Cardiac surgery for aortic valve replacement by mechanical prosthesis with antibiotic therapy according to antibiogram.

A 54-year-old patient is admitted for thermometric fever of 38°C in the previous five days and dyspnea at rest (LV) that appeared 6 hours before coming to the hospital. Examination in the emergency room was compatible with heart failure and the ECG showed complete atrioventricular block with an escape ventricular rate of 45 bpm. Signs of heart failure are refractory to medical treatment and transesophageal echocardiography shows an aortic valve with an effective regurgitant orifice of 0.5 cm2_ Serial cultures are positive for Streptococcus gallolyticus. Indicate the best course of action:

Antibiotic therapy according to antibiogram and implantation of intra-aortic balloon counterpulsation and transient pacemaker for up to 3 weeks, after which a permanent pacemaker will be implanted.

Implantation of transient pacemaker, antibiotic therapy according to antibiogram and percutaneous implantation of aortic valve prosthesis.

Urgent implantation of definitive pacemaker with antibiotic therapy according to antibiogram for 6 weeks.

Complete heart block resulting from quadricuspid aortic valve penicillin-resistant pneumococcal endocarditis: a case report.

A 62-year-old woman was referred to hospital to be treated for complete heart block with syncope. A quadricuspid aortic valve without vegetation and aortic valve regurgitation (AR) were observed by transesophageal echocardiography. Blood culture showed penicillin-resistant Streptococcus pneumoniae. The patient received a permanent pacemaker implantation (VDD type) and was given antibiotics. Although infection improved, heart failure was not improved because AR hemodynamic changes became worse. An aortic valve replacement was performed using a prosthesis on the 26th day of hospitalization. The patient recovered and was discharged.

Urgent splenectomy in the course of prosthetic valve endocarditis.

We present a case of a 51-year-old male patient hospitalized due to acute coronary syndrome requiring stent implantation to the left main stem. Double antiplatelet therapy was commenced. After 2-3 days, the patient presented with high fever, dyspnea on exertion, pain in the chest, myalgia, and general weakness. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed abnormal, turbulent flow across the aortic prosthesis, which was probably caused by the presence of a pathological smooth and mobile structure (10 × 9 × 5 mm) in front of the aortic annulus. Blood cultures were positive and staphylococcal prosthetic valve endocarditis (PVE) was diagnosed. Despite antibiotic treatment, the patient's condition deteriorated, and he was referred for prosthesis reimplantation. After being transferred to the Cardiac Surgery Clinic, he presented with nausea, vomiting, and abdominal pain. The results of imaging examinations suggested spleen hematoma. The patient underwent an urgent splenectomy. Histopathological examination revealed a spleen infarction consequent to an embolic event and subscapular hematoma. On the 10(th) day after the laparotomy, cardiac surgery was performed. No large vegetations were found on the aortic prosthesis. The mechanical valve, implanted 20 years earlier, was functioning properly; it was intact and well healed. Several fragments of a thrombus and fibrous tissue, resembling a pannus and covered with minor calcifications, were removed from the ventricular surface of the discs. A decision was reached to leave the aortic prosthesis in situ. The valvular material culture revealed the presence of Streptococcus anginosus, and the antibiotic scheme was modified. The postoperative period was uneventful.

[Aortic homograft implantation in severe endocarditis].

Severe endocarditis of the native aortic valve or a prosthetic valve with destruction of the cusps, paravalvular abscess formation and/or fistulas caused by aggressive bacteria has a mortality of almost 100% without surgery. The objective was to evaluate the results of treatment with an aortic homograft in combination with antibiotics. 24 patients with either aortic prosthetic valve endocarditis (n = 16) or severe aortic endocarditis (n = 8) were operated with implantation of an aortic homograft at a Danish university hospital from 1997-2006. Staphylococcus species were the most common pathogens followed by streptococcus. Intravenous antibiotic therapy was started before surgery and continued for 4-6 weeks. The patients were followed-up for (1/2)-10 years (mean 5 years). 3 patients with prosthetic valve endocarditis died within the first 24 hours from heart failure. 2 of these patients required in addition implantation of mitral valve prostheses. 5 patients died 1-7 years after the operation from non-cardiac causes. Within the follow-up period no patients had relapse of endocarditis, and only one episode of recurrence endocarditis in an intravenous drug abuser was registered after 4 years. An aortic homograft in combination with intravenous antibiotics is an excellent treatment of severe endocarditis in the aortic valve or an aortic valve prosthesis.

Surgical management of late prosthetic valve endocarditis.

Among 32 patients with late prosthetic valve endocarditis selected from two cooperative retrospective studies, ten had valve replacement: six men and four women, mean age being 48 years, ranging from 23 to 65 years old. An emergency reoperation was undertaken for refractory heart failure in seven out of ten cases, with an average delay of 6.6 days after the beginning of antibiotic therapy. In the other three cases, the operation was carried out at the end of 40 days of antibiotic therapy, once for recurrent endocarditis and twice for severe aortic insufficiency. The most common causative micro organism was the staphylococcus (7 out of 10 cases). The infected prosthetic valves were, in 8 out of the 10 cases, in the aortic position. The outcome was poor as the mortality rate was 60% (6 out of the 7 patients operated on in an emergency). Death was attributed to heart failure with conduction disturbances and severe aortic regurgitation (2 cases), cerebral emboli (2 cases), septicopyemia (2 cases). Four patients of the ten, after a mean follow up of 10 months, are cured without prosthetic valve dysfunction. The extreme gravity of prognosis seems related to the microorganism (staphylococcus), to the delay between the beginning of antibiotic therapy and the onset of the fever, and finally to the extension of destructive lesions under the prosthetic valve implantation base; the reimplantation of the prosthesis on frail and abscessed tissue implies a substantial risk of disinsertion. The indications for systematic early reoperation in cases of severe acute heart failure are discussed.

[Pedicled aortic wall flap for the reconstruction of aortico-ventricular discontinuity--a case report].

A 55-year-old man was operated on urgently for aortic valve endocarditis complicated by an annular abscess at the base of the non-coronary leaflet extending down to the left ventricle. Rapidly progressive heart failure and presence of a friable-appearing vegetation on echocardiography were the indications for urgent operation. Preoperative electrocardiogram showed first degree A-V block. At operation the aortic valve was generally thickened with mild calcification about the commissures. Non-coronary cusp was severely deformed and was nearly detached at its base due to annular abscess formation. Native valve was completely excised and the abscess was debrided. A club or a tongue-shaped pedicled aortic wall flap was prepared to the left of the oblique aortotomy incision with its free end to the distal side of the aorta. The flap was folded inward at its pedicle about 1 cm above the non-coronary annulus and was used to patch the abscess cavity. The aortic valve was replaced with a SJM 23 mm aortic valve prosthesis. The remaining defect of the aortic wall was repaired with a patch of woven-dacron vascular prosthesis. Post-operative hemodynamics of the patient was uneventful and he was given a 6-week course of parenteral antibiotics. He developed complete A-V block during the operation, and a permanent pacemaker was implanted on the 6th postoperative day. One year after operation he has not had recurrent infection and is leading a normal life. When used in the repair of ventriculo-aortic discontinuity created by infective endocarditis, the pedicled aortic wall flap has several advantages. It is easily obtainable and can cover abscesses of almost any shape and size. Unlike aortic root homograft, there is no problem of availability. Technically it is relatively simple to prepare a flap, bring it down through the non-coronary sinus and suture over the abscess. Aortic wall has just appropriate thickness and strength to reinforce the weakened periannular area, and if the debrided cavity is deep, the flap can be folded to obtain double thickness. By using this flap, potentially infected cavity is covered and packed by autologous tissue alone, and the synthetic patch to repair the aortic wall defect is placed well away from the site of possible contamination. In addition to the use in infective endocarditis, the aortic wall flap can predictably be used in the repair of aortic annular defect created by over-zealous removal of calcium in the surgery of calcific aortic stenosis, and in intracardiac patching in aortic annular enlargement operation such as Manouguian operation. To our knowledge, the use of pedicled aortic wall flap for aortic annular reconstruction has not been reported in the literature.

Bioprosthetic Stented Pericardial Porcine Aortic Valve Replacement -- Indications

A full culture-driven course of antibiotics should be the first-line treatment until one of the following scenarios pushes the multidisciplinary team toward early surgical source control: deteriorating heart failure, highly virulent or resistant organisms, new heart block, annular abscess, relapsing infection, persistent bacteremia for five to seven days, presence of a prosthetic valve infection, infected defibrillator, pacemaker, or leads, recurrent emboli, persistent vegetations, or mobile vegetation >1.0 cm.

Aortic Valve Endocarditis Surgical Treatment -- Treatment / Management

Infective endocarditis management is with prolonged duration of bactericidal antibiotics. The choice of antibiotic regimen (whether single or combination therapy) and the treatment duration are selected according to the pathogen’s susceptibility and resistance patterns, whether it’s a native or prosthetic valve endocarditis. Accordingly, the duration can vary from two weeks to as long as six weeks. Treatment is usually started in the hospital and completed as an outpatient once the fever subsides and the blood cultures are negative. But in some instances, antibiotic therapy alone is insufficient, and patients require surgery. Class I indications for surgery in patients with infective endocarditis include valvular dysfunction with symptoms of congestive heart failure, left-sided IE caused by S. aureus , fungal, or other highly resistant microorganisms, IE with conduction defects or heart block, annular or aortic abscess, persistent infection 5 to 7 days after initiation of antibiotic therapy. [2]

InternalMed_Harrison

Timing of Cardiac Surgery With the more life-threatening indications for surgery (valve dysfunction and severe CHF, paravalvular abscess, major prosthesis dehiscence), early surgery—i.e., during the initial week of therapy—is associated with a greater chance of survival than later surgery. With less compelling indications, surgery may reasonably be delayed to allow further treatment as well as improvement in overall health (Table 155-6). After 14 days of recommended antibiotic therapy, excised valves are culture-negative in 99% and 50% of patients with streptococcal and S. aureus endocarditis, 826 respectively. Recrudescent endocarditis on a new implanted prosthetic valve follows surgery for active NVE and PVE in 2% and 6–15% of patients, respectively. These frequencies do not justify the risk of an adverse outcome due to a delay in surgery, particularly in patients with severe heart failure, valve dysfunction, and uncontrolled staphylococcal infections. Delay is justified when

Outcome of aortic homograft implantation in 24 cases of severe infective endocarditis.

The objective of the study was to evaluate the results of treatment of severe aortic endocarditis with an aortic homograft (an aortic valve and root from a donor) in combination with antibiotic therapy. 24 patients with either aortic prosthetic valve endocarditis (n=16) or severe aortic native valve endocarditis (n=8) with destruction of 1 or more cusps, paravalvular abscess formation and/or cardiac fistulas caused by aggressive bacteria, underwent surgery in 1997-2006. Staphylococcal species were the most common pathogens followed by streptococci. Intravenous antibiotic therapy was started before surgery and continued for at least 4-6 weeks. Three patients with prosthetic valve endocarditis died within the first 24 h after surgery from heart failure. Two of these patients required an additional implantation of a mitral valve prosthesis. Five patients died from non-cardiac causes within 1-7 y of surgery. Within the follow-up period no patients had relapse of endocarditis, and only 1 episode of recurrent endocarditis in an intravenous drug abuser was registered. In conclusion, an aortic homograft in combination with intravenous antibiotics is an excellent option for treatment of severe aortic endocarditis.

Aortic valve replacement

Hospital stay and recovery time After aortic valve replacement, the patient will usually stay in an intensive care unit for 12–36 hours. Unless complications arise, the patient is then able to go home after approximately four to seven days. Common complications include disturbances to the heart’s rhythm (heart block), which typically require the permanent insertion of a cardiac pacemaker. Recovery from aortic valve replacement takes about three months if the patient is in good health. Patients are advised not to lift anything heavier than 10 lbs for several weeks, and not to do any heavy lifting for 4–6 months after surgery to avoid damaging their breastbone. Often patients will be referred to participate in cardiopulmonary rehabilitation, which optimizes recovery and physical function in patients with recent cardiac surgeries. This can be done in an outpatient setting. Outcomes

Aortic valve replacement

The risk of dying as a result of aortic valve replacement is estimated at 1–3%. Combining aortic valve replacement with coronary artery bypass grafting increases the risk of mortality. Older patients, as well as those who are frail and/or have other health problems (comorbidities), have a higher risk of experiencing complications. Possible problems include cardiac infarction/failure, arrhythmia or heart block (typically requires the permanent insertion of a cardiac pacemaker), mediastinal bleeding, stroke and infection. Late complications include endocarditis, thromboembolic events (blood clots), prosthetic valve dysfunction and paravalvular leak (blood flowing between the edge of the prosthetic valve and the cardiac tissue). Patient–prosthesis mismatch

Thrombosis and endocarditis in prosthetic heart valves, a case report.

The authors report the case of a 49-year-old female with a history of rheumatic valvular heart disease who underwent valve surgery in 1997, with implantation of St. Jude prosthetic valves in aortic and mitral position. She was asymptomatic until the end of July 2001, when she was admitted to Garcia de Orta Hospital emergency unit because of heart failure, fever and suspicion of endocarditis. Cardiologic evaluation was requested and the transthoracic (TTE) and transesophageal (TEE) echocardiograms revealed vegetations on the prosthetic mitral valve. Blood cultures were negative. She started empiric antibiotic therapy and the clinical course stabilized in the first week. After ten days of medical therapy her symptoms became worse and TTE and TEE were repeated. TTE showed significant left ventricular-aortic gradient, suggesting aortic valve obstruction. Decreased left ventricular function was now present with hypokinesia in the anterior descending coronary artery territory. In the TEE, a large thrombotic process on the mitral prosthesis valve was seen, with a prosthesis disk blocked. There were similar findings in the aortic valve. Cardiac fluoroscopic images were obtained at the mitral and aortic position confirming the TEE report. The coronary angiogram was normal. Promptly transferred to a cardiac surgery center, the patient underwent aortic and mitral prosthetic valve replacement. The intraoperative findings were compatible with those from echocardiography and cardiac fluoroscopy.

[Prosthesis-endocarditis in the aortic position in a 22-year case load. Surgical versus conservative treatment].

During the period 1965-1986, a total of 852 patients underwent isolated aortic valve replacement. With 4,875 patients-years at risk, 24 patients developed prosthetic valve endocarditis (PE; 0.49% per patient-year). The five, ten and fifteen year cumulative freedoms from PE were 98.2%, 95.4% and 93.0%, respectively. PE was unrelated to pre- or intraoperative data. No patients submitted to operation for acute/subacute bacterial endocarditis of the native aortic valve developed PE. Out of the 12 episodes of PE within two years of the operation, seven (58%) were caused by Staphylococcus albus compared with two out of 12 (17%; p less than 0.05) subsequent episodes of PE. Seven of the nine infections with Staphylococcus albus were caused by a highly resistant nosocomial variant. Ten of the PE patients underwent replacement of the prosthesis while 14 were treated conservatively. The two therapeutic groups were comparable, although the surgically treated patients tended to be younger and to have more impaired cardiac status. All surgically treated patients and all patients treated conservatively and in whom post mortem verification was possible had paravalvular defects, annular abscesses and/or vegetations on the prosthesis. The thirty-day, one year and ten year cumulative survivals were 80%, 80% and 50%, respectively, after replacement of the prosthesis and 64%, 21% and 7%, respectively, after conservative treatment (p = 0.02). A Cox regression analysis identified conservative treatment, infection with Escherichia coli or Haemophilus influenzae and the need to intensify digitalis/diuretic treatment for congestive heart failure as independent risk factors. It is concluded that replacement of the prosthesis early in the course of the disease should be considered as the treatment of choice.

Factors associated with cardiac conduction disorders and permanent pacemaker implantation after percutaneous aortic valve implantation with the CoreValve prosthesis.

Cardiac conduction disorders and requirement for permanent pacemaker implantation (PPI) are not uncommon after surgical aortic valve replacement and have important clinical implications. We aimed to investigate the incidence of cardiac conduction disorders after percutaneous aortic valve implantation (PAVI) and to identify possible clinical factors associated with their development. We studied 34 patients (mean age 80 +/- 8 years, 18 male) who underwent PAVI with the CoreValve bioprosthesis (Corevalve Inc, Irvine, CA). Electrocardiographic evaluation was performed pre- and postprocedurally, and at 1-week and 1-month follow-up. Other clinical variables were obtained from the medical history, echocardiography, and angiography. After PAVI, 7 patients required PPI, all of whom developed total atrioventricular block within 3 days postprocedurally. A smaller left ventricular outflow tract diameter (20.3 +/- 0.5 vs 21.6 +/- 1.8 cm, P = .01), more left-sided heart axis (-20 degrees +/- 29 degrees vs 19 degrees +/- 36 degrees , P = .02), more mitral annular calcification (10 +/- 1 vs 5 +/- 4 mm, P = .008), and a smaller postimplantation indexed effective orifice area (0.86 +/- 0.20 vs 1.10 +/- 0.26 cm(2)/m(2), P = .04) were associated with PPI. The incidence of new left bundle-branch block (LBBB) was 65% and was associated with a deeper implantation of the prosthesis: 10.2 +/- 2.3 mm in the new-LBBB group versus 7.7 +/- 3.1 mm in the non-LBBB group (P = .02). Percutaneous aortic valve implantation with the CoreValve prosthesis results in a high incidence of total atrioventricular block requiring PPI and new-onset LBBB. Preexisting disturbance of cardiac conduction, a narrow left ventricular outflow tract, and the severity of mitral annular calcification predict the need for permanent pacing, whereas the only factor shown to be predictive for new-onset LBBB is the depth of prosthesis implantation.

[Right-heart endocarditis after pacemaker implantation as a cause of a round pulmonary infiltrate].

A 57-year-old man developed intermittent fever and fatigue 11 months after a two-chamber cardiac pacemaker had been implanted because of 2 degrees and 3 degrees A-V block. Antituberculosis treatment was initiated as tuberculosis was suspected. The infiltrate regressed, but the other symptoms persisted. Four months later he was admitted as an emergency because of septicaemia. In addition to a recently discovered cardiac murmur there was a raised erythrocyte sedimentation rate (116 mm) and leucocytosis (13 600/microliters) with shift to the left. Coagulase-negative staphylococci were grown on several blood cultures. Transoesophageal echocardiography (TOE) demonstrated vegetation on the tricuspid valve, the pacing wires and the right ventricular outflow tract. After the diagnosis of infective endocarditis had been established, antibiotic treatment was give with imipenem, gentamycin and teicoplanin, the pacemaker system and adherent thrombotic material were removed and a DDD pacemaker implanted from the other side. The patient remained free of symptoms during a follow-up period of 12 months. Delayed diagnosis of infective endocarditis is not uncommon, because of the scarcity of typical symptoms. Repeated blood cultures and TOE are essential for the diagnosis.

[Results of surgical treatment of aortic root infection].

To investigate preoperative status and results of surgery of patients with confirmed diagnosis of aortic root infection. We have analyzed data of 21 patients who were operated on at the Heart Surgery Center, Vilnius University, since January 1, 1997, till December 31, 2006. All these patients underwent surgery because of aortic root infection. The patients were aged 25-72 years (mean age, 53+/-14 years). There were 17 (80.9%) male patients. Sixteen patients (76%) preoperatively were in NYHA class IV. The abscesses of aortic root were confirmed preoperatively by means of esophageal echocardiography in 18 patients (86%). Blood cultures positive for Staphylococcus aureus were found in four patients (19.9%). All the patients underwent replacement of the aortic valve by mechanic prosthesis; one of these patients was reoperated because of persistent sepsis, and replacement of the aortic root with homograft was performed. The duration of follow-up of the patients was 1 to 10 years. Inhospital mortality rate was 14.3%. The causes of death included sustained heart failure and sepsis. All these patients were in NYHA functional class IV preoperatively; one of these patients had culture positive for Staphylococcus aureus. Inhospital survival was 85.7%, one-year postoperative survival - 80.9%, and both five-year and ten-year survivals were 76.0%. The long-term survival was negatively influenced by recurrent infective endocarditis, heart failure, and age. Death occurred in 1 patient (11.1%) of the 9 patients who at the time of surgery were younger than 50 years and 4 patients (33.3%) of the 12 who were older than 50 years at the time of operation. The infection of aortic root is not common pathology; however, it is a complicated disease. Esophageal echocardiography is an informative method while diagnosing aortic root abscesses. The inhospital mortality is increased by the heart failure persisting after the operation and sepsis. The long-term survival is decreased by preoperative infective endocarditis of the prosthesis and heart failure. The mortality rate of patients older than 50 years is 3-fold higher than mortality rate of younger ones.

Complete atrioventricular block after isolated aortic valve replacement.

Temporary atrioventricular (AV) conduction disturbances are a common complication following cardiac surgery, especially involving the aortic valve. Permanent complete AV block is a serious and rare complication. Its prevalence has been estimated at 3-6% of all patients undergoing aortic valve replacement. Identification of factors that affect the occurrence of complete AV block requiring permanent pacemaker implantation might help reduce the risk of this problem in the future. To evaluate clinical, anatomical and surgical factors that might affect occurrence of complete AV, resulting in the need for permanent pacemaker implantation. In our prospective study, we analysed clinical data of consecutive 159 patients operated due to isolated aortic valve disease between February 2011 and March 2012. Patients with a pacemaker implanted before that time were excluded from the study. The main indication for surgery was aortic stenosis (n = 114, 71.7%). Infectious endocarditis was an indication in 6 (3.8%) cases. Mean patient age was 65.3 ± 11.4 years, and the proportion of males to females was 56.6%/43.4%. Overall, 135 (84.9%) patients had sinus rhythm preoperatively. All operations were performed using median sternotomy, cardiopulmonary bypass, and hypothermia at 30-32°C. A biological prosthesis was implanted in 120 (70.4%) patients. Patients who needed an additional procedure such as another valve surgery, aortic surgery or coronary artery bypass grafting were excluded from the study. Permanent pacemaker implantation was required in 11 (6.9%) patients. The pacemaker was implanted after at least 7 days of complete AV block which was then considered permanent. Univariate analysis showed that permanent pacemaker implantation was associated with prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, and the occurrence of electrolyte disturbances. Univariate logistic regression revealed that the need for permanent pacemaker implantation depended on 5 factors including prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, larger size of the implanted valve prosthesis, endocarditis as the indication for surgery, and electrolyte disturbances. In both backward and forward stepwise multivariate regression models, two parameters, prolonged aortic cross-clamp time and the presence of electrolyte disturbances, correlated with the occurrence of complete AV block. Permanent complete AV block is a serious complication after aortic valve surgery. Of all analysed clinical, anatomical and surgical factors, prolonged cardiopulmonary bypass time, prolonged aortic cross-clamp time, larger size of the implanted valve prosthesis, endocarditis as the indication for surgery, and electrolyte disturbances were found to be statistically significant predictors of permanent pacemaker implantation.

[Endocarditis with Ionescu-Shiley's bioprosthesis. Long-term results].

With the aim to attesting the ability of treated pericardial tissue to resist infection we analyzed the incidence of prosthetic valve endocarditis in 541 operative survivors with the Ionescu-Shiley (I-S) valve since January 1977. A total of 580 valves were available for the study, 21 (3.8%) sustained I-S endocarditis or 0.65% patients/annum. The mean age was 53.2 years; male/female ratio was 16/5. Native endocarditis was present in 20 cases (3.6%). There were 13 aortic endocarditis (2 in cases of multiple replacement) and eight mitral. The interval between insertion and endocarditis ranged from 2 weeks to 108 months (means 31); 8 cases were early I-S endocarditis (38%) and 13 late endocarditis (62%). The organisms isolated were: Staphylococcus (epidermidis, aureus) in 10 cases. Streptococcus (viridans, fecalis) in 7 cases, gram negative in three and no organism was cultured in 3 cases. The outcome was as follows: specific medical treatment in 4 cases (one early), valve re-replacement in 11 (four early) from whom eight survived, and 6 patients died with unspecific medical treatment. The total mortality rate 9/21 (43%), in early endocarditis 5/8 (62.5%) and in late endocarditis 5/13 (38%). Operative and necropsy findings in 12/21 showed always periprosthetic abscess but no leaflet perforations. The rate of I-S valve endocarditis compares favourably with other valve substitutes. Early re-replacement combined with adequate antibiotic treatment is mandatory according to our experience.

Adventist HealthCare White Oak Medical Center

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Rapid Evolution of an Aortic Endocarditis.

Cardiac surgery is necessary in almost 50% of patients with endocarditis. Early surgery, i.e., the surgery performed during the first hospitalization, is required in the following cases: heart failure secondary to valve regurgitation; <iS. aureus</i, fungal organism, or other highly resistant organism infection; heart block, annular or aortic abscess, or destructive penetrating lesions; evidence of persistent infection as manifested by persistent bacteremia or fevers lasting >5 days after onset of appropriate antimicrobial therapy. A 62-year-old man developed a fever (38 °C) 3 days after a transaortic electrophysiological study; blood cultures were positive for <iS. aureus</i, and were sensitive to vancomycin and ceftaroline. Antibiotic therapy was started, controlling the fever and the patient's infective and inflammatory profiles well; however, 3 days later, acute aortic regurgitation developed. At transesophageal echocardiography (TEE), a rare condition was revealed-vegetation was attached to the aortic wall, impeding correct aortic valve closure. Cardiac operation was carried out and the time for surgery was discussed; based on the patient's clinically stable condition, and on the infection, which was controlled well by antibiotics therapy, surgery was not performed in emergency circumstance (within 24-48 h)-rather, it was programmed during the hospitalization. A TEE surveillance was initiated, and after 7 days, TEE revealed a new picture, with images of an aortic abscess with small perforation in the right atrium, requiring emergency surgery, carried out 20 h later. In our case, the rapid evolution of the vegetation attached to the aortic wall suggested the following: (1) that the time for the surgery cannot be guided only by clinical procedure but must also be guided by imaging pictures; (2) that strictly TEE surveillance is mandatory in patients with aortic endocarditis not initially referred for emergency surgery.

A novel solution to prosthetic valve dehiscence after aortic valve surgery in Behçet's disease.

Prosthetic valve dehiscence after aortic valve surgery in Behçet's disease patients is common. We aimed to validate the usefulness of our new technique 'subannular endomyocardial implantation of valve prosthesis' designed to prevent prosthetic valve dehiscence. Subannular endomyocardial implantation of valve prosthesis involves suturing the sewing cuff of the valve prosthesis in the endomyocardium below the aortic annulus, which is based on the idea that annular tissue should be excluded from the suture line in Behçet's disease patients. Medical records of 7 patients in whom the new technique was performed between 2002 and 2014 were reviewed. Five men and two women were included (median age, 44 years). Aortic root replacement was performed in 6 cases, and aortic valve replacement in 1. No operative mortality occurred. Postoperatively, complete atrioventricular block developed in 3 cases, and permanent pacemakers were implanted in 2. No reoperation was performed for prosthetic valve dehiscence during the median 7.8-year follow-up. One late death occurred due to sudden cardiac arrest 8.4 years after surgery. One additional permanent pacemaker was implanted for complete atrioventricular block, which developed at 4.2 years postoperatively. The last echocardiography (median, 6.7 years after surgery) revealed no paravalvular leakages. Subannular endomyocardial implantation of valve prosthesis seems useful for preventing prosthetic valve dehiscence after aortic valve surgery for Behçet's disease. It poses a risk of complete atrioventricular block, but considering the high reoperation rate and mortality due to prosthetic valve dehiscence after conventional aortic valve surgery, this risk seems reasonable.

[Prosthetic valve endocarditis after double valve replacement].

This is a report of a patient who underwent re-AVR due to prosthetic valve endocarditis after double valve replacement (MVR, AVR). A 54-year-old female was admitted to other hospital on April 14, 1990, because of high fever, progressive anemia, and cardiomegaly. The patient was hospitalized to our department urgently with the diagnosis of prosthetic valve endocarditis. Arterial blood culture grew methicillin-resistant Staphylococcus epidermidis. Echocardiography showed a vegetation at the disc of the mechanical valve in the mitral position, but we could not find any vegetation or thrombus there at the reoperation, and the aortic mechanical valve seemed to be intact. Signs of inflammation continued to be positive after reoperation. On the 33rd hospital day, a diastolic murmur was heard, and emergency cardiac catheterization was done. Detachment of the prosthetic aortic valve and rupture of the sinus of Valsalva due to mycotic aneurysm, and the dissection of the aorta had occurred. We performed re-AVR and replacement of the ascending aorta. The patient died of multiple organ failure following drug-induced hepatic failure. It is suggestive that we missed the prosthetic aortic valve endocarditis during the reoperation. Our thoughts and introspections on the echocardiographic diagnosis of the prosthetic valve endocarditis after double valve replacement were discussed.

Low permanent pacemaker rates following Lotus device implantation for transcatheter aortic valve replacement due to modified implantation protocol.

Conduction disturbances requiring permanent pacemaker implantation following transcatheter aortic valve replacement (TAVR) are a common problem. Pacemaker implantation rates after TAVR appear to be higher compared to conventional aortic valve replacement. The aim of this study was to analyze whether a high annulus implantation conveys the benefit of a decreased rate of permanent pacemaker implantation while being safe and successful according to Valve Academic Research Consortium 2 (VARC2)-criteria. A total of 23 patients with symptomatic severe aortic valve stenosis, an aortic annulus of 19-27 mm and at high risk for surgery were treated with the Lotus valve. In all patients the valve was implanted in a high annulus position via femoral access. The primary device performance endpoint was VARC2-defined device success after 30 days and the primary safety endpoint was the need for permanent pacemaker implantation. The mean age was 73.23 ± 7.65 years, 46% were female, 38% were New York Heart Association class III/IV at baseline. Thirty-day follow-up data were available for all patients. The VARC2-defined device success rate after 30 days was 22/23 (96%). 2/21 (10%) patients required a newly implanted pacemaker due to 3rd degree atrioventricular block. 25% of the patients developed a new left bundle branch block after valvuloplasty or device implantation. 21 of the 23 patients (96%) had no other signs of conduction disturbances after 30 days. The approach of the modified implantation technique of Lotus TAVR device was safe and effective. The incidence of need for a permanent pacemaker following TAVR could be significantly reduced due to adopted implantation protocol.

[Pacemaker infection developed one month after the surgery for prosthetic valve endocarditis].

A 57-year-old man underwent mitral valve replacement and tricuspid annuloplasty for mitral and tricuspid regurgitation. Pacemaker implantation was conducted because of postoperative sick sinus syndrome 2 months after the operation. One year later, the patient was readmitted to the hospital because of high fever. Echocardiography showed 2 vegetations of 10 mm in diameter attached to the mitral mechanical valve. No vegetations were detected on the tricuspid valve or the pacemaker leads. Mitral valve re-replacement was urgently performed under the diagnosis of prosthetic valve endocarditis caused by Staphylococcus aureus. One month after the reoperation, pacemaker infection developed in spite of suitable infection control by daily intravenous injection of sensitive antibiotics. We proceeded to place a temporary pacing wire and extracted the entire permanent pacing system. A new permanent pacemaker was implanted 5 days later. The patient was discharged on the 62th postoperative day without recurrence of infection.

Conduction delays after transcatheter aortic valve implantation with balloon-expandable prosthesis and high implantation technique.

Performing transcatheter aortic valve implantation with high implantation technique, i.e. with an aorto-ventricular ratio > 60/40, reduces the need of permanent pacemaker implantation. Valve calcification and prosthesis oversizing are predictors of permanent pacemaker implantation, but there are no available data on their role when transcatheter aortic valve implantation is performed with an aorto-ventricular ratio > 60/40. The aim of this study was to evaluate the effect of leaflets/annulus calcification and prosthesis oversizing on the incidence of permanent pacemaker implantation after transcatheter aortic valve implantation with a high implantation technique. Transcatheter aortic valve implantation was performed in 48 patients implanting a balloon-expandable transcatheter heart valve with an aorto-ventricular ratio > 60/40. Calcium burden was assessed by preprocedural multidetector computed tomography. An invasive electrophysiological study was performed before and after transcatheter aortic valve implantation. Five patients (10.4%) needed permanent pacemaker implantation. At univariate analysis, baseline right bundle branch block and postprocedural PR, QRS and His-ventricular interval elongation significantly predicted permanent pacemaker implantation (p < 0.05). Receiver-operating characteristic curve analysis showed a correlation between transcatheter heart valve oversizing and permanent pacemaker implantation need, with the best cut-off being 17% (AUC = 0.72, p = 0.033). Linear regression analysis demonstrated that QRS complex elongation was related to total, left and non-coronary leaflet calcification (p < 0.05). This study demonstrates that, when transcatheter aortic valve implantation is performed using a balloon-expandable transcatheter heart valve deployed with an aorto-ventricular ratio > 60/40, the presence of leaflets/annulus calcification or the need to oversize the prosthesis correlate with the occurrence of pathological cardiac conduction delays.

Immediate and long-term results of emergency aortic valve replacement in acute bacterial endocarditis.

A surgically treated material comprising 18 patinets with heart failure from aortic insufficiency during acute endocarditis has been reviewed. At the time of operation the mean duration of heart failure was 3 weeks and duration of endocarditis 9 weeks. Blood culture was positive in half of the patients, 39% had predisposing valve disease, 14 (78%) had a preoperative heart catheterization. The peroperatively measured regurgitation averaged 55%. All 18 patients had an artifical valve implanted, and the mean observation time for 13 long-term survivors was 3 1/3 years. There were 3 postoperative and 2 late deaths. A long-term survival rate of 73% strongly supports early surgical treatment in patients with aortic insufficiency and heart failure during acute endocarditis.

Cardiothoracic anesthesiology

Cardiac surgical training Fellows are trained to provide perioperative anesthetic management for patients with severe cardiopulmonary pathology. Some of the cardiac surgeries they train for include the following: coronary artery bypass surgery (CABG) both on cardiopulmonary bypass as well as on a beating heart, heart valve surgery, aortic reconstruction requiring deep hypothermic arrest, mechanical ventricular assist device (VAD) placement, thoracic aortic aneurysm repair, aortic dissection repair, heart transplants, lung transplants, heart/lung transplants, and adult congenital heart surgery. Adequate exposure and experience provided in the management of adult patients for cardiac pacemaker and automatic implantable cardiac defibrillator placement, surgical treatment of cardiac arrhythmias, and the complete gamut of invasive cardiologic (catheter-based) and electrophysiological procedures is expected as well.

[Active infective endocarditis complicated by paravalvular abscess. Review of 40 cases].

We have performed a retrospective analysis of the clinical, echocardiographic, surgical and necropsy data in 40 patients affected by infective endocarditis complicated by paravalvular abscess. The abscess developed on prosthetic valve in 13 cases, and on native valve in 27. Aortic valve was the most affected (85%). The clinical course was considered to be acute in 52% of the patients. Fever persisted despite of adequate antibiotic therapy in 57%. In 90%, overt heart failure were present. Staphylococcus were the most frequent causative microorganism (S. aureus, 22.5%; S. epidermidis, 20%). Bundle branch or atrioventricular block were detected in 18 patients (sensibility, 45%; specificity, 88%). Bidimensional echocardiography, along with Doppler techniques when necessary, detected an abscess in 81% of patients (sensibility, 80%; specificity, 84%). Thirty patients were operated. Eight of them (26%) died, two intraoperatively. Ten patients were not operated and nine died (90%). The difference was significant (p less than 0.001). Only age and surgical treatment were related to early survival. Over the follow-up of the operated patients, five presented prosthetic dehiscence, but only two required a new operation 3 months after the first intervention, and none died. In conclusion, the detection of a paravalvular abscess complicating an infective endocarditis is an indication for surgical treatment. Both surgical mortality and postoperative prosthetic dehiscence are acceptable. Bidimensional echocardiography is the most reliable tool for the diagnosis of this complication.

Changes in atrioventricular conduction and predictors of pacemaker need after percutaneous implantation of the CoreValve®. Aortic valve prosthesis.

Although changes in atrioventricular conduction frequently occur after percutaneous implantation of an aortic valve prosthesis, little is known about the mechanisms involved or how these changes progress. We investigated ECG abnormalities and predictors of pacemaker need after percutaneous implantation of the CoreValve® aortic valve prosthesis. Between April 2008 and October 2009, 65 patients with symptomatic severe aortic stenosis received a CoreValve® prosthesis. Clinical and ECG parameters were recorded and predictors of pacemaker need due to advanced atrioventricular block were investigated. The analysis excluded three patients because they had pacemakers and a fourth who died during the procedure. The patients' mean age was 79 ± 7.8 years and their logistic EuroSCORE was 20 ± 14%. Implantation was successful in 98.4%. After implantation, 47.5% had left bundle branch block and 21 patients (34.4%) required a permanent pacemaker. The need for a pacemaker was associated with a greater depth of prosthesis implantation in the left ventricular outflow tract (LVOT): 13 ± 2.5 mm vs. 8.8 ± 2.8 mm (P< .001). Moreover, depth was the only predictor: odds ratio 1.9, 95% confidence interval 1.19-3.05 (P< .007). A cutpoint of 11.1 mm for the prosthesis depth in the LVOT had a sensitivity of 81% and a specificity of 84.6% for predicting the need for a pacemaker. After CoreValve® aortic valve prosthesis implantation, a high percentage of patients needed a permanent pacemaker for advanced atrioventricular block. The only independent predictor was the depth of the prosthesis in the LVOT, which could serve as an early indicator of pacemaker need.

[Infective endocarditis of a valve prosthesis. Multicenter study (179 cases)].

Over a 5-year period (1982-1986) 176 cases of infective endocarditis on prosthesis (IEP) were recorded in 40 cardiology departments. 65 p. 100 of the patients were male, and the mean age of the population was 51 years. Mechanical prostheses were involved in 57 p. 100 of the cases and bioprosthesis in 43 p. 100. There was a high proportion of initial indications for bacterial endocarditis (18 p. 100) and for reoperation on prosthesis (10 p. 100). IEP developed early in 40 cases and late in 139 cases; 19 (48 p. 100) of the early IEPs were staphylococcal, while 31 p. 100 of late IEPs were streptococcal (p less than 0.01). 143 patients were reoperated upon within less than 1 month in 41 p. 100 of the cases, with a pre-operative antibiotic therapy of less than 10 days in 39 p. 100. Reoperation was performed in stage IV or as an emergency in 45 p. 100 of the cases. Abscesses were three times more frequent with aortic prostheses than with mitral prostheses (58 p. 100 vs 20 p. 100, p less than 0.001). Vegetations were more frequent on mechanical prostheses than on bioprostheses (43 p. 100 vs 31 p. 100, NS). The operative mortality rate was 25 p. 100; the mortality rate of unoperated patients was even higher (31 p. 100). The survival rate in operated IEP was 51 p. 100 at 30 months, as against 46 p. 100 at 12 months in unoperated IEP.(ABSTRACT TRUNCATED AT 250 WORDS)

Conduction Abnormalities and Permanent Pacemaker Implantation After Transcatheter Aortic Valve Replacement Using the Repositionable LOTUS Device: The United Kingdom Experience.

The authors report the incidence of pacemaker implantation up to hospital discharge and the factors influencing pacing rate following implantation of the LOTUS bioprosthesis (Boston Scientific, Natick, Massachusetts) in the United Kingdom. Transcatheter aortic valve replacement (TAVR) is associated with a significant need for permanent pacemaker implantation. Pacing rates vary according to the device used. The REPRISE II (Repositionable Percutaneous Replacement of Stenotic Aortic Valve Through Implantation of Lotus Valve System) trial reported a pacing rate of 29% at 30 days after implantation of the LOTUS device. Data were collected retrospectively on 228 patients who had the LOTUS device implanted between March 2013 and February 2015 across 10 centers in the United Kingdom. Twenty-seven patients (12%) had pacemakers implanted pre-procedure and were excluded from the analysis. Patients were aged 81.2 ± 7.7 years; 50.7% were male. The mean pre-procedural QRS duration was 101.7 ± 20.4 ms. More than one-half of the cohort (n = 111, 55%) developed new left bundle branch block (LBBB) following the procedure. Permanent pacemakers were implanted in 64 patients (32%) with a median time to insertion of 3.0 ± 3.4 days. Chief indications for pacing were atrioventricular (AV) block (n = 46, 72%), or LBBB with 1st degree AV block (n = 11, 17%). Amongst those who received a pacemaker following TAVR the pre-procedural electrocardiogram findings included: No conduction disturbance (n = 41, 64%); 1st degree AV block (n = 10, 16%); right bundle branch block (n = 6, 9%) and LBBB (n = 5, 8%). LBBB (but not permanent pacemaker) occurred more frequently in patients who had balloon aortic valvuloplasty before TAVR (odds ratio [OR]: 1.25; p = 0.03). Pre-procedural conduction abnormality (composite of 1st degree AV block, hemiblock, right bundle branch block, LBBB) was independently associated with the need for permanent pacemaker (OR: 2.54; p = 0.048). The absence of aortic valve calcification was also associated with a higher pacing rate (OR: 0.55; p = 0.031). Multivariate regression analysis did not show an independent association between depth of implant, valve oversizing, balloon post-dilatation, and the need for pacing post-procedure. Following implantation of the repositionable LOTUS valve, 55% of patients developed LBBB and 32% of patients required a pacemaker during their index hospital admission. Patients with pre-procedural conduction disturbance and non-calcified aortic valves were more likely to need pacing. No other anatomic features were identified with increased pacing requirement with the LOTUS device.

[Endocarditis on cardiac pacemaker endocavitary electrodes. Apropos of 7 cases].

The authors report 7 cases of endocarditis on cardiac pacing catheters observed out of a total of 2 950 primary implantations and 1 600 pacemaker replacements. This is a rare condition (0.15%) but carries a poor prognosis as it usually occurs in elderly patients and demands aggressive management. The presence of multiple pacing catheters and surgical contamination due to manipulation of the pulse generator (reimplantation, pacemaker replacement) are predisposing factors. The infecting organism in these cases was a staphylococcus. One case of metastatic infection was also observed (acinetobacter). Ablation of the septic endocarditic material under effective, prolonged, double antibiotherapy is essential. Recently implanted electrodes were withdrawn by simple traction in 2 cases. This manoeuvre was attempted initially in all cases but stopped when chest pain or runs of ventricular extrasystoles occurred. Open heart explantation of pacing electrodes adherent to the ventricular apex was performed in 5 patients. Cardiopulmonary bypass without cardiac standstill enabled dissection of the fibrous rings surrounding the catheter after purging the blood from the atrial and ventricular cavities. In one patient, associated tricuspid valve endocarditis was found and valvular replacement was performed with a bioprosthesis. Endocardial pacing was replaced by epicardial pacing in patients with permanent AV block. The prognosis of this condition is poor; there were 2 deaths in this series of 7 patients.