Jens Tingleff

Perivalvular cavities in endocarditis : abscesses versus pseudoaneurysms ? A transesophageal Doppler echocardiographic study in 118 patients with endocarditis

The appearance of perivalvular cavities (PCs) in patients with infectious endocarditis (IE) was studied by transesophageal echocardiography (TEE) color Doppler examinations to determine whether the color Doppler TEE presentation was in keeping with the current concept of PCs representing abscesses. Two heart centers participated in the study. Videotape recordings of TEE examinations in patients with IE were analyzed retrospectively for 18 months in both centers, and one center included patients prospectively for an additional 18 months. A total of 118 patients with a diagnosis of IE based on TEE and clinical and laboratory findings were seen during the study period. TEE showed PCs in 34 patients. In 3 patients who died, no autopsy was performed; the PCs were proved at autopsy or surgery in the remaining 31 patients, who constituted the study population. All PCs were echo free at TEE. Apart from one technically inadequate examination, all PCs contained color Doppler signals indicating intracavitary blood flow; the PCs communicated through a narrow channel with high-pressure regions (the left ventricle or the ascending aorta). At surgery or autopsy, only 2 of the 31 patients had pus accumulations besides the blood-filled PCs. At TEE the pus accumulations presented as echo-rich, shaggy tissue thickening. It is concluded that well-delineated, echo-free PCs with intracavitary color Doppler signals at TEE appear to be pseudoaneurysms, and therefore the term abscess should not be used in these cases. Although further studies are needed, our findings suggest that PCs more likely occur by infectious tissue weakening and subsequent dissection rather than as a result of primary abscess formation with secondary rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of aortic valve endocarditis with the Ross operation.

OBJECTIVE Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aortic valve disease is increasing, but use of the pulmonary autograft in the treatment of aortic valve endocarditis has been limited. The objective of this prospective study is to present the technique and results of our experience with aortic valve endocarditis treated with the Ross operation. MATERIALS AND METHODS Since 1992 we have treated 35 patients (median age 41 years, range 6-71 years) having aortic valve endocarditis with a Ross operation. Twenty-four patients had advanced disease defined as pathology due to endocarditis extending beyond the valve cusps (13 patients) or prosthetic valve endocarditis (11 patients). Twenty-two patients had active disease at the time of surgery, and 12 had undergone one to four previous heart operations. RESULTS There were two operative deaths (5.8%), both related to severe disease with very advanced pathology and heart failure. Intraoperative echocardiography demonstrated no or trivial autograft insufficiency in all patients. There have been no late deaths. There has been one (probable) recurrent right-sided endocarditis in a drug addict during a follow-up period of 3-56 months. One patient has been reoperated on for homograft stenosis. CONCLUSIONS We are enthusiastic about the use of the Ross operation in aortic valve endocarditis and in younger patients with advanced pathology, it is our preferred treatment modality. Following removal of the autograft, unparalleled exposure of the left ventricular outflow tract is obtained. Even in patients with very advanced pathology the left ventricular outflow tract is usually intact, allowing autograft implantation in the standard fashion. For selected patients with simple endocarditis, the Ross operation is an attractive option on its usual merits.

The ross operation: results of early experience including treatment for endocarditis

The Ross operation has been performed for more than 25 years and its popularity has increased dramatically in recent years. We developed an interest in this procedure through a combination of a basic dissatisfaction with a device that requires life-long anticoagulation and the belief that a vital, autologous tissue valve with normal valve morphology and hemodynamics would prove to be superior to the mechanical valve, and that these advantages would outweigh the potential drawbacks related to the operations technical difficulty and the risk of autograft or homograft dysfunction. From December 1992 to November 1994 40 Ross operations as total root replacements in a diverse group of patients between 5 and 72 years of age (median 32) were performed at Rigshospitalet. Seventeen (43%) of the patients had undergone at least one previous open heart operation. Eleven patients (28%) required surgery because of ongoing or previous endocarditis, and of these, nine had aortic annular destruction and cavity/pseudoaneurysm formation and five had prosthetic valve endocarditis. Three patients (8%) were operated because of mechanical valve dysfunction. One patient was treated for an ascending aortic aneurysm and aortic insufficiency. The remaining 25 patients were operated because of congenital or acquired aortic insufficiency, stenosis, or both. Ten patients (25%) underwent concomitant procedures. No mortality or serious complications occurred. Morbidity was limited to one case each of total atrioventricular (A-V) block, sternal pseudarthrosis, minor stroke, and deep vein thrombosis. Thirty-five patients had no or trivial, two patients mild, and three patients moderate autograft valve insufficiency during a median follow-up of 8 months (range 0-23 months). Two patients had pulmonary stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic effect of sustained pulmonary hyperinflation in patients after cardiac surgery: open vs. closed chest

Background:  In a previous study, we showed that sustained pulmonary hyperinflation, i.e. a lung recruitment maneuver, after closure of the chest in patients undergoing cardiac surgery had significantly negative effects on the central hemodynamics. As elevated pleural pressure is believed to be a major cause of this cardiovascular impairment, we hypothesized that performing the sustained pulmonary hyperinflation under open chest conditions would affect the circulation less.

Rarity of invasiveness in right-sided infective endocarditis

Objective The rarity of invasiveness of right‐sided infective endocarditis (IE) compared with left‐sided has not been well recognized and evaluated. Thus, we compared invasiveness of right‐ versus left‐sided IE in surgically treated patients. Patients and Methods From January 2002 to January 2015, 1292 patients underwent surgery for active IE, 138 right‐sided and 1224 left‐sided. Among patients with right‐sided IE, 131 had tricuspid and 7 pulmonary valve IE; 12% had prosthetic valve endocarditis. Endocarditis‐related invasiveness was based on echocardiographic and operative findings. Results Invasive disease was rare on the right side, occurring in 1 patient (0.72%; 95% confidence interval 0.02%‐4.0%); rather, it was limited to valve cusps/leaflets or was superficial. In contrast, IE was invasive in 408 of 633 patients with aortic valve (AV) IE (65%), 113 of 369 with mitral valve (MV) IE (31%), and 148 of 222 with AV and MV IE (67%). Staphylococcus aureus was a more predominant organism in right‐sided than left‐sided IE (right 40%, AV 19%, MV 29%), yet invasion was observed almost exclusively on the left side of the heart, which was more common and more severe with AV than MV IE and more common with prosthetic valve endocarditis than native valve IE. Conclusions Rarity of right‐sided invasion even when caused by S aureus suggests that invasion and development of cavities/“abscesses” in patients with IE may be driven more by chamber pressure than organism, along with other reported host–microbial interactions. The lesser invasiveness of MV compared with AV IE suggests a similar mechanism: decompression of MV annulus invasion site(s) toward the left atrium.