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Herzklappenendokarditis - Diagnostik & operative Strategien
Rekonstruktion vs. Klappenersatz im Rahmen minimal-invasiver und
konventioneller Eingriffe als Erstoperation oder Re-Eingriff
PD Dr. Stephan Geidel, Ltd. OA der Abt. für Herzchirurgie, Asklepios Klinik St. Georg
Samstag 23.06.2018, Curio-Haus, Hamburg, 8:30 – 17:30
Hamburger Herzkreislauftag 2018
Es bestehen keinerlei Interessenskonflikte
Definition:
Die Endokarditis ist eine Entzündung der Herzinnenhaut,
die die Herzhöhlen und die herznahen Gefäßanteile aus-
kleidet und auch die Struktur der Herzklappensegel und
Herzklappentaschen bildet.
Das chirurgische Vorgehen bei Herzklappenendokarditis
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Ausgeprägte entzündliche li-atriale Auflagerungen bei MK-Endokarditis
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
S Geidel - 11.01.2012
Candida: schwer zu beherrschen (hier Re-Infektion einer Bioprothese)
RV
RA
TK
Staphylokokken 42.6%
Streptokokken 25.2%
Enterokokken 25.2%
Candida 2.6%
Pseudomonas 2.6% E. coli 0.9% Enterobakter 0.9%
Aktuelle Keimnachweise bei Herzklappenendokarditis(Herzchir. St. Georg , n=115; 56.9% von 202)
2/3 Staph. aureus
(kein VRE)
n=1 MRSA
(kein 3MRGN)(kein 4MRGN)
7% Gramnegative
und Pilze
93% GrampositiveMRGN = Multiresistente gramnegative Bakterien
MRSA = Methicillin resistenter Staphylokokkus aureus
VRE = Vancomycin resistente Enterokokken
Gesund werden. Gesund leben.
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Beobachtungen zur Epidemiologie
„In den letzten Jahren wird in den westlichen Ländern eine
Zunahme von Endokarditiden durch Staphylokokken,
Enterokokken und seltene Erreger beobachtet.“
Thomas Wichter & Günter Breithardt in H Greten, F Rinninger, T Greten,
Innere Medizin, Thieme Verlag (13. Auflage 2010)
Gesund werden. Gesund leben.
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Herzklappenendokarditiden Herzchirurgie St. Georg
01.01.2001 – 31.12.2008 6.0% aller MK
01.01.2011 – 31.03.2012 12.1% aller Klappen (n=47)
-
2014, n=59
2015, n=62
2016, n=68
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
19.6% aller Klappen (68 von 341)
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
01.01.2014 bis 31.03.2017, n=202 (67±4J)
Herzklappenendokarditiden Herzchirurgie St. Georg
AK MK TK PK
AK 99
MK 64
TK 20
PK 1
AK + MK 15 15
MK + TK 1 1
AK + TK 2 2
Gesamt 116 (52.7%) 80 (36.4%) 23 (10.5%) 1 (0.45%) 220 (100%)
91.1%
8.9%
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Anzahl der Klappen-Vor-Operationen (n=36) bzw. vorangegangener Klappenintervention (n=7)
21.3% von 202 pts.
n
Klappen-Vor-OP bzw. Intervention
0 1 2 3 4
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
ca. jeder fünfte
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Bewertungsversuch von Endokarditis-Häufigkeiten
S Geidel - 11.01.2012
Gesund werden. Gesund leben.
Erhebliche Veränderung der Prädisposition & Risikogruppen-Zugehörigkeit:
- mehr nosokomiale Infektionen (Verweilkatheter, Hämodialyse-Shunts,
Langzeitintubation etc.)
- mehr Pts. mit immunologischer Abwehrschwäche (Systemerkrankungen,
Malignome, Immunsuppression, Diabetes mellitus etc.)
- Niereninsuffizienz, Leberzirrhose, Alkoholkrankheit, i.v.-Drogenabusus
- viele vorbestehende kardiale Erkrankungen bzw. Z.n. kardiologischer
oder herzchirurgischer Vorbehandlung [ Herzchir. St.G. 2/3 der Klappen-
endokarditispatienten ], intravaskuläre Devices/Fremdmaterial, relevante Vitien ...
S Geidel - 11.01.2012 S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
S Geidel -
15.02.2012
Endokarditis nach MitraClip
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
Frerker & Geidel et al. Eurointervention 2015;11:673-61
Endokarditis nach MitraClip
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Hauptbefund: auf der dem Blutstrom abgewandten Seite (hier LA)
Gesund werden. Gesund leben.
Frerker & Geidel et al. Eurointervention 2015;11:673-61
Endokarditis nach MitraClip
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
Hauptbefund: auf der dem Blutstrom abgewandten Seite
Frerker & Geidel et al. Eurointervention 2015;11:673-61
S Geidel - 11.01.2012
Hauptbefund: auf der dem Blutstrom abgewandten Seite (hier LV)
AK
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
Akoronare Tasche
(Unterseite)
Linkskoronare Tasche
Rechtskoronare Tasche
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
S Geidel - 11.01.2012
Klinische + hämodynamische Ziele
1. Kompromisslose Infektsanierung: Unterbrechung der Sepsis
2. Vollständige Wiederherstellung der Klappenfunktion: Beheben der
Herzinsuffizienz
3. Aus-Behandlung der „auslösenden“ Grunderkrankung
Ziel: eine möglichst optimale Prognose …
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Das chirurgische Vorgehen bei Herzklappenendokarditis
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
S Geidel - 20.04.2011 -
Diagnose + OP-Indikationsstellung
Duke-Kriterien: 1. pos. Echobefund, pos. Blutkultur
2. Fieber, Prädisposition, immunolog. Phänomene etc.
Wie ist der Verlauf unter nicht-chirurgischer Therapie ???
OP wenn - sich die Infektion lokal auszubreiten droht
- eine schwere Klappendysfunktion vorliegt
- ein hohes Embolie-Risiko besteht
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Das chirurgische Vorgehen bei Herzklappenendokarditis Das chirurgische Vorgehen bei Herzklappenendokarditis
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Urgent surgery !!!
S Geidel - 20.04.2011 -S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
ESC GUIDELINES
2015 ESC Guidelines for the management
of infect ive endocardit is
The Task Force for the Management of Infect ive Endocardit is of the
European Society of Cardiology (ESC)
Endorsed by: European Associat ion for Cardio-Thoracic Surgery
(EACTS), the European Associat ion of Nuclear Medicine (EANM)
Authors/Task Force Members: Gilber t Habib* (Chairperson) (France),
Pat r izio Lancellot t i* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal ),
Mar ia Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zot t i (Italy),
Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erbaa (Italy),
Bernard Iung (France), Jose M. Mirob (Spain), Barbara J. Mulder (The Nether lands),
Edyta Plonska-Gosciniak (Poland), Susanna Pr ice (UK), Jolien Roos-Hesselink
(The Nether lands), Ulr ika Snygg-Mart in (Sweden), Franck Thuny (France),
Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)
Document Reviewers: Çet in Erol (CPG Review Coordinator) (Turkey), Pet ros Nihoyannopoulos (CPG Review
Coordinator) (UK), Victor Aboyans (France), Stefan Agewall (Norway), George Athanassopoulos (Greece),
Saide Aytekin (Turkey), W erner Benzer (Aust r ia), Hector Bueno (Spain), Lidewij Broekhuizen (The Nether lands),
Scipione Carer j (Italy), Bernard Cosyns (Belgium), Julie De Backer (Belgium), Michele De Bonis (Italy),
Konstant inos Dimopoulos (UK), Erwan Donal (France), Heinz Drexel (Aust r ia), Frank Arnold Flachskampf (Sweden),
Roger Hall (UK), Sigrun Halvorsen (Norway), Bruno Hoenb (France), Paulus Kirchhof (UK/Germany),
* Corresponding authors: Gilbert Habib, Service de Cardiologie, C.H.U. De La Timone, Bd Jean Moulin, 13005 Marseille, France, Tel: + 33 4 91 38 75 88, Fax: + 33 4 91 38 47 64,
Email: [email protected]
Patrizio Lancellotti, University of Liege Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium – GVM Care and
Research, E.S. Health Science Foundation, Lugo (RA), Italy, Tel: + 3243667196, Fax: + 3243667194, Email: [email protected]
ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix
ESC ent it ies having part icipated in the development of this document:
ESC Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of
Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC).
ESC W orking Groups:Cardiovascular Pharmacotherapy,Cardiovascular Surgery,Grown-up Congenital Heart Disease,Myocardial and Pericardial Diseases,PulmonaryCirculation
and Right Ventricular Function, Thrombosis, Valvular Heart Disease.
Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelines exempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2015. All rights reserved. For permissions please email: [email protected].
European Heart Journal
doi:10.1093/eurheartj/ehv319
European Heart Journal Advance Access published August 29, 2015
by
guest o
n N
ovem
ber 2
1, 2
016
http
://eurh
eartj.oxfo
rdjo
urn
als.org
/D
ow
nlo
aded
from
NVE = native valve endocarditis
PVE = prostethic valve endocarditis
Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Endokarditis der 1) Aorteklappe (≈ jeder zweite)
2) Mitralklappe (≈ jeder dritte)
3) Tricuspidalklappe (≈ jeder zehnte)
- Konventionell vs. MIC (≈ jeder sechste)
- Besonderheiten bei Re-Ops (≈ jeder fünfte)
Operative Sanierung + Wiederherstellung der Ventilfunktion
ESC GUIDELINES
2015 ESC Guidelines for the management
of infect ive endocardit is
The Task Force for the Management of Infect ive Endocardit is of the
European Society of Cardiology (ESC)
Endorsed by: European Associat ion for Cardio-Thoracic Surgery
(EACTS), the European Associat ion of Nuclear Medicine (EANM)
Authors/Task Force Members: Gilber t Habib* (Chairperson) (France),
Pat r izio Lancellot t i* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal ),
Mar ia Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zot t i (Italy),
Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erbaa (Italy),
Bernard Iung (France), Jose M. Mirob (Spain), Barbara J. Mulder (The Nether lands),
Edyta Plonska-Gosciniak (Poland), Susanna Pr ice (UK), Jolien Roos-Hesselink
(The Nether lands), Ulr ika Snygg-Mart in (Sweden), Franck Thuny (France),
Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)
Document Reviewers: Çet in Erol (CPG Review Coordinator) (Turkey), Pet ros Nihoyannopoulos (CPG Review
Coordinator) (UK), Victor Aboyans (France), Stefan Agewall (Norway), George Athanassopoulos (Greece),
Saide Aytekin (Turkey), W erner Benzer (Aust r ia), Hector Bueno (Spain), Lidewij Broekhuizen (The Nether lands),
Scipione Carer j (Italy), Bernard Cosyns (Belgium), Julie De Backer (Belgium), Michele De Bonis (Italy),
Konstant inos Dimopoulos (UK), Erwan Donal (France), Heinz Drexel (Aust r ia), Frank Arnold Flachskampf (Sweden),
Roger Hall (UK), Sigrun Halvorsen (Norway), Bruno Hoenb (France), Paulus Kirchhof (UK/Germany),
* Corresponding authors: Gilbert Habib, Service de Cardiologie, C.H.U. De La Timone, Bd Jean Moulin, 13005 Marseille, France, Tel: + 33 4 91 38 75 88, Fax: + 33 4 91 38 47 64,
Email: [email protected]
Patrizio Lancellotti, University of Liege Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium – GVM Care and
Research, E.S. Health Science Foundation, Lugo (RA), Italy, Tel: + 3243667196, Fax: + 3243667194, Email: [email protected]
ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix
ESC ent it ies having part icipated in the development of this document:
ESC Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of
Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC).
ESC W orking Groups:Cardiovascular Pharmacotherapy,Cardiovascular Surgery,Grown-up Congenital Heart Disease,Myocardial and Pericardial Diseases,PulmonaryCirculation
and Right Ventricular Function, Thrombosis, Valvular Heart Disease.
Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelines exempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2015. All rights reserved. For permissions please email: [email protected].
European Heart Journal
doi:10.1093/eurheartj/ehv319
European Heart Journal Advance Access published August 29, 2015
by
guest o
n N
ovem
ber 2
1, 2
016
http
://eurh
eartj.o
xfo
rdjo
urn
als.org
/D
ow
nlo
aded
from
S Geidel - 20.04.2011 -S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 06. Juni 2012
„Bicuspidalisierte“ AK-Stenose + Endokarditis (Streptokokken)
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
Perianulärer Abszess,
Staph. aureus
Ggf. kompletter Wurzelersatz
S Geidel - 11.01.2012
S Geidel - 11.01.2012
S Geidel - 11.01.2012
„Bicuspidalisierte“ AK-Stenose + Endokarditis (Streptokokken)
Klappenerhaltend: Patch-Plastik bei kleiner Vegetation (Streptokokken)
S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 06. Juni 2012
Das chir. Vorgehen bei Endokarditis – Rekonstruktion vs. Ersatz
Maßnahmen im Bereich der Aortenklappe
Klappenersatz: bei Beteiligung des freien Randes (Enterokokken)
S Geidel - 11.01.2012
Re-OP, problematisch: Prothesenendokarditis mit partiellem Ausriss (Staph. aureus)
S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 06. Juni 2012
Wesentlichstes Merkmal: Multiple Erscheinungsformen …
Das chirurgische Vorgehen bei Herzklappenendokarditis
Maßnahmen im Bereich der Mitralklappe
Wenn möglich MK-Rekonstruktion
ESC GUIDELINES
2015 ESC Guidelines for the management
of infect ive endocardit is
The Task Force for the Management of Infect ive Endocardit is of the
European Society of Cardiology (ESC)
Endorsed by: European Associat ion for Cardio-Thoracic Surgery
(EACTS), the European Associat ion of Nuclear Medicine (EANM)
Authors/Task Force Members: Gilber t Habib* (Chairperson) (France),
Pat r izio Lancellot t i* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal ),
Mar ia Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zot t i (Italy),
Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erbaa (Italy),
Bernard Iung (France), Jose M. Mirob (Spain), Barbara J. Mulder (The Nether lands),
Edyta Plonska-Gosciniak (Poland), Susanna Pr ice (UK), Jolien Roos-Hesselink
(The Nether lands), Ulr ika Snygg-Mart in (Sweden), Franck Thuny (France),
Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)
Document Reviewers: Çet in Erol (CPG Review Coordinator) (Turkey), Pet ros Nihoyannopoulos (CPG Review
Coordinator) (UK), Victor Aboyans (France), Stefan Agewall (Norway), George Athanassopoulos (Greece),
Saide Aytekin (Turkey), W erner Benzer (Aust r ia), Hector Bueno (Spain), Lidewij Broekhuizen (The Nether lands),
Scipione Carer j (Italy), Bernard Cosyns (Belgium), Julie De Backer (Belgium), Michele De Bonis (Italy),
Konstant inos Dimopoulos (UK), Erwan Donal (France), Heinz Drexel (Aust r ia), Frank Arnold Flachskampf (Sweden),
Roger Hall (UK), Sigrun Halvorsen (Norway), Bruno Hoenb (France), Paulus Kirchhof (UK/Germany),
* Corresponding authors: Gilbert Habib, Service de Cardiologie, C.H.U. De La Timone, Bd Jean Moulin, 13005 Marseille, France, Tel: + 33 4 91 38 75 88, Fax: + 33 4 91 38 47 64,
Email: [email protected]
Patrizio Lancellotti, University of Liege Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium – GVM Care and
Research, E.S. Health Science Foundation, Lugo (RA), Italy, Tel: + 3243667196, Fax: + 3243667194, Email: [email protected]
ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix
ESC ent it ies having part icipated in the development of this document:
ESC Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of
Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC).
ESC W orking Groups:Cardiovascular Pharmacotherapy,Cardiovascular Surgery,Grown-up Congenital Heart Disease,Myocardial and Pericardial Diseases,PulmonaryCirculation
and Right Ventricular Function, Thrombosis, Valvular Heart Disease.
Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelines exempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2015. All rights reserved. For permissions please email: [email protected].
European Heart Journal
doi:10.1093/eurheartj/ehv319
European Heart Journal Advance Access published August 29, 2015
by
guest o
n N
ovem
ber 2
1, 2
016
http
://eurh
eartj.oxfo
rdjo
urn
als.org
/D
ow
nlo
aded
from
S Geidel - 11.01.2012 S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
MIC MKR/E
S Geidel - 11.01.2012 5. postop. Tag nach MIC-MKR
Aorta vor dem Klemmen Zugang LA
Großer Prolaps P2 Erfolgreiche Rekonstruktion
3D-Visualisierung
Kunstklappenersatz
P3 häufig post-endokarditisch
A3
PC
P2 ?
P3
A3PC
P2, P3: frisch endokarditisch
(Streptokokken)
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
P3
P2
P1
A1
AC
AC, A1, P1: vermutlich post-entzündlich
PC
P3
A3
Staph. aureus
Geidel et al., Hamburger Ärzteblatt 2018;72(1):12-16
PC, A3, P3: frisch entzündlich
S Geidel - 11.01.2012
S Geidel - 11.01.2012
S Geidel - 20.04.2011 -MK-Endokarditis A2, Perforation
Staph. epi
Perikard-Patch
Re-OP, problematisch: Prothesenendokarditis mit Emboliegefahr / Blockade
S Geidel -
04.10.2011
septal
anterior
posterior
Fossa ovalis
CS
PM
Tricuspidalklappe: Anatomie
Chordae
Staph.-aureus-Infektion bei i.v.-Drogenabusus !
S Geidel - 11.01.2012
Sanierung nur durch Exzision möglich
Ältere Endokarditis
Patch-Plastik + Sehenfadenersatz
S Geidel - 11.01.2012
Schwere SM-Infektion
S Geidel - 11.01.2012 S Geidel - 11.01.2012
Infizierte Sonden
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Operative risk assessment (risk scores)
S Geidel - 11.01.2012
STS score Gaca et al. J Thorac Cardiovasc Surg 2011;141:98-106.
DeFeo score De Feo et al. ScientificWorldJournal 2012;2012:307571,
Volume 2012, Article ID 307571, 8 pages
EuroScore II
LogEuroScore ( ... geteilt durch 3 bzw. 4 = OP-Risiko)
„No single operative risk score is perfect … Although
the theoretical indications for surgery in IE are clear, their
practical application relies largely on the clinical status
of the patient and the patient`s co-morbidities.“
Nashef et al. Eur J Cardiothorac Surgery 2012;41:734-44
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Sechs Prädiktoren, u.a.
… peri-valvuläre Beteiligung
… fortbestehende positive Blutkultur
Operative risk assessment (risk scores)Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
OP-Risiko (30-Tage-Sterblichkeit)
„Normaler“ Klappenpatient (ohne Risikofaktoren): 1 - 3%
Endokarditispatient (ohne Risikofaktoren): 4 - 5%
Doppelklappenendokarditis (ohne Risikofaktoren): 8 - 10%
Doppelklappen-Prothesenendokarditis
und/oder Patienten mit Risikofaktoren
- Sepsis, Stauungspneumonie … 10 - 30%
- Leber- oder Niereninsuffizienz …
- schwere KHK, reduz. LVEF … > 50%
Das chirurgische Vorgehen bei Herzklappenendokarditis
Ergebnisse und Resümee
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Längerfristige Prognose
„Normaler“ Klappenpatient (ohne Risikofaktoren): sehr gut
Endokarditispatient (ohne Risikofaktoren): gut
Doppelklappenendokarditis (ohne Risikofaktoren): gut
Doppelklappen-Prothesenendokarditis
und/oder Patienten mit Risikofaktoren
- Sepsis, Stauungspneumonie … eingeschränkt
- Leber- oder Niereninsuffizienz …
- schwere KHK, reduz. LVEF …
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Das chirurgische Vorgehen bei Herzklappenendokarditis
Ergebnisse und Resümee
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Prognose
S Geidel - 11.01.2012 S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Abhängig von Alter, Comorbidität, Grad der
Herzinsuffizienz und Rezidiv/Reinfektion (5 - 10%):
Überleben nach 1 J 80 - 90%
Überleben nach 5 J 60 - 70%
ESC GUIDELINES
2015 ESC Guidelines for the management
of infect ive endocardit is
The Task Force for the Management of Infect ive Endocardit is of the
European Society of Cardiology (ESC)
Endorsed by: European Associat ion for Cardio-Thoracic Surgery
(EACTS), the European Associat ion of Nuclear Medicine (EANM)
Authors/Task Force Members: Gilber t Habib* (Chairperson) (France),
Pat r izio Lancellot t i* (co-Chairperson) (Belgium), Manuel J. Antunes (Portugal ),
Mar ia Grazia Bongiorni (Italy), Jean-Paul Casalta (France), Francesco Del Zot t i (Italy),
Raluca Dulgheru (Belgium), Gebrine El Khoury (Belgium), Paola Anna Erbaa (Italy),
Bernard Iung (France), Jose M. Mirob (Spain), Barbara J. Mulder (The Nether lands),
Edyta Plonska-Gosciniak (Poland), Susanna Pr ice (UK), Jolien Roos-Hesselink
(The Nether lands), Ulr ika Snygg-Mart in (Sweden), Franck Thuny (France),
Pilar Tornos Mas (Spain), Isidre Vilacosta (Spain), and Jose Luis Zamorano (Spain)
Document Reviewers: Çet in Erol (CPG Review Coordinator) (Turkey), Pet ros Nihoyannopoulos (CPG Review
Coordinator) (UK), Victor Aboyans (France), Stefan Agewall (Norway), George Athanassopoulos (Greece),
Saide Aytekin (Turkey), W erner Benzer (Aust r ia), Hector Bueno (Spain), Lidewij Broekhuizen (The Nether lands),
Scipione Carer j (Italy), Bernard Cosyns (Belgium), Julie De Backer (Belgium), Michele De Bonis (Italy),
Konstant inos Dimopoulos (UK), Erwan Donal (France), Heinz Drexel (Aust r ia), Frank Arnold Flachskampf (Sweden),
Roger Hall (UK), Sigrun Halvorsen (Norway), Bruno Hoenb (France), Paulus Kirchhof (UK/Germany),
* Corresponding authors: Gilbert Habib, Service de Cardiologie, C.H.U. De La Timone, Bd Jean Moulin, 13005 Marseille, France, Tel: + 33 4 91 38 75 88, Fax: + 33 4 91 38 47 64,
Email: [email protected]
Patrizio Lancellotti, University of Liege Hospital, GIGA Cardiovascular Sciences, Departments of Cardiology, Heart Valve Clinic, CHU Sart Tilman, Liege, Belgium – GVM Care and
Research, E.S. Health Science Foundation, Lugo (RA), Italy, Tel: + 3243667196, Fax: + 3243667194, Email: [email protected]
ESC Commit tee for Pract ice Guidelines (CPG) and Nat ional Cardiac Societ ies document reviewers: listed in the Appendix
ESC ent it ies having part icipated in the development of this document:
ESC Associat ions: Acute Cardiovascular Care Association (ACCA), European Association for Cardiovascular Prevention & Rehabilitation (EACPR), European Association of
Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA).
ESC Councils: Council for Cardiology Practice (CCP), Council on Cardiovascular Nursing and Allied Professions (CCNAP), Council on Cardiovascular Primary Care (CCPC).
ESC W orking Groups:Cardiovascular Pharmacotherapy,Cardiovascular Surgery,Grown-up Congenital Heart Disease,Myocardial and Pericardial Diseases,PulmonaryCirculation
and Right Ventricular Function, Thrombosis, Valvular Heart Disease.
Thecontent of these European Society of Cardiology (ESC) Guidelines hasbeen published for personal and educational use only.No commercial use isauthorized.No part of theESC
Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford Uni-
versity Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.
Disclaimer . The ESC Guidelines represent the viewsof the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at
the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recom-
mendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encour-
aged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or
therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and
accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropriate and/or necessary, the patient’s caregiver. Nor
do theESC Guidelines exempt health professionals from takinginto full and careful consideration the relevant official updated recommendations or guidelines issued by the competent
public health authorities, in order to manage each patient’s case in light of the scientifically accepted datapursuant to their respective ethical and professional obligations. It isalso the
health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.
& The European Society of Cardiology 2015. All rights reserved. For permissions please email: [email protected].
European Heart Journal
doi:10.1093/eurheartj/ehv319
European Heart Journal Advance Access published August 29, 2015
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Gesund werden. Gesund leben.
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
- Schwere und komplexe Verlaufsformen
- Veränderung der Prädisposition & Risikogruppenzugehörigkeit
- Vorbestehende kardiale Erkrankungen sind die Regel
- MIC-Verfahren haben eine wachsende Bedeutung
Eine kompromisslose Infektsanierung und die Wiederher-
stellung der Ventilfunktion sind vornehmliche Ziele der
Herzchirurgie
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Das chirurgische Vorgehen bei Herzklappenendokarditis
Ergebnisse und Resümee
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
Möglichst Rekonstruktion bei MK- und TK-Endokarditis
Die periop. Letalität kann im Einzelfall hoch sein (4% – über 50%)
S. Geidel – 06. Juni 2012S. Geidel – 05. Juli 2017
Gute Endokarditis-Chirurgie ist hoch-individualisiert
und bestens vorbereitet
Das chirurgische Vorgehen bei Herzklappenendokarditis
Ergebnisse und Resümee
Die Prognose hängt ab vom: (1) individuellen kardialen Befund, (2) Keim/Blutkulturen, (3) Comorbiditäten und (4) Lebensalter
Hamburger Herzkreislauftag 2018 S Geidel 23.06.2018
S Geidel -
15.02.2012
LIFE Magazine 1948
„Outcomes of surgery will allways be determined by the
choice of the right procedure by the right surgeon for the right patient.“
Marc Gillinov, Heart and Vascular Institute, Cleveland Clinic; Ann Thorac Surgery 2012
S Geidel -
15.02.2012
WM-Halbfinale - 08. Juli 2014
5 : 0 innerhalb von 30min ...
Vielen Dank
S Geidel -
15.02.2012
Herzklappenendokarditis - Diagnostik & operative Strategien
Rekonstruktion vs. Klappenersatz im Rahmen minimal-invasiver und
konventioneller Eingriffe als Erstoperation oder Re-Eingriff
PD Dr. Stephan Geidel, Ltd. OA der Abt. für Herzchirurgie, Asklepios Klinik St. Georg
Samstag 23.06.2018, Curio-Haus, Hamburg, 8:30 – 17:30
Hamburger Herzkreislauftag 2018