Ann Thorac Surg 1996;61:1222
© 1996 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Sary F. Aranki, MD
Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02215
See also page 1217.
The clinical course and natural history of infective endocarditis has been radically modified by the discovery of antibodies, and by the introduction of valve replacement devices. Antibiotic treatment prevented death resulting from overwhelming and uncontrolled sepsis. Consequently congestive heart failure secondary to severe valvular dysfunction emerged as the major cause of morbidity and mortality. Correcting valvular dysfunction with valve replacement has further improved the outcome for patients with infective endocarditis. Nevertheless, in a significant number of patients with valvular prosthesis a more serious and devastating form of endocarditis emerged in the form of prosthetic valve endocarditis, irrespective of whether the initial procedure was performed for an infective or noninfective cause. As a result patients with prosthetic valves became part and parcel of the population at risk for the development of endocarditis. The increase in life expectancy, the decline in rheumatic heart disease, the prevalence of degenerative valvular heart disease, the increase in the number of intravenous drug abusers, and the emergence of more virulent responsible microorganisms have resulted in a major rearrangement of the susceptible population at risk.
This well-written study addresses the favorable impact of timely surgical intervention on the natural history of infective endocarditis treated medically in a similar subgroup of patients. It examines the complex relationship between the site of valve involvement, the presence of a prosthesis, the degree of hemodynamic instability, the activity of the septic process, and their impact on the management strategy. Such an analysis undoubtedly contributes to the continued quest for a more focused indication regarding the need for and the timing of surgical interventions. The importance of this study by Vlessis and associates lies in stressing the importance of a combined medical/surgical management strategy for this difficult group of patients. Close cooperation between cardiologists and surgeons is essential, and their roles are complementary as far as the need for surgical intervention and its optimal timing are concerned. In addition, this study has reemphasized some important points reported by others previously. The high mortality associated with infective endocarditis whether native or prosthetic remains formidable, and although it can be favorably modified with surgical therapy, it remains markedly higher than that of similar procedures required for noninfective causes. Aortic valve endocarditis and prosthetic valve endocarditis are ominously resistant to medical treatment with antibiotics alone where the infective process cannot be entirely eradicated or the resultant hemodynamic dysfunction is more severe and less likely to improve with continued medical therapy alone. Another important aspect of the study was the marked difference in the incidence of recurrent endocarditis: 22 of 23 patients were in the medical group. Although Vlessis and associates did not mention the relationship between the infecting microorganisms and the rate of recurrence, it is well known that certain microorganisms such as Staphylococcus and fungus, especially involving the aortic valve or in the presence of a prosthesis, require combined aggressive antibiotic and earlier surgical intervention for complete eradication.
This is a retrospective study as most studies on infective endocarditis are, and although no new major findings are reported, it nevertheless is an important study that highlights the critical management strategies that ought to be considered in this difficult group of patients. Recent advances in surgical techniques and the care of critically ill patients allow surgeons to manage critically ill patients in the presence of firm indications of early surgical intervention before the onset of irreversible multiorgan failure. Finally, avoidance of prosthetic materials in the presence of infection ought to be strongly considered. Several studies have demonstrated that the use of valve repair procedures, aortic homografts, and stentless porcine valves contribute to marked reduction in the incidence of recurrent endocarditis, and recent case reports have described the use of cryopreserved mitral homografts for mitral valve endocarditis.
Related Article
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Infective Endocarditis: Ten-Year Review of Medical and Surgical Therapy
- Angelo A Vlessis, Hagop Hovaguimian, James Jaggers, Aftab Ahmad, and Albert Starr
Ann. Thorac. Surg. 1996 61: 1217-1222.
[Abstract]
[Full Text]
