Syed T. Hussain

2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary

From the Departments of Thor Medicine, and Infectious Dise of Cardiothoracic Surgery, and of Medicine; Texas Heart Inst This work was supported by instit Clinic editorial staff. Received for publication May 9, 2 publication Sept 16, 2016. Address for reprints: G€osta B. Pett diovascular Surgery, Cleveland 44195 (E-mail: petterg@ccf.or J Thorac Cardiovasc Surg 2017;0022-5223/

Heart valve culture and sequencing to identify the infective endocarditis pathogen in surgically treated patients

36.00 Copyright 2017 by The Ameri http://dx.doi.org/10.1016/j.jtcvs.2 €osta B. Pettersson, MD, PhD, and oseph S. Coselli, MD

Current Hypotheses in Cardiac Surgery: Biofilm in Infective Endocarditis

BACKGROUND Testing excised valves in surgically treated infective endocarditis (IE) patients provides an opportunity to identify the microbial etiology of IE. Microbial sequencing (universal bacterial, mycobacterial, or fungal polymerase chain reaction followed by DNA sequencing) of valves can identify microorganisms accurately, but the value it adds beyond information provided by blood and valve cultures has not been adequately explored. METHODS Three hundred fifty-six patients who underwent surgery for active IE from January 1, 2010, to January 1, 2013, were identified from our cardiovascular information registry and outpatient parenteral antibiotic therapy registry. Their records were reviewed to identify 174 patients whose valves were sent for sequencing. The microbial etiology of IE was defined using comprehensive clinical, pathologic, and microbiological criteria. Blood culture, valve culture, and valve sequencing were examined to determine how frequently they identified the definitive cause of IE. RESULTS Of the 174 patients, 162 (93%) had acute inflammation on histopathologic examination of their valves. Valve sequencing was significantly more sensitive than valve culture in identifying the causative pathogen (90% versus 31%, p < 0.001), and yielded fewer false positive results (3% versus 33%, p <0.001). The pathogen would not have been identified in 25 patients (15%) had it not been for valve sequencing. All the value provided by sequencing was attributable to bacterial DNA sequencing; mycobacterial and fungal sequencing provided no additional information beyond that provided by blood culture, histopathology, and valve culture. CONCLUSIONS Valve sequencing, not valve culture, should be considered the primary test for identifying bacteria in excised cardiac valves.

Trends in blood utilization in United States cardiac surgical patients.

Despite recent advances in diagnostics and treatments, infective endocarditis is still associated with substantial morbidity and mortality. Even prolonged courses of broad-spectrum antimicrobials often fail to eradicate the infection, making surgical intervention necessary in many cases. In this review, we present recent advances in molecular microbiology techniques that have uncovered a plausible explanation for this resistance to treatment: the recently discovered social behavior of some microbes, in which colonies form a nearly impenetrable barrier around themselves called a biofilm. These biofilm structures isolate the colony from the body׳s immune response and antimicrobial drugs. We also present current thinking about possible ways biofilms can be destroyed.

Injection drug use and outcomes after surgical intervention for infective endocarditis

We sought to determine whether publication of blood conservation guidelines by the Society of Thoracic Surgeons in 2007 influenced transfusion rates and to understand how patient‐ and hospital‐level factors influenced blood product usage.

Use of annulus washer after debridement: A new mitral valve replacement technique for patients with severe mitral annular calcification

BACKGROUND Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. METHODS All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. RESULTS Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and 180 days (hazard ratio [HR], 9.8; 95% confidence interval [CI], 2.7-35.3) but not before 90 days (HR, 0.38; 95% CI, 0.05-3.1) or after 180 days (HR, 1.8; 95% CI, 0.8-3.8). Among patients who injected drugs, reoperation and death contributed equally to the outcome, whereas among patients who did not inject drugs, reoperation for IE was far less common. CONCLUSIONS Between 3 and 6 months after operation for IE, patients who inject drugs have a hazard of death or reoperation that is about 10 times that of patients who do not inject drugs. Before and after, the HRs are much smaller and not statistically significant.

Residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis

Extreme calcification of the mitral annulus (MAC) is a formidable challenge during mitral valve surgery, with the risk of serious and potentially fatal complications such as stroke, atrioventricular disruption, ventricular rup- ture, valve dehiscence, and periprosthetic leakage. 1 A vari- ety of surgical techniques have been developed that vary from avoiding or minimizing any decalcification 2 to exten- sive radical removal of the calcium bar followed by recon- struction of the atrioventricular annulus. 3-5 We describe our experience with an intermediate approach that involves limited debridement of the calcified annulus, allowing implantation of a good-sized prosthesis using a felt washer, sandwiched between the annulus and prosthesis, as a support. aortic calcification), and normothermic cardiopulmonary bypass were used in all patients. The mitral valve is approached transeptally. First the severity of the dis- ease and valvular dysfunction is reevaluated to finalize the surgical plan. This includes sizing the valve opening and estimating the debridement necessary to implant a good-sized valve. Exposure is optimized with a low threshold to extend the atrial septal incision to the dome of the left atrium and add a proximal aortotomy. The anterior leaflet is preserved and transposed posteriorly to support the annulus, and when doable, the posterior leaflet is released and also salvaged for support. Debridement is performed carefully piece by piece by rongeur, often using a dual ap- proach from the left atrium and aortic root. Great care is taken to avoid transmural defects in the atrioventricular groove or deep defects in the pos- terior wall muscle. Size and shape of the mitral opening are repeatedly reevaluated until it is deemed possible to place sutures and implant a pros- thesis of good size. In some cases this requires extensive debridement. The valve sutures are placed through or around the residual calcium and annu- lus, with pledgets on the ventricular side (Figure 1, A). Working through the aortotomy often allows better placement of valve sutures in the region of the central fibrous body. A 1- to 1.5-cm wide (1/2 inch) PTFE felt washer is inserted in between the annulus and sewing ring of the prosthesis from trigone to trigone posteriorly (Figure 1, B). The valve and the washer are tied down. The washer is then sutured to the atrial wall with a second suture line using running No. 4-0 polypropylene (Figure 1, C). Generous irrigation is performed repeatedly to clear the heart of loose pieces of calcium.

Surgical techniques in type A dissection

OBJECTIVES To identify and understand residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis (IE), we categorized the intraoperative pathologic entities in patients with left-sided IE and correlated the pathology (noninvasive vs invasive) and organism with IE context (affected valve, native vs prosthetic [PVE]) and surgical results. METHODS From January 2002 to January 2011, 775 patients underwent surgery for active left-sided IE. Registries were queried, and endocarditis-related pathology was based on the echocardiographic findings and operative notes. Propensity adjustment and matching (55 pairs) were used for risk-adjusted outcome comparisons between the invasive aortic and mitral cases. RESULTS A total of 395 patients had isolated aortic (PVE 59%, invasive 68%), 238 isolated mitral (PVE 29%, invasive 35%), and 142 combined aortic and mitral (PVE 44%, invasive 69%) IE. The 30-day survival was 92% and was similar for native valve endocarditis and PVE in all 3 valve combinations. Invasive versus noninvasive IE was associated with greater hospital mortality (11% vs 4.4%, P = .001). Patients with invasive IE had worse intermediate-term survival than those with noninvasive IE for mitral (P = .001) and aortic plus mitral (P = .02) IE but not for isolated aortic IE. This difference persisted in the matched patients. CONCLUSIONS During the past decade, we have had low hospital mortality for surgically treated left-sided IE and have neutralized the added risk of PVE. However, outcomes remain worse for mitral versus aortic valve IE, with residual obstacles related to patient factors, inherent mitral valve anatomy in patients with invasive disease, and lack of an alternative mitral valve prosthesis optimal for IE.

Successful surgical treatment of rare Aspergillus terreus prosthetic valve endocarditis complicated by intracranial and mesenteric artery mycotic aneurysms

Acute aortic dissection is a surgical emergency that must be urgently managed, with the primary goal of restoring flow to the dominant true lumen in the downstream aorta. Our preference at the Cleveland Clinic is for an open distal anastomosis technique without aortic clamping, as it permits more accurate approximation of dissected layers and more homeostatically secure anastomosis. During this procedure we employ right axillary end-to-side graft perfusion, followed by deep hypothermic circulatory arrest and antegrade brain perfusion. The distal anastomosis is performed without felt strips or glue. Critical to achieving a successful outcome is meticulous de-airing of the arch, diligent myocardial protection, and a water-tight anastomosis prior to discontinuing cardiopulmonary bypass.

Rarity of invasiveness in right-sided infective endocarditis

From the Department of Infectious Disease, Medicine Institute; the Departments of Thoracic and Cardiovascular Surgery and Vascular Surgery, Heart and Vascular Institute; and the Department of Anatomic Pathology, Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio. R.A.R.A. is currently at SheikhKhalifaMedical City,AbuDhabi,UnitedArabEmirates. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication June 4, 2014; accepted for publication June 5, 2014; available ahead of print Aug 23, 2014. Address for reprints: G€osta B. Pettersson, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195 (E-mail: petterg@ccf.org). J Thorac Cardiovasc Surg 2014;148:e221-3 0022-5223/