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Cardiac surgery in any context of left-sided infective endocarditis?
  1. Erwan Donal1,
  2. Erwan Flecher2,
  3. Pierre Tattevin3,
  4. Gilbert Habib4
  1. 1 Cardiology, CHU Rennes, Rennes, France
  2. 2 Cardiac Surgery, CHU Rennes, Rennes, France
  3. 3 Infectious Disease, CHU Rennes, Rennes, France
  4. 4 Cardiology, APHM, Marseille, France
  1. Correspondence to Dr Erwan Donal, Cardiology, CHU Rennes, Rennes 35033, France; erwan.donal{at}chu-rennes.fr

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Left-sided endocarditis (LSE) represents a significant proportion of urgent cardiac surgeries.1 It requires expertise and capabilities for dealing with endocardial and myocardial damages involving all or portion of mitral valve, all or portion of the aortic valve, aortic root and the structures in their anatomical contiguity.2 Literature and guidelines on the management of LSE rely mainly on observational studies, given the challenges associated with the conduct of randomised trials in emergency settings. Endocarditis teams (ETs) are mandatory.3 The role of regular meetings among specialties is fundamental, particularly for frail or extremely sick patients. Decision-making should take into account not only the localisation and the extension of the infection, but also the patient preoperative status and his comorbidities. Previous cardiac surgery, and especially previous valve prosthesis, impact on the prognosis. The best timing is still a matter of debate not only according to the risks but also the feasibility of very early surgery for LSE. Various scores have been developed for preoperative estimates of the mortality associated with cardiac surgeries in different settings.4 5 The ENDOVAL score aims to help and guide the ET for an individualised decision-making process.4 Despite evidence suggests that early surgery may be associated with improved survival in patients with complicated LSE, it also incurred an increased risk of recurrence and postoperative valvular dysfunctions, according to several studies. Garcia-Granja et al 6 did a fantastic work looking at 605 patients with LSE and formal surgical indication. Among them, 200 did not undergo surgery, and it had a significant prognostic impact. In their study conducted over more than 10 years, surgery was an independent predictor of survival and its greatest benefit was observed in patients at highest risk according to the ENDOVAL risk score. Interestingly, the benefit of surgery was noticed for uncontrolled infection even more than for heart failure, embolic risk or other complications.3

One can argue that early surgery could save lives for some but at the cost of very long and complicated stays in intensive care units with a prohibitive risk of severe complications. Garcia-Granja et al reached to the observation that early surgery is independently associated with decreased in-hospital mortality.6 Their message is rather straightforward. It re-enforced the need for an early management by expert multidisciplinary teams, so that every patient with LSE may benefit from early surgery whenever indicated. Nevertheless, this ‘interventionist’ approach, in line with the European Society of Cardiology (ESC) guidelines, requires the participation of multidisciplinary experts for the ET discussions, especially for the indication and timing of cardiac surgery, and for the postoperative management.3 This perioperative period cannot be managed without exceptional reliability, availability and performance of the teams involved. It is demanding in terms of time and levels of technicity. All therapeutic options should be available, up to the cardiac transplant for selected patients.

Most importantly, in addition to the multidisciplinary meeting (ET) where the case is discussed, we believe it is essential that directly involved physicians (especially surgeon, anaesthesiologist/intensivists) meet the patient to fully apprehend their physiological and mind status. Scores are one thing, but bedside clinical appreciation remains a major element to consider for such surgical programme.

Garcia-Granja et al underscore, like many before them, the poor prognosis associated with Staphylococcus aureus LSE.6 Under the term ‘uncontrolled infection’, there are also the patients with periannular complication, fungi or Gram-negative bacilli’s prosthetic valve endocarditis.7 They also underscore the relevance of the size of the vegetation, at the same level as renal or heart failure.

The surgery of endocarditis has been regarded as the most effective strategy for several categories of LSE. Despite converging data coming from several observational studies and from the guidelines, one can keep in mind the results of the largest retrospective study provided by the International Collaboration on Endocarditis consortium: the comparison of early cardiac surgery versus conservative management was neutral. There remains thus a need for an expert ET and for individualised patient’s management.8 9

In Garcia-Granja et al, the surgery was extremely rapidly performed when indicated by the ET. For half of the population, the surgery took place during the 24 hours following the decision.6 Of note, the diagnosis and the images providing the description of heart lesions were also obtained in an extremely short period of time after admission. This is thus clearly referring to patients who were managed in extremely well-trained teams. This concept of level-of-expertise is perhaps missing from the paper, as well as the technical strategies used for solving complicated situations in regard to the gigantic size of septic lesions reported by the surgeon. Long-term substitute durability is the key factor for the success of surgery. If surgery decreases the early risk of death, it has also to be made for optimal long-term durability of the ‘repair’, rarely limited to valve repair (‘plasty’), as most cardiac surgeries for LSE require valve replacement with mechanic and/or biological prosthesis most of the time.10–12

Another interesting result (although not sufficiently discussed) of the paper from Garcia-Granja is the impact of the timing of surgery on the prognosis.6 Online supplemental table 3 reports that the time between diagnosis and surgery did not influence prognosis, but that the time between the ET discussion and surgery did, with higher mortality when the patients were operated on more urgently, which is an opposite result as compared with a previous study on this specific topic.1 The lack of clear definition of ‘early’, ‘urgent’ and ‘emergency’ surgery is also confusing.11 12 Although they claim that ‘Surgical indications followed the European guidelines through the study period’, their definition of ‘urgent surgery’ (less than 24 hours) is not the same as the ESC guidelines, which differentiate emergency (within 24 hours), urgent (within less than 7 days) and early (during the hospital stay) surgery.3 In conclusion, Garcia-Granja et al have to be congratulated for their tremendous work.6 They bring another piece of evidence that LSE is a disease that requires rapid, well-organised and expert teams for an early diagnosis, early decision-making process and very early access to the operating room and to the intensive cares required to save, undoubtedly, lives!

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Footnotes

  • Twitter @Gilbert HABIB

  • Contributors ED did the first manuscript and got the contribution of EF as a surgeon. PT as an infectiologist and GH as the writer of the guidelines both contributed and provided ideas.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; internally peer reviewed.

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