European Journal of Cardiovascular Medicine

Infective endocarditis (IE) is a life-threatening disease, with mortality ranging upto almost 15% (1,2) in some, and exceeding 20%(3) in some series. Current guidelines from the American Association for Thoracic Surgery (AATS) in 2019(4) and the European Society of Cardiology (ESC) in 2023(5), highly recommends early surgery to mitigate risk in these high risk cases. Early surgery helps prevent complications and increases survival rates (6). We have 13 cases of native valve endocarditis (NVE) treated at our center in the past 2.5 years, all with no deaths. This shows how effective quick surgery and following current management guidelines can be.

Indications:

Indications for which these cases were taken up for surgery (7):

1. Acute severe heart failure due to valve dysfunction, taken up as Emergency surgery.
2. Post appropriate antibiotic therapy and negative blood culture, taken up as an elective case.
3. Persistent bacteremia and fever lasting for more than 5-7 days, despite adequate antibiotic therapy.
4. In case of large mobile vegetation, emergent surgery to reduce the chances of embolic stroke/septic pulmonary embolism.

General Principles for Operation:

• Cases were done via median sternotomy.
• Pericardiotomy was done and heart exposed in all cases.
• Cardiopulmonary bypass (CPB) was initiated in all cases via Aorta, SVC and IVC cannulation.
• For right sided procedures (Tricuspid Valve), SVC and IVC were looped and snugged.
• In all cases, vegetation tissue was completely excised, and then the valve checked for possibility of repair (2, 8).
• Valve was repaired where a repair was possible. Repair was reinforced with an annuloplasty ring (2, 8, 9).
• Otherwise, valve replacement was done.
• For right sided procedures involving Tricuspid Valve, tissue prosthetic valve was used for replacement (slow flow system, more thrombogenic with mechanical valve).

For left sided procedures involving Mitral or Aortic valve, mechanical or tissue prosthetic valve was used for replacement, based on patient age and other criteria

Tricuspid Valve Endocarditis (5 Cases)

Five cases of right-sided endocarditis.

Case 1: A 36-year-old man [non-intravenous drug user (IVDU)] with Stenotrophomonas Maltophila bacteremia and septic pulmonary emboli. The bacteremia most likely originated from community acquired Pneumonia. Large (2.75×2.2 cm) friable mass attached to Anterior Tricuspid leaflet (ATL) on echocardiography. Emergency surgery was undertaken due to patient being in acute heart failure (AATS 2019 Class I recommendation). The vegetation had completely eaten away the anterior and septal leaflet of TV; chordea and annulus were also affected. So valve repair was decided against, and TV was replaced with a No 31 tissue valve after excising the affected parts. Complete recovery, patient doing well till now with no recurrence.

Case 2: A 29-year-old man (non-IVDU) with methicillin-resistant S. aureus (MRSA) and acute heart failure. Had 2.8×1.3 cm vegetation attached to ATL superior surface leading to severe TR. Emergency surgery(AATS 2019 class I) with debridement of ATL and reconstruction with autologus pericardium, followed by reinforcement with a ring. No residual TR, patient doing well till now.

Case 3: A 31-year-old man (known IVDU) with MRSA endocarditis and heart failure (HF) with ana sarca. Echo gave vegetation in all the 3 leaflets of tricuspid valve, with the largest one measuring 2.4×1.6 cm. Emergency Surgery was done for severe tricuspid regurgitation with refractory HF (ESC 2023 Class I). TV had to be excised and replaced with tissue valve. Patient recovered uneventfully, and is doing well till date.

Case 4: A 14-year-old female with IE of septal and anterior tricuspid leaflet due to complication of a Perimembranous VSD (PM-VSD) and, with severe TR and severe PAH, presenting with refractory HF. Had emergency surgery(AATS 2019 class I) with debridement of ATL and STL, closure of VSD with treated autologus Pericardium,  TV reconstruction with ATL and STL augmentation with 3 neochordea formation, with repair reinforced with a tricuspid ring. Post CPB TEE revealed mild TR with a trivial VSD leak. Patient went home on 6th POD, and is still doing well.

Case 5: A 9-year-old male with MRSA IE with heart failure, ascitis and fever and hypoplastic ATL, STL and posterior tricuspid leaflet, with the ATL grossly affected by the IE.  Had surgery due to refractory HF (AATS 2019 class I) and to prevent ongoing infection (ESC 2023 class I). On surgery, he also had ruptured anterior pappilary muscle with its chordea. ATL reconstructed with a large treated autologus pericardial patch, and 5.0 PTFE was used to construct a neochord, reinforced by ring. This resulted in trivial post repair TR on table. Patient went home on 6th post-operative day, and is doing well till now.

Mitral Valve Endocarditis (4 Cases)

All presented with left-sided IE, and increased complication rates.

Case 6: A 34-year-old woman, known case of systemic lupus erythematosus(SLE) with negative blood culture, admitted with LRTI, sepsis and AKI, complicated by cardiogenic shock and ana sarca due to acute severe mitral regurgitation caused by posterior mitral leaflet(PML) perfoation, along with a 6.2×6.3 mm vegetationin the tip of PML. Emergency surgery was done (AATS 2019 class I, ESC 2023: HF in IE necessitates urgent surgery), where the vegetation was debrided, PML repaired with pericardium, and reinforced with no 28 mitral saddle ring. Exposure of the mitral valve was by left atrial (LA) roof due to small LA size. Post-operative recovery was uneventful, and patient is doing well till now.

Case 7: A 30-year-old woman with Enterococcus IE and PML vegetation (1.6×1.3 cm), causing severe MR and heart failure. Underwent emergent mitral valve replacement + debridement (AATS 2019 class I: refractory heart failure and ESC 2023 class I: To prevent left sided embolism). Patient doing well till now.

Case 8: A 4-year-old girl with blood culture negative IE and on and off fever since last 6 months. Echo revealed a vegetation of 1.2×1.1 cm on AML, causing mitral valve prolapse,  and severe MR. Surgery was taken up(ESC 2023 class I: To prevent left sided embolism) and mitral valve replacement done after the failure of initial attempt at repair. Patient went home on 5th POD, and doing well till now.

 Case 9: A 10-year-old girl with MRSA IE and 9×2 mm vegetation in PML with associated annular abscess with mild MR following right ankle osteomyelitis following trauma. Case taken up in emergency from pediatric ICU (AATS 2019 and ESC 2023: Abscess requires early surgery). In surgery, afftected part of PML with the area of abscess was excised and reconstructed with bovine pericardial patch. The repair was reinforced with a ring. Post-operative recovery was uneventful and the patient is doing well till now.

Aortic Valve Endocarditis (2 Cases)

Both cases had high-risk features necessitating urgent surgery.

Case 10: A 27-year-old female with small vegetation in non-coronary cusp (NCC) of aortic valve with a 6 mm PM-VSD and culture negative IE. Developed severe aortic regurgitation (AR) and moderate mitral regurgitation (MR) and underwent double valve replacement (DVR) with primary pledgeted closure of VSD (both valves were destroyed beyond repair) (ESC 2023: AR with HF is Class I for surgery). She is doing well till now.

Case 11: A 23-year-old female with culture negative IE and history of on and off fever since last 1 year, had vegetation on both NCC(1.2×1.1 cm) and Left coronary cusp(LCC)(1.4×1.7 cm). Underwent aortic valve repair with treated autologus Pericardium (ESC 2023: Long standing infection and prevention of left sided embolization both class I for surgery). The patient is doing well now with no recurrence or reappearance of AR.

Pulmonary Valve Endocarditis (1 Case)

Case 12: A 32-year-old woman (non-IVDU) with culture negative IE and refractory heart failure. Had a large 2.2×1.4 cm vegetation in the middle of anterior pulmonary leaflet, causing severe PR. Emergency pulmonary valve repair with autologus pericardium was undertaken (AATS 2019 class I). Patient went home on 6th POD after symptoms of heart failure subsided. She is doing well till date.

Combined Tricuspid + Mitral Valve Endocarditis (1 Case)

Case 13: A 47-year-old man (chronic alcoholic) with Enterococcus fecalis IE. Patient had refractory HF, ascites and evidence of ischemic CVA. Echo revealed a 25×16 mm vegetation in AML, another 27×20 mm vegetation in PML with severe MR, also 17×2 mm vegetation in ATL leading to severe TR. Emergency surgery was done, and both MV and TV replaced as they were found destroyed beyond repair (ESC 2023: Early surgery in case of left sided IE with stroke where hemorrhage is ruled out, AATS 2019 Class I for surgery).  Patient is doing well till date.

Overview:

• Total 13 cases of NVE done over the last 2.5 years.
• 5 cases in the tricuspid valve, 4 in Mitral, 2 in Aortic, and 1 in pulmonary valve.  1 very rare case involved both mitral and tricuspid valve (both sided NVE).
• 1 mitral valve was approached through LA roof to tackle the problem of small LA due to acute MR.
• Among the 5 TV cases, surprisingly, only 1 was a known IV drug abuser.
• Focus was to try to repair the valves in all cases.
• 8 cases were decided for repair after the initial exploration, 7 of them succeeded, 1 resulted in moderate residual MR and valve was replaced.
• 5 cases were decided for replacement after initial exploration.
• No in hospital mortality.  All patients are doing fine with no recurrence till now.

Summarising the cases via a table:

Key Lessons from AATS 2019 & ESC 2023 Guidelines:

1. Early Surgery Saves Lives (10, 11):

• Heart failure (HF): Cases 1-7 and 12, 13 were given “surgery as a matter of urgency” (ESC 2023: HF due to IE is most important for surgery).(12)
• Uncontrolled infection: Cases 5, 8, 9, and 11 had “operation in days” since diagnosis was with abscess or recurrent bacteremia (AATS 2019: operation halves mortality in such cases) (13).
• Prevention of embolism: Cases 7, 8 and 11 underwent “prophylactic/early surgery” for large vegetations (ESC 2023: >10mm with embolic risk indicates surgery).(12,14)

Multidisciplinary Endocarditis Team (Heart Team) Approach

   - All cases were presented in a “multidisciplinary meeting” (cardiologist, cardiac surgeon, infectious disease expert) prior to surgery (ESC 2023: mandatory for best outcomes).

No Mortality in This Series

- “100% survival” resulted from adherence to guidelines, absence of delays, and proper selection of surgical candidates (15).

This “13-case series of NVE with no mortality” reaffirms the life-saving benefit of early surgery in high-risk IE, as supported by “AATS 2019 and ESC 2023 guidelines”. Lessons learned:

• “Surgery must not be delayed” in HF, abscess, large vegetations, or ongoing infection.
• “Multidisciplinary management is essential” for best decision-making.
• “Compliance with contemporary guidelines avoids deaths” in IE.

Future Directions:

Larger trials should further establish the “zero-mortality strategy” with early surgery in IE.

Conflict of Interest:

None.

1. Talha KM, Dayer MJ, Thornhill MH, Tariq W, Arshad V, Tleyjeh IM, Bailey KR, Palraj R, Anavekar NS, Rizwan Sohail M, DeSimone DC, Baddour LM. Temporal Trends of Infective Endocarditis in North America From 2000 to 2017-A Systematic Review. Open Forum Infect Dis. 2021 Sep 25;8(11):ofab479. doi: 10.1093/ofid/ofab479. Erratum in: Open Forum Infect Dis. 2022 Jun 22;9(7):ofac359. doi: 10.1093/ofid/ofac359. PMID: 35224128; PMCID: PMC8864733.
2. David TE, Gavra G, Feindel CM, et al. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc Surg. 2007;133(1):144-9.
3. Gaca JG, Sheng S, Daneshmand MA, et al.** Outcomes for endocarditis surgery in North America: an analysis from the STS database. Ann Thorac Surg. 2018;105(5):1427-33.
4. American Association for Thoracic Surgery (AATS). Guidelines for surgical treatment of infective endocarditis. J Thorac Cardiovasc Surg. 2019;157(1):72-90.
5. European Society of Cardiology (ESC). 2023 ESC guidelines for the management of infective endocarditis. Eur Heart J. 2023;44(20):1825-96.
6. Wang A, Gaca JG, Chu VH. Management considerations in infective endocarditis: a review. JAMA. 2018;320(1):72-83.
7. Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121(9):1141-52
8. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. Circulation. 2015;132(15):1435-86.
9. Feringa HHH, Shaw LJ, Poldermans D, et al. Mitral valve repair and replacement in endocarditis: a systematic review of literature. Ann Thorac Surg. 2007;83(2):564-70.
10. Lalani T, Cabell CH, Benjamin DK, et al. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis.
11. Liang F, Song B, Liu R, Yang L, Tang H, Li Y. Optimal timing for early surgery in infective endocarditis: a meta-analysis. Interact Cardiovasc Thorac Surg. 2016 Mar;22(3):336-45. doi: 10.1093/icvts/ivv368. Epub 2015 Dec 17. PMID: 26678152; PMCID: PMC4986570.
12. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J. 2015;36(44):3075-128.
13. Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019;8(6):630-44.
14. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466-73.
15. Chu VH, Park LP, Athan E, et al. Association between surgical indications, operative risk, and clinical outcome in infective endocarditis. J Am Coll Cardiol. 2015;65(17):1784-94.