the tissues to be removed [4,5,7,10,15-17]. Not to comply with this basic principle is to be certain of relapse and its consequences. In our work and in particular over the last ten years, these principles have been observed rigorously. The surgeon, sometimes, has to use his resourcefulness for the reconstruction that is necessary, using skill [4] and improvisation. The important thing is the reconstruction of the function without septic residue.

In our casuistic there were 24 large abscesses with diameters greater than 10 mm for which, after cleaning and removal of all the infected tissue, bovine pericardial patches fixed in glutaraldehyde were required. Through these patches sutures are employed in order to fix the respective prostheses. In 2 patients, abscesses affected 2/3 of the aortic annulus.

In another 2 patients, the annular damage associated to previous reoperations compromised the aortic annulus in such a way as to compel the utilization of valved tubes in the supracoronary position and concomitant coronary artery bypass grafting [10].

In 13 mitral valves, the lesions were small and focal constituting of vegetative points the majority of which (9 valves) were located on the anterior cuspid, with the possibility of their removal giving a good result.

In 8 tricuspid valves, removal was partial, the septal cuspid in 6 and the septal and posterior cuspids in 2. The remaining anterior cuspids were sufficient to guarantee a good functional result with negligible hemodynamic reflux [18].

In one of the eight patients submitted to resection and implantation of bioprostheses in the tricuspid position, there was relapse of the infectious process by P. aeruginosa. The patient was re-operated and the annulus was found to be severely compromised. The prosthesis was dried out and another was not implanted in its place, as was proposed by Arbulu & Asfaw in 1981 [19].

Occlusion of the fistulae was achieved with bovine pericardial patches fixed in both orifices, after cleaning the fistulous course. There are published reports of the use of fresh autologous pericardium with a good result [10].

We consider our hospital mortality rate of 20.77% (75 of the total cases) as high, although this fact bears a direct relation to the condition that many patients arrive in our hospital, with severe cardiovascular compromise, sepsis, abscesses, etc. These factors are predictors of a higher surgical risk that is always accompanied by a greater morbid-mortality rate [20-24].

Our experience demonstrates that the best results are obtained in cases which are correctly indicated for surgery at an early stage, combined with astuteness of the physician and the experience of the surgeon to perform adequate treatment within the principles and norms summarized herein.

CONCLUSION

The predominant indication for surgery (50.73%) was the presence of severe heart failure, resistant to correctly established clinical treatment, followed by a persistent septic state (42.43%).

Surgical treatment should be radical, completely removing all the infected tissue, without which relapse in inevitable.

Reconstruction of the affected structures should be performed with technical rigor in order to obtain the best functional result possible.

Hospital and late morbidity and mortality are closely related to cardiovascular events.

The majority of surviving patients (77.62%) fully recover normal functional conditions.

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