Implantation of Sutureless Aortic Valve in a High- Risk Patient with Active Infective Endocarditis TAVI-Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF CARDIOLOGY &
CARDIOVASCULAR THERAPY
Active infective endocarditis (AIE) is major problem
especially for patients with prior valve intervention or device
implantation. We present a 77-year-old patient suffering from AIE 14
months after transcatheter-implanted aortic valve (TAVI). The heart team
considerated TAVI by increased operative risk, Euro SCORE of 10.42%,
including sever pulmonary hypertension, chronic obstructive pulmonary
disease, insulin depending diabetes mellitus, chronic renal failure and
polyneuropathy. Post-interventional, the patient suffered from an
aneurysm spurium. During follow-up, the patient underwent dental
treatment and afterwards developed 39°C fever und blood culture showed
repeatedly Escherichia Coli. Echocardiographic examination showed a new
paravalvular leakage with limited vegetation at the TAVI. The heart team
decided, although a Euro SCORE of 63.57%, appropriate antimicrobial
therapy in combination with surgery. A sutureless aortic valve was embed
after annulus patch reconstruction. The postoperative course was
uneventful. This case demonstrated that sutureless valves maybe a
valuable option for AIE-TAVI treatment.
Introduction
Active infective endocarditis (AIE) is a serious
septic risk for all patients, especially if prostheses in conventional
aortic valve replacements (AVR) or transcatheter aortic valve
implantation (TAVI) are afflicted [1]. Indications for urgent operative
debridement and valve replacement in complicated cases of AIE that
cannot always be managed with conventional appropriate antibiotic
therapy such as embolisms, multi resistant- or atypical pathogens,
including methicillin resistant staphylococcus aureus (MRSA) and fungi,
recurring IE and acute heart failure [2,3]. However, this is in conflict
with a fraction of the patient population at high or very high
operative risk according to Euro SCORE II [4]. In fact, with increasing
age and multi-morbidity, operative risk profiles are increasing over
time [5]. A strategy to circumvent this dilemma has been the
introduction of TAVI systems for high-risk or inoperable patients [6,7].
However, also TAVI valves are at risk of AIE, leaving patients at a
dead end concerning operative endocarditis treatment, as complicated
courses of AIE need surgical decontamination and debridement before
implantinga new valve [8-10]. Sutureless heart valves can decrease the
operative risk by reduction of cross-clamp-, cardio pulmonary bypass,
and thus overall operative time [11]. This is not only beneficial
regarding peri-operative- and short-term mortality, but also reduces the
risk for additional inflammation in these already septic patients
[12,13]. We report the successfully use of a sutureless aortic in a
patient with AIE-TAVI.
We present a 77-year-old patient, who was admitted to
our cardiologic unit due to progressive dyspnea and tightness of the
chest. Symptoms at admission were graded as New-York-Heart-Association
(NYHA) Class III. Fourteen months ago, the patient was admitted for
symptomatic aortic valve stenosis. The heart team considerated TAVI by
increased operative risk, Euro SCORE of 10.42%, due to sever pulmonary
hypertension, chronic obstructive pulmonary disease, insulin depending
diabetes mellitus, polyneuropathy, MorbusBechterew and chronic renal
failure. A transfemoral TAVI application was performed, using a 29mm
SAPIEN 3 (Edwards Lifesciences Inc.,Irvine, California).
Post-interventional, the patient suffered
from an aneurysm spurium, which was treated conservative.
Echocardiography showed a paravalvular leakage, grade I-II,
and a mean flow velocity of 1.47m/s. There was no cave seen at
the aorto-mitral curtain (Figure 1a, 1b & 1c). During follow-up,
the patient needed dental treatment, which was successfully
performed. Some weeks later, however the patient developed
fever (39°C) and several blood cultures were taken, showing to
be repeatedly positive for Escherichia Coli. Echocardiographic
examination showed an increase of the paravalvular leakage
with limited vegetation at the TAVI, however a cave developed
at the aorto-mitral curtain (Figure 2). A new heart team
conference was performed and decided, desperate the very
high Euro SCORE of 63.57%, surgery in combination with
appropriate antimicrobial therapy. The AIE-TAVI was explanted
(Figure 3). A Perceval L (SorinBiomedica Cardio Srl., Saluggia,
Italy) sutureless aortic valve was embed after annulus patch
reconstruction in a standard fashion (ref) (Figure 4 & 5).
Cross-clamping time was 30 minutes and cardiopulmonary
bypass time was 52 minutes. The postoperative course was
uneventful. The patient was extubated 7 hours after surgery
and a 2-day stay at the intensive care unit was needed.
Cribier et al. [14] introduced the transcatheter aortic
valve implantation (TAVI) for high-risk or inoperable patients
suffering from severe aortic valve stenosis. Today more than
150,000 patients worldwide received TAVI treatment and
growing at a rate of 40% annually [15], however in Germany
the rate in 2015 extended 50% [16]. As many patients benefit of
TAVI, new challenging complications occur which needs to be
addressed. Olsen et al. [17] investigated different risk factors
in patient undergoing TAVI which included low transcatheter
valve implantation (p=0.03), paravalvular leak grade 2+
(p=0.006), TAVI-in-TAVI (p=0.009) and vascular complications
(p=0.005).
During the last decade of AIE treatment has been stable
accept after introduction of the so-called “the endocarditis
team”, in which a standardized multidisciplinary approach
for patient with AIE were introduced [18]. Botelho-Nevers
et al. [19] could significantly decrease the 1-year mortality
from 18.5% to 8.2% (HR, 0.41: 95% CI, 0.21-0.79; p=0.008).
Indications for early surgical treatment of prosthesis AIE
together with appropriate antibiotic therapy has been clearly
stated in the current guidelines [20], which includes persistent
congestive heart failure signs of poor hemodynamics tolerance,
periannular extension or abscess and staphylococci or Gramnegative
microbes. [21] This strategy increases survival,
showed by Chu et al. [22] as well as Kang et al. [23], who also
showed to positive effect of embolism prevention in these
patients.
A serious dilemma was found in patients, who received
TAVI due to high-risk or being inoperable and appropriate
antibiotic therapy is not able to control AIE. The incidence in a
recent study of Olsen et al. [17] showed an incidence of AIE-TAVIof
2.1-2.99% per patient-year. Pericas et al. [24] showed a trend
towards surgery compared with non-surgical treatment in
survival respectively 90% (1/10) versus 61.9% (8/21; p=0.221)
in AIE-TAVI. This study, however also showed that in case of
heart failure all patient survival in the surgical treated group
and 88.9% in the non-surgical treated group will die which was
highly significant (p<0.001). Therefore, patient suffering from
AIE-TAVI should not be left at a dead-end concerning operative
endocarditis treatment, as complicated courses of AIE need
surgical decontamination and debridement.
New surgical strategies needs to be explored, such as
sutureless heart valves can also decrease the operative risk in
AIE-TAVI patients by reduction of cardio pulmonary bypass-,
cross-clamp- and thus overall operative time [25,26]. These
bioprostheses have been evaluated in propensity-matched
study to compare with TAVI in high-risk patient with excellent
results [27,28]. We have been used sutureless heart valves in
the past to treat AIE of the native aortic valve with excellent
results [29,30]. We should also not forget that surgically
reoperation for AIE-TAVI in high-risk or inoperable patients
suffering from native aortic valve stenosis are as a primary
intervention without previous sternotomy.
This case demonstrated that a sutureless aortic valves
maybe a valuable option for AIE-TAVI treatment in high-risk
patients.
For more articles in Open Access Journal of
Cardiology & Cardiovascular Therapy please click on: https://juniperpublishers.com/jocct/index.php
Comments
Post a Comment