5ème Pluridisciplinaire sur l’Endocardite Infectieuse du ...media.univ-lyon1.fr/2018/endocardite/com18/farhat.pdf · Hôpital Louis Pradel, Bron, FRANCE. 5. ème. ... Endocardite

NOM Intitulé du topo Date ….

ENDOCARDITE AIGUE INFECTIEUSEY A-T-IL UN SUBSTITUT VALVULAIRE

IDEAL?Pr Fadi FARHAT

Service de Chirurgie Cardiovasculaire Adulte et TransplantationHôpital Louis Pradel, Bron, FRANCE

5ème Journée Scientifique de la Réunion de Concertation Pluridisciplinaire sur l’Endocardite Infectieuse du

CHU de Lyon


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TRAITEMENT CHIRURGICAL DES ENDOCARDITES INFECTIEUSES

• Quand doit-on opérer ?

• Quel geste peut-on / doit-on réaliser ?


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Problématique :

− Plus l’intervention chirurgicale est réalisée précocement, plus le risque de récidive infectieuse est important.

− Plus elle est tardive, plus le risque de complications augmente.


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Quand doit-on opérer ?

Indications "anatomiques" :

− Abcès annulaire volumineux, évoluant, compliqué d’un BAV

− Communications aortocardiaques (Aorte-OG, Aorte-OD) et CIV


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Quel geste chirurgical?

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Principes du traitement chirurgical :− Analyse des lésions : valve, anneau, culot aortique,

septum inter-ventriculaire, trigone mitro-aortique…− Excision complète et extensive des tissus infectés− Reconstruction anatomique des structures lésées


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Reconstructions valvulaires


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Continuité mitro- aortique


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d'Udekem, David, et al. Ann Thorac Surg 1996


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d'Udekem, David, et al. Ann Thorac Surg 1996


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Bloc mitro aortique mécanique pour endocardite sur prothèse (2ème récidive en 2008, survie à 7 ans)


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Farhat, Interactive Cardiovasc Thorac Surg 2007


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Byrne, Ann Thorac Surg 2011

- Revue de la littérature de 2000 à 2010- Visant à établir des bonne pratiques chirurgicales sur l’approche

technique ainsi que le type de prothèse à implanter


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Endocardite aortique sur valve native


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Endocardite aortique sur valve native avec abcès périvalvulaire


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Endocardite aortique sur prothèse valvulaire



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Endocardite aortique sur prothèse valvulaire avec abcès périvalvulaire



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Endocardite mitrale sur valve native



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Endocardite mitrale sur prothèse valvulaire



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Endocardite valvulaire tricuspide



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Endocardite valvulaire multiple


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David, Eur J Cardiothorac Surg 2006


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BACKGROUND:Nearly half of patients require cardiac surgery during the acute phase of infective endocarditis (IE). We describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and examine whether the type of prosthesis was associated with in-hospital and 1-year mortality.METHODS AND RESULTS:Among 5591 patients included in the International Collaboration on Endocarditis Prospective Cohort Study, 1467 patients with definite IE were operated on during the active phase and had a biological (37%) or mechanical (63%) valve replacement. Patients who received bioprostheses were older (62 vs 54years), more often had a history of cancer (9% vs 6%), and had moderate or severe renal disease (9% vs 4%); proportion of health care-associated IE was higher (26% vs 17%); intracardiacabscesses were more frequent (30% vs 23%). In-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p=0.0009) and 25.3% vs 16.6% (p<.0001), respectively. In multivariable analysis, mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10years), and in patients with a history of cancer (0.72), but were more commonly implanted in mitral position (1.60). Bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298).CONCLUSIONS:Patients with IE who receive a biological valve replacement have significant differences in clinical characteristics compared topatients who receive a mechanical prosthesis. Biological valve replacement is independently associated with a higher in-hospital and 1-year mortality, a result which is possibly related to patient characteristics rather than valve dysfunction.

Delahaye, Int J Cardiol 2015

One-year outcome following biological or mechanical valve replacement for infective endocarditis


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BACKGROUND:Acute bacterial endocarditis may be extremely destructive for cardiac valves and their periannular structures. It has been suggested that complex reconstruction procedures require the use of homografts because of their versatility and potency to resist repeated infection.METHODS:We studied the long-term results of 69 patients with complex endocarditis who received homografts in the aortic position.RESULTS:The results after a mean follow-up of 8.1 ± 5.1 years (median, 8.0 years) showed that the recurrence of endocarditis even in these complex cases is low (7%), but the incidence of structural valve degeneration (SVD) is high. Freedom from SVD at 10 years is only 60.0%. When aortic homografts degenerate, they predominantly calcify.CONCLUSIONS:The use of homografts to reconstruct endocarditis-related aortic valve destruction is associated with a low recurrence of endocarditis but a high incidence of SVD in the long run.

Durability of homografts used to treat complex aortic valve endocarditis

Flameng, Ann Thorac Surg 2015


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OBJECTIVES:The choice of substitute during aortic valve replacement for infective endocarditis (IE) is still widely debated. We retrospectively reviewed all patients operated for aortic IE and compared groups according to the complexity of IE and substitutes implanted.METHODS:From 2000 to 2015, 187 patients were treated using stentless bioprostheses (SBP) as root replacement (n = 30), mechanical prostheses (MP, n = 45) or stented bioprostheses (SP, n = 112) (mean follow-up 4.6 years, survival data 100% complete).RESULTS:MP patients were younger (42.5 ± 10.7 vs 57.2 ± 16.9 years [SBP], 59.1 ± 14.1 years [SP], P < 0.01), but rates of intravenous drug use and chronic dialysis were not different. SBP patients more often had root involvement (83.3% vs33.3% [MP], 25.9% [SP], P < 0.01) and prosthetic valve endocarditis (53.3% vs 6.7% [MP], 12.5% [SP], P < 0.01). In-hospital complications and length of stay were not different. Thirty-day mortality was 13.3% [SBP], 6.7% [MP] and 12.5% [SP] (P = 0.53). Five-year survival tended to be superior in SBP (83.3% vs 77.6% [MP], 67.1% [SP], P = 0.09). In patients with complicated IE (root involvement or prosthetic valve endocarditis, n = 77), SBP had superior long-term survival (86.9% vs81.3% [MP], 57.2% [SP], PSBP/MP = 0.07, PSBP/SP = 0.05). No early reinfection (<90 days) occurred in SBP vs 4.4% [MP] and 7.1% [SP] (P = 0.29). Reoperation for late reinfection occurred in 6.7% [SBP] vs 11.1% [MP] and 12.5% [SP] (P = 0.65). Prosthesis failure occurred in 3.3% [SBP] and 1.8% [SP] (P = 0.52).CONCLUSIONS:Use of SBP provides favorable outcomes in patients with IE with low rates of reinfection and valve deterioration. It seems to be an optimal device in patients with complex IE.

Complicated infective aortic endocarditis: comparison of different surgical strategies.

Silaschi, Interact Cardiovasc Thorac Surg 2017


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OBJECTIVE:Surgery remains the primary form of treatment for infective endocarditis (IE). However, it is not clear what type of prosthetic valve provides a better prognosis. We conducted a meta-analysis to compare the prognosis of infective endocarditis treated with biologicalvalves to cases treated with mechanical valves.METHODS:Pubmed, Embase and Cochrane databases were searched from January 1960 to November 2016.Randomized controlled trials, retrospective cohorts and prospective studies comparing outcomes between biological valve and mechanical valve management for infective endocarditis were analyzed. The Newcastle-Ottawa Scale(NOS) was used to evaluate the quality of the literature and extracted data, and Stata 12.0 software was used for the meta-analysis.RESULTS:A total of 11 publications were included; 10,754 cases were selected, involving 6776 cases of biological valves and 3,978 cases of mechanical valves. The all-cause mortality risk of the biological valve group was higher than that of the mechanical valve group (HR = 1.22, 95% CI 1.03 to 1.44, P = 0.023), as was early mortality (RR = 1.21, 95% CI 1.02 to 1.43, P = 0.033). The recurrence of endocarditis (HR = 1.75, 95% CI 1.26 to 2.42, P = 0.001), as well as the risk of reoperation (HR = 1.79, 95% CI 1.15 to 2.80, P = 0.010) were more likely to occur in the biological valve group. The incidence of postoperative embolism was less in the biological valve group than in the mechanical valve group, but this difference was not statistically significant (RR = 0.90, 95% CI 0.76 to 1.07, P = 0.245). For patients with prosthetic valve endocarditis (PVE), there was no significant difference in survival rates between the biological valve group and the mechanical valve group (HR = 0.91, 95% CI 0.68 to 1.21, P = 0.520).CONCLUSION:The results of our meta-analysis suggest that mechanical valves can provide a significantly better prognosis in patients with infective endocarditis. There were significant differences in the clinical features of patients receiving a biological valve compared to patients receiving a mechanical valve. A large, multicenter retrospective study included in our meta-analysis suggested that anymortality risk of the biological valve group was significant higher than that of the mechanical valve group. However, the risk was no different after risk was adjusted. So, we thought the reason for this result may be related to the characteristics of the patient rather than valve dysfunction. It is still necessary to future randomized studies to verify this conclusion.

The prognosis of infective endocarditis treated with biological valves versus mechanical valves: A meta-analysis

Tao, PLoS One 2017


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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients undergoing a surgery for endocarditis is a biological valve or mechanical valve superior for achieving long-term low rates of reinfection?' Altogether more than 41 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Out of the studies that include statistical comparisons, in mechanical valve replacement the average endocarditis recurrence rate ranged from approximately 3 to 9% and in biological valves from approximately 7 to 29%. Out of the studies that specifically compared the outcomes of the two valves, 50%concluded there to be no significant difference when separated from other risk factors and 50% recommended a mechanical valve for lower recurrence and higher survival rates. The Euro Heart Survey found that 63% of valve replacements were mechanical, due to young age (90%) and physician preference (75%) and only 21% bioprosthetic. Current guidelines from American College of Cardiology/American Heart Association (ACC/AHA) recommend a mechanical valve in patients <65 years old and a bioprosthetic valve if >65, without risk factors for thromboembolism, but this is based on class II evidence (conflicting evidence or opinion). These guidelines are not specific to patients with infective endocarditis, so it is vital to review the literature related to this. Three of the studies in the search specify that for patients under 60-65 years old, a mechanical valve has greater benefit, but this was not found to be true for the over 65 years. It can be concluded that for patients under 65 years old, a mechanical valve may offer greater freedom from reoperation and increased long-term survival when compared to a bioprosthetic valve (assuming no other co-morbidities), although this divide is narrowing with the use of newer generation bioprosthetic valves and has to be off-set against potential bleeding risks. For patients over 65 years, other important variants need to be considered including patient choice, correct protocols of antibiotics and radical debridement.

What type of valve replacement should be used in patients with endocarditis?

Newton, Interac Cardiovasc Thorac Surg 2010


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− Analyse des lésions pour traitement adapté

− Excision complète et extensive des tissus infectés

− Reconstruction anatomique des structures lésées

− Pas de matériau prothétique préférentiel : attitude au cas par cas

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Documents

5ème Pluridisciplinaire sur l’Endocardite Infectieuse du ...media.univ-lyon1.fr/2018/endocardite/com18/farhat.pdf · Hôpital Louis Pradel, Bron, FRANCE. 5. ème. ... Endocardite