IE手术适应症和时机

ISSN: 1524-4539 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.108.773598 2010;121;1141-1152 Circulation Bernard D. Prendergast and Pilar Tornos Surgery for Infective Endocarditis: Who and When? http://circ.ahajournals.org/cgi/content/full/121/9/1141 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Circulation is online at by on June 3, 2011 circ.ahajournals.orgDownloaded from Surgery for Infective Endocarditis Who and When? Bernard D. Prendergast, DM, FRCP; Pilar Tornos, MD, FESC Infective endocarditis (IE) remains a dangerous conditionwith unchanging incidence and a mortality approaching 30% at 1 year.1,2 Surgery is potentially lifesaving3 and is required in 25% to 50% of cases during acute infection and 20% to 40% during convalescence.4–7 Operative procedures are often technically difficult and associated with high risk, not least because patients are frequently extremely sick with multisystem disease. Nevertheless, indications for surgery are clear in many patients, and international guidelines8,9 provide strong recommendations that are applicable for the majority. These guidelines are not supported by robust clinical evi- dence, however, and clinical decision making is often ham- pered by diverse considerations, including advancing age of the overall patient cohort, the presence of extracardiac com- plications or preexistent comorbidity, prior antibiotic therapy of varying duration, and the availability of appropriate surgical expertise. In this article, we review the evidence base that supports current clinical practice and attempt to provide recommendations in areas where doubt persists. The Role of Surgery The role of surgery in active IE has expanded progressively since early reports of successful outcome.10 Subsequent declines in mortality may be attributed to a variety of improvements in management, although expeditious surgery in carefully selected patients has played a major role. Con- temporary data in Europe indicate that surgery is now undertaken in approximately 50% of patients with IE; the most frequent indications are congestive heart failure (60%), refractory sepsis (40%), embolic complications (18%), and vegetation size (48%), with a combination of these factors being present in many patients.11 Overall surgical mortality in active IE is 6% to 25%, with long-term survival rates of approximately 70% in most series.4–7,12–31 Assessment of the impact of surgery on out- come is difficult, because the patients referred are frequently those with severe complications related to virulent organisms. Conversely, the most ill patients (frequently the elderly, with attendant comorbidity) are often deemed unfit for surgery. In general terms, prognosis is better if surgery is undertaken early, before cardiac tissue destruction and deterioration in the overall condition of the patient increase the hazards of intervention. Final outcome has never been related to the duration and intensity of prior antibiotic treatment, and surgery should not be delayed when clearly indicated in the vain hope that a sterile operative field can be achieved. Numerous series have attempted to identify variables predictive of early and late mortality,4–6,12–25 and these are summarized in Table 1. However, interpretation is hampered by the heterogeneous nature of the patients studied and the outcome measures used. Specifically, the vast majority of studies have been single-center, retrospective series enrolling patients with both native and prosthetic valve IE. Further- more, analysis is inherently biased given the selection of patients for surgery who have an anticipated poor outcome but acceptable operative risk. Although surgery may be recommended and commonly performed for indications such as embolic complications or persistent infection, it should be recognized that no definitive proof exists of improved out- come in these situations (in contrast to congestive heart failure due to valvular regurgitation; see below). More recent investigations using sophisticated propensity scoring models have yielded conflicting results on the benefits of sur- gery,15,22–25 and a future need exists for high-quality prospec- tive assessment. Even with the help of these data, decision making is frequently difficult, and overall management is highly dependent on the experience of the surgical team (as well as the individual surgeon) and a strong interaction with cardiology and microbiology colleagues. Surgical Management Preoperative Considerations Transthoracic and transesophageal echocardiography are now ubiquitous, and their utility in the assessment of complica- tions of IE is clearly recognized. Transesophageal imaging has superior sensitivity and specificity and is recommended in virtually all patients in whom surgery is contemplated. Cardiac catheterization is unnecessary for diagnosis and anatomic characterization. Coronary angiography should be From the Departments of Cardiology (B.D.P.), The John Radcliffe Hospital, Oxford, United Kingdom and Hopital Vall D’Hebron (P.T.), Barcelona, Spain. Correspondence to Dr B.D. Prendergast, Consultant Cardiologist, The John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, United Kingdom. E-mail bernard.prendergast@orh.nhs.uk (Circulation. 2010;121:1141-1152.) © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.108.773598 1141 Valvular Heart Disease: Changing Concepts in Disease Management by on June 3, 2011 circ.ahajournals.orgDownloaded from Table 1. Key Articles Assessing Surgical Outcome in IE First Author and Reference Citation Year Study Design Statistical Methods Setting No. of Subjects Patient Characteristics In-Hospital Mortality, % Mean Follow-Up, y Long- Term Survival Rate, % Summary of Findings Jault4 1997 Retrospective single-center surgical cohort study Multivariate logistic regression analysis France 247 Native valve IE alone; surgery 100% 7.6 (Surgical series) 6 71 Predictors of operative mortality: age, insidious illness, CHF. Long-term survival good except for neurological complications and mitral valve IE. Castillo5 2000 Prospective single-center cohort study Simple group comparisons Spain 138 Native valve IE 69%, PVE 31%; surgery 51% Overall 21; surgical 21, medical 20 (P�NS) 10 71 Early surgery associated with good long-term results and no increase in mortality. Not a comparative study. Alexiou12 2000 Retrospective single-center surgical cohort study Multivariate logistic regression analysis UK 118 Native valve IE 70%, PVE 30%; surgery 100% 7.6 (Surgical series) 10 73 Predictors of operative mortality: CHF, impaired LV function. Predictors of recurrence: PVE. Predictors of late mortality: myocardial invasion, reoperation. Predictors of poor long-term survival: coagulase-negative staphylococcus, annular abscess, long ICU stay. Wallace13 2002 Retrospective single-center cohort study Multivariate logistic regression analysis UK 208 Native valve IE 68%, PVE 32%; surgery 52% Overall 18; impact of surgery not reported 0.5 73 Duration of illness, age, gender, site of infection, organism, and LV function did not predict outcome. Abnormal white cell count, raised creatinine, �2 Duke criteria, or visible vegetation conferred poor prognosis. Hasbun14 2003 Retrospective multicenter cohort study Multivariate logistic regression analysis USA 513 Native valve IE alone; surgery 45% Not reported 0.5 74 Mortality associated with comorbidity, abnormal mental status, CHF, nonstreptococcal IE, or medical therapy. Prognostic classification proposed. Vikram15 2003 Retrospective multicenter cohort study Propensity analysis USA 513 Native valve IE alone; surgery 45% Not reported 0.5 74 Valve surgery associated with reduced mortality after adjustment for baseline variables and propensity scores. Benefits of surgery greatest in patients with CHF. Habib16 2005 Retrospective multicenter cohort study Multivariate logistic regression analysis France 104 PVE alone; surgery 49% Overall 21; surgical 17, medical 25 (P�NS) 2.7 62 Predictors of in-hospital mortality: CHF, S aureus. Predictors of long-term mortality: early PVE, comorbidity, CHF, staphylococcal infection, new prosthetic dehiscence. Mortality reduced by surgery in high-risk subgroups with staphylococcal infection and complicated PVE. Delahaye17 2007 Prospective multicenter population- based survey Multivariate logistic regression analysis France 559 Native valve IE 85%, PVE 15%; surgery 47% Overall 17; surgical 14, medical 19 (P�NS) Not reported Not reported Predictors of mortality: CHF, immunosuppression, insulin dependent DM, left-sided IE, septic shock, coma, cerebral hemorrhage, high C-reactive protein. (Continued) 1142 Circulation March 9, 2010 by on June 3, 2011 circ.ahajournals.orgDownloaded from Table 1. Continued First Author and Reference Citation Year Study Design Statistical Methods Setting No. of Subjects Patient Characteristics In-Hospital Mortality, % Mean Follow-Up, y Long- Term Survival Rate, % Summary of Findings San Román18 2007 Prospective multicenter cohort study Multivariate logistic regression analysis Spain 317 Native valve IE 64%, PVE 36%; surgery 28% Overall 21 Not reported Not reported Predictors of high risk: interhospital transfer, AV block, acute onset, CHF, periannular complications, S aureus infection. Revilla19 2007 Prospective multicenter cohort study Multivariate logistic regression analysis Spain 508 Native valve IE 66%, PVE 34%; surgery 100% Overall 36; native valve 32, PVE 45 (surgical series) Not reported Not reported Poor clinical outcome after urgent surgery. Persistent infection and renal failure associated with higher mortality. Hill20 2007 Prospective single-center cohort study Multivariate logistic regression analysis Belgium 193 Native valve IE 66%, PVE 34%; surgery 63% Not reported 0.5 78 Overall (26 if CI to surgery) Predictors of mortality: age, S aureus, CI to surgery (present in 50% of deaths). Remadi21 2007 Prospective multicenter cohort study Multivariate logistic regression analysis France 116 S aureus IE alone; native valve IE 83%, PVE 17%; surgery 47% Overall 26; surgical 16, medical 34 (P�0.05) 3 57 Predictors of mortality: comorbidity, CHF, severe sepsis, PVE, major neurological events. Early surgery associated with improved outcome. Wang6 2007 Prospective multicenter cohort study Multivariate logistic regression analysis Global registry 556 PVE alone; surgery 49% Overall 23; impact of surgery not reported Not reported Not reported Predictors of in-hospital mortality: age, healthcare-associated infection, S aureus infection, CHF, stroke, intracardiac abscess, persistent bacteremia. Aksoy22 2007 Prospective single-center cohort study Propensity score matching: logistic regression analysis USA 426 Native valve IE 69%, PVE 19%, “other” 12%; surgery 29% Overall 17; left-sided IE: surgical 12, medical 18 5 Surgical �48, medical �28 Factors associated with surgical treatment: age, interhospital transfer, staphylococcal infection, CHF, intracardiac abscess, hemodialysis with IV catheter. Surgery associated with long-term benefit. Factors associated with mortality: DM, paravalvular infection, indwelling IV catheter. Tleyjeh23 2007 Retrospective single-center cohort study Matched propensity analysis USA 546 Native valve IE alone; surgery 24% Not reported 0.5 Surgical 73, medical 76 No survival benefits associated with surgery despite correction for timing and early operative deaths. Prospective study recommended. Tleyjeh24 2008 Retrospective single-center cohort study Propensity analysis USA 546 Native valve IE alone; surgery 24% Not reported 0.5 Surgical 73, medical 76 Strong correlation between propensity score and timing of surgery. Individual effect of each variable difficult to measure. Thuny25 2009 Retrospective single center observational cohort study Propensity analysis France 291 Native valve IE 82%, PVE 18%; surgery 100% Not reported 6 months 13% Very early surgery (�7 days) associated with improved survival (especially in highest risk patients) but greater likelihood of relapse or post-operative valve dysfunction. CHF indicates congestive heart failure; PVE, prosthetic valve endocarditis; NS, not significant; UK, United Kingdom; LV, left ventricle; ICU, intensive care unit; USA, United States; CI, contraindication; IV, intravenous; DM, diabetes mellitus; and AV, atrioventricular. Prendergast and Tornos Surgery for Infective Endocarditis 1143 by on June 3, 2011 circ.ahajournals.orgDownloaded from considered in men �40 years of age, postmenopausal women, and those with a history of ischemic heart disease or an adverse risk factor profile, although caution is necessary in the presence of large aortic vegetations that may be dislodged by catheter manipulation. Alternative noninvasive techniques such as multislice CT or MRI may be used if available. Oral anticoagulation is associated with adverse outcome in IE, particularly during the first 2 weeks, when embolic risk is highest and surgical decisions are usually necessary.32 Anti- coagulants should be discontinued in this phase if possible. If essential (for example, in those with prosthetic valve endocarditis that affects a mechanical valve), then a switch to intravenous unfractionated heparin is recommended. Whenever possible, the primary source of infection re- sponsible for IE should be eliminated before cardiac surgical intervention. Intraoperative Management Imaging The operating table is an inappropriate place for cardiac diagnosis, and full anatomic characterization is required before surgery is undertaken. Perioperative transesophageal echocardiography is a useful tool to determine the exact location and extent of infection,33 assist the choice of recon- struction procedure, validate the surgical result, and guide perioperative hemodynamic management. Microbiology The excised native or prosthetic valve should be sent to the microbiology laboratory in physiological saline for immedi- ate culture. A Gram’s stain is useful for immediate diagnosis, and molecular examination of excised valve tissue may play a role, particularly in culture-negative patients.34 Surgical Technique The 2 primary objectives of surgery are control of infection and reconstruction of cardiac morphology.35 The mode of surgery (replacement versus repair) or type of prosthesis used (mechanical versus biological) has no influence on operative mortality,36 although repair techniques, when applicable, offer long-term advantages, including a re- duced risk of late complications (notably, recurrent IE) and obviation of the need for lifelong anticoagulation.37 Ho- mografts offer a reduced risk of recurrent infection in aortic IE,38 although their use remains controversial owing to a higher risk of late complications.39 Cardiac transplantation may be considered in extreme cases with recurrent prosthetic valve endocarditis.40 Indications for Surgery Tables 2 and 3 present information on indications for and timing of surgery, and the Figure presents surgical indications in native valve IE. However, it is important to remember that no randomized controlled trials are available to guide current practice. Nor are they likely; such studies would be difficult to perform owing to the diversity of patients with IE, the relatively small numbers available for study, and potential ethical concerns if surgery were to be withheld in control patients. What available evidence, therefore, guides current practice and international recommendations? Congestive Heart Failure Due to Valvular Regurgitation Among the complications of IE, congestive heart failure has the greatest impact on prognosis.14,15 Studies from the 1970s and 1980s compared medical and surgical treatment of congestive heart failure complicating IE and demonstrated a consistent reduction in mortality after surgery, from a range of 56% to 86% to a range of 11% to 35%.41,42 Although no correction was made for underlying comorbidity, similar results were reported in 2 more recent Scandinavian stud- ies,26,43 in which the best results were obtained with early intervention within 1 week of presentation. Early valve surgery in patients with congestive heart failure is associated with a substantial reduction in mortality compared with medical therapy alone,5,15,21,22,44 and this scenario is now the most common and clearest indication for surgery, being present in 72% of patients who underwent early intervention in a recent European series.19 Congestive heart failure is usually the result of valvular regurgitation, which may develop acutely as a result of perforation of a native valve or bioprosthetic valve leaflet or rupture of infected mitral chordae. Rarer causes include valve obstruction by bulky vegetations and sudden intracardiac shunts from fistulous tracts or prosthetic dehiscence. Acute aortic regurgitation is poorly tolerated and usually rapidly progressive. Urgent surgery is indicated regardless of the status of the infection, particularly when evidence of pulmo- nary edema or cardiogenic shock exists, or echocardiographic evidence of rapidly rising left ventricular end-diastolic pres- sure (premature closure of the mitral valve). Acute mitral regurgitation may be better tolerated as a consequence of offloading into the left atrium and pulmonary bed; however, acute pulmonary edema may develop as a result of the rapid increase in left atrial pressure, and urgent surgical interven- tion is frequently required. Patients with less dramatic presentation may respond well to initial medical therapy with diuretics and short-term afterload reduction with vasodilator therapy. No clear evi- dence exists to guide management strategy in this situation, and many physicians and surgeons are reluctant to recom- mend early surgery. Thus, in the absence of other immediate indications, intervention may be postponed in the short term to allow a brief period of antibiotic therapy under careful clinical and echocardiographic observation. Conversely, mild congestive heart failure at initial presentation may progress insidiously despite appropriate antibiotic therapy, usually within the first month of treatment. Delayed surgery in these circumstances is unacceptable, being associated with a dra- matic rise in operative mortality45 as a consequence of progressive cardiac decompensation and exposure of the patient to secondary risks of the disease and its treatment. In the occasional patient with well-tolerated valvular re- gurgitation and no other indication for surgery, medical management with antibiotics is recommended under strict clinical and echocardiographic control. Surgery can then be considered at a later stage after healing of the infection, depending on tolerance of the valve lesion. This strategy may be particularly attractive in the elderly comorbid patient who presents extreme surgical risk and in the young patient for 1144 Circulation March 9, 2010 by on June 3, 2011 circ.ahajournals.orgDownloaded from whom valve replacement may