Andersons pediatric cardiology 1495

Timingoftheoperationislikelycrucialfortheoutcome.Itdifferssignificantly
betweencentersthroughouttheworld.Thebenefitofearlysurgeryhasbecome
wellestablishedduringthepastdecade.Thisisdefinedas:emergency(within24
hours),urgent(withinafewdays),andearlyelectivesurgery(after1to2weeks
ofdiagnosisandbeforecompletionofthefullcourseofantibiotics).
Theindicationsforemergencyandurgentsurgeryarewelloutlinedinthe
currentlyusedguidelines.Intractable,severe,andcomplicatedheartfailureisan
emergencyindication.Itisusuallycausedbyacuteorincreasingvalvar
regurgitation.Theadditionofventriculardysfunctionisanunfavorable
prognosticsign.Thepresenceofriskfactorsforsystemicembolismisanother
groupofindications:itseemsthatlargevegetations(>10mm),especiallyonthe
anteriormitralleaflet,arethebestdescribedriskfactor.
Anadaptedsummaryoftheindicationsforearlysurgeryinleft-sidedIEis
showninTable56.10.
Table56.10
IndicationsforEarlySurgeryinLeft-SidedInfectiveEndocarditis
HEARTFAILURE
AorticormitralIEwithsevereacuteregurgitationorvalveobstructioncausingrefractory
pulmonaryedemaorcardiogenicshock
AorticormitralIEwithfistulaintoacardiacchamberorpericardiumcausingrefractory
pulmonaryedemaorshock
AorticormitralIEwithsevereacuteregurgitationorvalveobstructionandpersistingheart
failureorpoorhemodynamictolerance(earlymitralclosure,pulmonaryhypertension)
AorticormitralIEwithsevereregurgitationandnoHF
UNCONTROLLEDINFECTION
Locallyuncontrolledinfection(abscess,falseaneurysm,fistula,enlargingvegetation)
Persistingfeverandpositivebloodcultures>10daysonappropriateantibiotic
Infectioncausedbyfungiormultiresistantorganisms
PREVENTIONOFEMBOLISM
AorticormitralIEwithlargevegetations(>10mm)followingoneormoreembolicepisodes
despiteappropriateantibiotictherapy

AorticormitralIEwithlargevegetations(>10mm)andotherpredictorsofcomplicatedcourse
(HF,persistentinfection,abscess)
Isolatedverylargevegetations(>15mm)

Emergencya
Emergency
Urgenta
Electivea
Urgent
Urgent
Urgent/elective
Urgent
Urgent
Urgent

aEmergency<24hours;Urgent<fewdays;Elective>1–2weeksofantibiotictherapy.

IE,Infectiveendocarditis;HF,heartfailure.
ModifiedfromHabibG,LancellottiP,AntunesMJ,etal.2015ESCGuidelinesforthe
managementofinfectiveendocarditis:TheTaskForcefortheManagementofInfective
EndocarditisoftheEuropeanSocietyofCardiology(ESC).Endorsedby:EuropeanAssociation
forCardio-ThoracicSurgery(EACTS),theEuropeanAssociationofNuclearMedicine(EANM).
EurHeartJ.2015;36(44):3075–3128.


Thebenefitofearlysurgeryinadultshasbecomewellestablishedduringthe
pastdecade.Thebenefitsofearlysurgeryhavepreviouslybeenreportedin
adultsinsmallerstudies,122includinginprospectivestudies123,124andthefirst
controlledrandomizedstudyinadults.125Somestudiescouldnotshowbenefitof
earlysurgeryforPVEinadultIE.126,127Thereisarecentcomprehensivereview

onthetopic128andmeta-analysis.129Thisevolutionofunderstandingisalso
basedonthefollowing:

■Improvedoutcomesaftersurgery.
■Growingevidencethatthenegativesidefor
operatingonpatientswithactiveinfectionisminimal.
■Substantialdatathatdurationofpreoperative
antibiotictreatmenthasnoorlittleeffecton
outcomes.7
■ThefactthatinthecaseofBC-negativeIE,surgery
alsocanhelptoidentifythecausativemicroorganism
thankstomicrobiologicexaminationoftheoperative
specimen,includingmoleculartestingwithPCR.
EarlysurgeryforpediatricIEresultsareaddressedina2013paperofasingle
center15-yearanalysis.130Itreportsthepossibilityofearlysurgeryinmorethan
60%,nativevalve-preservingsurgeryin50%,lowrecurrenceriskof2%,
mortalityrateof6.5%(comparedwith10%inthenonsurgicalgroup),anda
survivalrateat1,5,and10yearsof98%,90%,and81%,respectively,inthe
surgicalgroup(comparedwith96%,89%,and81%inthenonsurgicalgroup).
Thereisageneralunderstandingthatearlysurgeryissafe,althoughitmightbe
technicallychallengingforavalve-preservingsurgerybecauseofthe
characteristicsoftheinfectedandnecrotictissue.
InfectiveEndocarditisSurgeryinCerebralComplications.
Mycoticaneurysmsmayoccurinanysystemicarteryorthepulmonaryarteries
butareparticularlydangerousinthecerebralcirculation;surgicaltherapymay


beconsideredbecauseoftheriskofrupture.
TheESC2015guidelinesadviseurgentsurgeryforIEcomplicatedby
cerebralembolismortransientischemicevents.Recentdatasuggestthattherisk

ofneurologicexacerbationislowerthanpreviouslythought.Therearerecent
recommendationsonsurgeryinpatientswithembolicstroke.12Itisdifficultto
extrapolatetheserecommendationstothepediatricIEbecauseevennowthe
decisionsinIEwithneurologiccomplicationsaremoreofteninfavorofan
operation.
Thedecisionforacardiopulmonarybypasssurgeryismoredifficultincases
ofintracranialhemorrhage.Anoperativedelayof3weeksormorehasbeen
advisedasreasonableamongpatientswithrecentintracranialhemorrhage.7
However,thismightnotbepossibletobeadheredtoincaseoflifesaving
indications.
AorticRootAbscessSurgery.
Theaorticrootabscesssurgerycontinuestobeachallenge.Thedestructionof
theaorticannulususuallydoesnotallowformereaorticvalvereplacementand
requiresaorticrootreplacement.Itisbelievedthattheradicalresectionofthe
abscessisveryimportant.Managementofaorticrootabscessinadultshasbeen
discussedinmultiplepapers131–134;thepediatricseriesarescarce.
Thetypeofaorticrootreplacementisofsignificance.Aortichomograftshave
beenusedwithreportedexcellence,135–139andourteamshavepersonal
preferenceforthisapproach.Morerecently,inviewofthedeficitofhomografts,
therehasbeenasearchforalternativemethods.Pulmonaryautograftaorticroot
replacement(Rossprocedure)hasbeenreportedtohaveexcellentresultsin
pediatricIEwithaorticrootabscess.140Therehavebeenpreviousreportsofthe
useofautopericardialreplacementoftheleftventricularoutflowtract,141,142as
wellasequineandDacrongraftsforclosureoftheabscess.Thegraftselection
wasthoughttobeofsignificancewithrecommendedavoidanceofprosthetic
material.143However,therearerecentreportsoftheuseofflangedcomposite
graft(artificialtubewithimplantedvalve)wherethesubprostheticpartofthe
syntheticgraftcanbeusedtopatchallkindsofdefectscreatedbyresectionof
theabscessandtheprosthesiscanbeproducedindifferentsizesandeasily
shaped.144Aorticvalverepairwithneocuspidization(Ozakirepair)mightalso

becomepossibleafterpatchingofthedefectscreatedbytheinfectedwall
resection.145,146