The Surgical Management of Bacterial Endocarditis: A Review JAMES C. W. PARROTT, M.D., J. DONALD HILL, M.D., WILLIAM J. KERTH, M.D., FRANK GERBODE, M.D.

A total of 239 surgically treated patients with primary endocarditis were reviewed both from the literature and from our own experience. The age range was 10 to 74 years with a male to female ratio of 3:1. A wide variety of organisms was found. However, as a group, gram positive organisms predominate. The onset of congestive failure was the major indication for surgery. The aortic valve was predominantly involved with the mitral valve running a distant second. The hospital mortality rate was 20o and the late mortality rate was 6.7% with an overall mortality of 26.7%. The prognosis in infective endocarditis when congestive failure develops, even in the presence of antibiotic therapy, is poor (79-89o mortality). In view of this poor prognosis, an aggressive attitude with regard to early surgical intervention can greatly improve the outcome of valvular endocarditis.

From the Department of Cardiovascular Surgery, Institute of Medical Sciences, Pacific Medical Center, San Francisco, California

et al. patients were classified into those with "active" and "inactive" disease.26 One hundred and thirtynine patients were operated upon during the active stage, 68 in the inactive stage and in 32 the information was unavailable.

Age and Sex The age range, when stated, was from 10 to 74 years I N 1965, Wallace successfully implanted a prosthetic with the majority of patients in the second to fifth decade. valve during the acute stage of bacterial endoMales outnumbered females by a ratio of about 3:1. carditis.38 Since that time, surgical attack on infected heart valves has increased. It seems contrary to surgical Bacteriology principles to implant foreign material in an infected area; however, once intractable heart failure begins, a rapid The various causative organisms are presented in Table downhill course can be expected, and in spite of adequate 1. As a group, gram positive cocci predominate. Pseudoantbiotic therapy, surgical intervention is the only al- monas was the most common gram negative infecting ternative. organism and candida infection occurred in 7 patieonts. In this review, an assessment of the surgical manage- In a total of 15 patients, no organism could be cultured ment of 239 patients with bacterial endocarditis will be preoperatively and bacteriology was unstated in 70 presented in an attempt to establish surgery as an im- patients. portant mode of therapy. Indications for Surgery Materials and Methods The indications for surgery are listed in Table 2. ConA total of 239 surgically treated patients with primary gestive heart failure alone or with other complications endocarditis were reviewed, both from the literature and was overwhelmingly the major indication for surgery. from our own experience.1-44 As according to Manhas Resistant infection alone or with other complications was the indication in 27 and septic embolization was in 23. Four patients were operated upon encountered Submitted for publication August 27, 1975. because of hypersensitivity to antibiotics employed. Correspondence and reprint requests: Dr. Frank Gerbode, Institutes of Medical Sciences, P.O. Box 7999, San Francisco, California 94120. Although congestive heart failure was the major indica289

290

PARROTT AND OTHERS TABLE 1. Bacteriology*

68 50 13 7 7 2 2 2 1 I I 1 15

more

than

one

indication for

surgery.

Pathological Findings Table 3 indicates the various pathological findings observed at the time of surgery. Leaflet destruction and/or perforation was more often seen on the aortic valves. Vegetations, often sterile, were encountered on both aortic and mitral valves. Since in all cases the time from initial infection to surgical correction was short, usually days to weeks, it can be assumed that valvular calcification was due to previous disease and not the result of the bacterial endocarditis. In several cases ruptured chordae or papillary muscle accounted for the sudden and rapid onset of congestive failure seen in these patients. These patients were operated upon as surgical emergencies. Abscess formation and fistulae were encountered in 27 patients and when present were difficult to repair at the time of surgery. Operative Procedure Table 4 lists the operative procedures performed. Aortic valve procedures predominate. For 6 cases out of 165, the valve was repaired rather than replaced. In one case, an aorto-pulmonary fistula was obliterated following debridement of the infected tissue. One subvalvular abscess was obliterated without replacement of the valve. In two instances, a sinus of Valsalva fistula could be closed without valve replacement and two valves had debridement of vegetations only. In 159 cases, the aortic valve was replaced. In all 159 aortic valve reTABLE 2. Indications for Surgery*

Congestive heart failure Resistant infection Embolization Drug Toxicity

Stated-211; unstated-28.

March 1976

Leaflet destruction and/or perforation

Vegetations Ruptured chordae and/or papillary muscle Leaflet deformity and/or scarring and/or calcification

Abscess fonnation Sinus of valsalva fistula Aortopulmonary artery fistula *

96 79 29 27 17 9 I

Stated- 175; unstated-64.

placements, aortic insufficiency was present, or would have occurred if the valve had been repaired or debrided

only.

* Stated- 169; unstated-70.

*

Surg. *

TABLE 3. Pathological Findings*

Streptococcus Staphylococcus Pneumococcus Pseudomonas Candida Klebsiella Diptheroids Serratia Neisseria Paracolon Brucella Vibrio Negative culture

tion, several patients had

Ann.

190 27 25 4

The mitral valve was replaced or repaired 53 times. Twenty-four of the valves were reconstructed at the time of surgery. Reconstruction consisted of debridement of vegetations and detached chordae with reapproximation of the valve edges. Twenty-nine patients had valve replacements because of extensive damage or involvement of the valve annulus. The tricuspid valve was less often involved with infection. Seven of the 15 patients operated upon had valvular replacement, however, 8 could be managed with debridement and reconstruction, or total excision without re-

placement. The pulmonary valve was rarely involved in the infective process and debridement of the valve cusps was performed in only one patient. Results Table 5 shows the results after surgery for bacterial endocarditis. The overall hospital mortality rate (death within 30 days of operation) was 20%o. The overall late mortality rate was 6.7%. Causes of death are listed in Table 6. Congestive heart failure and sepsis are the leading causes with attributed deaths of 16 and 15 respectively. Of the 14 deaths attributed to septicemia 6 were due to gram negative organisms, 4 of which were pseudomonas infection. Three deaths were attributed to candida while gram positive cocci septicemia was the cause of death in 6 patients. The overall mortality rate was 26.7%. However, 17 of the 64 deaths were due to unrelated causes and one late death was due to pneumonia associated with lung cancer. Therefore, 46 deaths can be attributed directly to the endocarditis and/or the surgery (19.2%).

Discussion Two major advances have occurred in the management of bacterial endocarditis. The first was the development of antibiotics. In the post-antibiotic era 61% of deaths were due to congestive heart failure compared with 6% in the pre-antibiotic era.32 With the ability to control infection, a very prominent feature of the disease,

291

BACTERIAL ENDOCARDITIS

Vol. 183 * No. 3

TABLE 6. Cause of Death

TABLE 4. Operative Procedure

Aortic valve replaced repaired Mitral valve replaced repaired Tricuspid valve replaced repaired Pulmonary valve replaced repaired

159 6 29 24 7 8* 0 1

* 6/8 had total excision; 2/8 had valve debridement.

namely heart failure, was unmasked. The development of congestive heart failure in infective endocarditis carries a grave prognosis. Before antibiotics were available 97% of patients with endocarditis died when severe congestive failure was present. However, 79o to 89%o still die with infective endocarditis when congestive failure develops despite antibiotic therapy.20 The second major advance in the management of endocarditis was the introduction of open-heart surgery and with this came the realization that prosthetic valves may be inserted in an infected area provided the infected valve tissue is adequately debrided. Furthermore, while it is desirable to have a sterile blood stream at the time of surgery, procrastination in order to achieve bacteriological sterility or to control congestive heart failure, often leads to irreversible myocardial damage. The hemodynamic status of the patient, in this instance, must be the determining factor leading to surgical intervention. Gram positive cocci are the predominant infecting group of organisms; however, infection with a gram negative organism or yeast such as candida carries a much worse prognosis. Of the 169 cases for which positive cultures were obtained, 12 were due to gram negative organisms and of the 14 deaths attributed to septicemia, 6 were due to gram negative infections. Likewise, of the 7 candida infections, 3 died of candida septicemia. Elaboration of endotoxins and resistance to antibiotics of gram negative organisms plus the systemic side effects of chemotherapy for candida probably contribute to this overall picture. The recent abuse of intravenous drugs has led to a higher incidence of tricuspid valvular endocarditis. In hardened drug abusers, reinfection of a prosthetic valve TABLE 5. Results

Hospital mortality* Late mortality Overall mortality rate Overall mortality rate due to endocarditis and/or surgery * Death within 30 days of operation.

20%o 6.7% 27% 19.2%

Congestive heart failure Sepsis Arrhythmias Ruptured suture line Pulmonary emboli Pneumonia, lung cancer Clotted prosthetic valve Unrelated death Unknown

Early

Late

12 11 4 2 2 0 0 12 5

4 4 0 1 0 1 1 5

0

is frequently encountered. Total excision of the tricuspid valve without prosthetic replacement has been reported with good results.1'2 The primary management of endocarditis is antibiotic therapy. However, the onset of congestive heart failure carries a grave prognosis with 79 to 89Wo of patients dying despite adequate antibiotic therapy. A low overall surgical mortality rate of 26.7% suggests that an aggressive attitude with regard to surgical intervention can greatly improve the prognosis of valvular endocarditis. References 1. Arbulu, A., Thoms, N. W., and Wilson, R. F.: Complete Valvulectomy Without Prosthetic Replacement in the Treatment of Tricuspid Pseudomonas endocarditis. Circulation; 44 (Suppl. II) 108, 1971. 2. Arbulu, A., Thoms, N. W., and Wilson, R. F.: Valvulectomy Without Prosthetic Replacement. J. Thorac. Cardiovasc. Surg., 64:103, 1972. 3. Banks, T., Ali, N., and Fletcher, R. R.: Bacterial Endocarditis in Heroin Addicts. Circulation, 44:(Suppl. II):44, 1971. 4. Barratt-Boyes, B. G.: Surgical Correction of Mitral Incompetence Resulting from Bacterial Endocarditis. Br. Heart J., 25:415, 1961. 5. Buckley, J. M., Mundth, E. D., Dagget, W. M., et al.: Surgical Management of the Complications of Sepsis Involving the Aortic Valve, Aortic Root and Ascending Aorta. Ann. Thorac. Surg., 12:391, 1971. 6. Braniff, B. A., Shumway, N. E. and Harrison, D. C.: Valve Replacement in Active Bacterial Endocarditis. N. Engl. J. Med.,

276:1464, 1967. 7. Cachera, J. P., Drouin, B., Carpentier, A., et al.: Trois cas d'Endocardite Tricuspidienne a Staphylocoque Traitee par Remplacement Valvulaire Prothetique. Arch. Mal. Coeru, 65: 515, 1972. 8. Cohen, L., and Freedman, L. C.: Damage to the Aortic Valve as a Cause of Death in Bacterial Endocarditis. Ann. Intern. Med., 55:562, 1%1. 9. English, T. A. H. and Ross, J. K.: Surgical Aspects of Bacterial Endocarditis. Thorax, 27:260, 1972. 10. Gonzalez-Levin, L., Scapptura, E., Lisa, M., et al.: Mycotic Aneurysms of the Aortic Root. A Complication of Aortic Valve Endocarditis. Ann. Thorac. Surg., 9:551, 1970. 11. Hancock, E. W., Shumway, N. E., and Remington, J. S.: Valve Replacement in Active Bacterial Endocarditis. J. Infect. Dis., 123:106, 1971. 12. Hatcher, C. R., Symbas, P. N., Logan, W. D., et al.: Surgical Aspects of Endocarditis of the Aortic Root. Am. J. Cardiol., 23:192, 1969. 13. Hurley, E. J., Eldridge, F. L., and Hultgren, H. N.: Emergency Replacement of Valves in Endocarditis. Am. Heart J., 73:798, 1967.

Ann. Surg. March 1976 PARROTT AND OTHERS 292 Aortic Valve Replacement in Bacterial Endocarditis. J. Thorac. 14. Jacobs, M. G.: Bacterial Endocarditis with Pulmonary Edema Cardiovasc. Surg., 61:916. 1971. Necessitating Mitral Valve Replacement in a Hemodialysis30. Okies, J. E., Williams, T. W., Howell. J. F.. et al.: Valvular Dependent Patient. J. Thorac. Cardiovasc. Surg., 62:59, 1971. Replacement in Bacterial Endocarditis. Cardiovasc. Res. Cent. 15. Jimenez-Martinez, M., Lopez-Cuellar, M., and Quinones-Morales, Bull., 8:126, 1970. R.: Isolated Tricuspid Endocarditis. J. Thorac. Cardiovasc. 31. Robicek, F., Payne, R. B., Daughterty, H. F., et al.: Bacterial Surg., 61:665, 1971. Endocarditis of the Mitral Valve Treated by Excision and Re16. Kaiser, G. C., Willman, V. L., Thurman, M., et al.: Valve placement. Ann. Surg., 166:854, 1967. Replacement in Cases of Aortic Insufficiency Due to Active 32. Robinson, M. J., and Reudy, J.: Sequelae of Bacterial EndoEndocarditis. J. Thorac. Cardiovasc. Surg., 54:491, 1967. carditis. Am. J. Med., 32:922, 1962. 17. Kay, J. H., Bernstein, S., Feinstein, O., et al.: Surgical Cure of Candida Albicans Endocarditis with Open Heart Surgery. N. 33. Sarot, I. A., Weber, D. and Schecter, D. C.: Cardiac Surgery in Engl. J. Med., 264:907, 1961. Active Primary Infective Endocarditis. Chest, 57:58, 1970. 18. Kay, J. H., Bernstein, S., Tsuji, H. K., et al.: Surgical Treat- 34. Scott, S. M., Fish, R. G. and Crutcher, J. C.: Early Surgical Intervention for Aortic Insufficiency Due to Bacterial Endoment of Candida Endocarditis. JAMA, 203:621, 1968. carditis. Ann. Thorac. Surg., 3:158, 1967. 19. Kennedy, J. H., Sabga, G. A., Fisk, A. A., et al.: Isolated Tricuspid Valvular Insufficiency Due to Subacute Bacterial 35. Stason, W. B., DeSanctis, R. W., Weinberg, A. N., et al.: Cardiac Surgery in Bacterial Endocarditis. Circulation, 38:514, Endocarditis. J. Thorac. Cardiovasc. Surg., 51:498, 1966. 1968. 20. Kerr, A., Jr.: Subacute Bacterial Endocarditis. Springfield, Charles 36. Tompsett, R., and Lubash, G. D.: Aortic Valve Perforation in C Thomas, 1955; pp. 126-250. Bacterial Endocarditis. Circulation, 23:662, 1961. 21. Killen, D. A., Collins, H. A., Koenig, M. G., et al.: Prosthetic Cardiac Valves and Bacterial Endocarditis. Ann. Thorac. Surg., 37. Utley, J. R., Mills, J., and Roe, B. B.: The Role of Valve Replacement in the Treatment of Fungal Endocarditis. J. 9:238, 1970. Thorac. Cardiovasc. Surg., 69:255, 1975. 22. Kretschmer, K. P., and Lawrence, G. H.: Valve Replacement in Patients with Bacterial Endocarditis. Am. J. Surg., 118:273, 1969. 38. Wallace, A. G., Young, G. W. and Osterhout, S.: Treatment of 23. Laniado, S., Frater, R. W. M., Jordan, A., et al.: Endocarditis Acute Bacterial Endocarditis by Valve Excision and Replaceof the Pulmonic Valve Simulating Cardiac Tumor. Chest, 59: ment Circulation, 31:450, 1965. 39. Wilcox, B. R., Proctor, H. J., Rackley, C. E., et al.: Early 464, 1971. 24. Lerner, P. I., and Weinstein, L.: Infective Endocarditis in the Surgical Treatment of Valvular Endocarditis. JAMA, 200:820, Antibiotic Era. N. Engl. J. Med., 274:199, 1966. 1967. 25. Manhas, D. R., Hessel, E. A., II, Winterscheid, L. C., et al.: 40. Williams, T. W., Viroslav, J., and Knight, V.: Management of Bacterial Endocarditis. Am. J. Cardiol., 26:186, 1970. Open Heart Surgery in Infective Endocarditis. Circulation, 41: 41. Wilson, L. C., Wilcox, B. R., Sugg, W. L., et al.: Valvular 841, 1970. 26. Manhas, D. R., Mohri, H., Hessel, E. A., et al.: Experience Regurgitation in Acute Infective Endocarditis. Arch. Surg., With Surgical Management of Primary Infective Endocarditis: A 101:756, 1970. 42. Windsor, H. M. and Shanahan, M. X.: Emergency Valve ReplaceReview of 139 Patients. Am. Heart J., 84:738, 1972. 27. Manhas, D. R., Rittenhouse, E. A., Hessel, E. A., II, et al.: ment in Bacterial Endocarditis. Thorax, 22:25, 1967. Reconstructive Surgery for the Treatment of Mitral Incom- 43. Wolnisty, C., and Friedman, S. L.: Mitral Insufficiency Secondary to Ruptured Chordae Tendineae. Report of a Surgically Corpetance: Early and Late Results in 91 Patients. J. Thorac. Cardiovasc. Surg., 62:781, 1971. rected case. JAMA, 188:687, 1964. 28. Najafi, H.: Aortic Insufficiency: Clinical Manifestations and 44. Yeh, R. J., Hall, D. P., and Ellison, R. G.: Surgical Treatment of Aortic Valve Perforation due to Bacterial Endocarditis. Surgical Treatment. Am. Heart J., 82:120, 1971. 29. Neville, W. E., Magno, M., Foxworthy, D. T., et al.: Emergency Am. Surg., 30:766, 1964. *