Infective endocarditis in patients with aortic grafts

https://doi.org/10.1016/j.ijcard.2021.02.030Get rights and content

Highlights

  • In patients with ascending aortic graft infections multimodality imaging has an important role for diagnosis and follow-up.

  • Heart failure is a frequent complication and is associated with an increased in-hospital mortality.

  • Prompt radical debridement and graft replacement when clinically indicated is advocated.

  • However, medical treatment is a valid therapeutic alternative in patients without IE complications or very high surgical risk.

Abstract

Background

Infective endocarditis (IE) in patients with a valve-tube ascending aortic graft (AAG) is a rare entity with a challenging diagnosis and treatment. This study describes the clinical features, diagnosis and outcome of these patients.

Methods

Between 1996 and 2019, 1654 episodes of IE were recruited in 3 centres, of which 37 patients (2.2%) had prosthetic aortic valve and AAG-IE (21 composite valve graft, 16 supracoronary graft) and conformed our study group.

Results

Patients with aortic grafts were predominantly male (91.9%) and the mean age was 67.7 years. Staphylococci were the most frequently isolated microorganisms (32%). Viridans group streptococci were only isolated in patients with composite valve graft. TEE was positive in 89.2%. PET/CT was positive in all 15 patients in whom it was performed. Surgical treatment was performed in 62.2% of patients. In-hospital mortality was 16.2%. Heart failure and the type of infected graft (supracoronary aortic graft) were associated with mortality. Mortality among operated patients was 21.7%. Interestingly, 14 patients received antibiotic therapy alone, and only one died. Mortality was lower among patients with a composite valve graft compared to those with a supracoronary graft (4.8% vs 31.3%; p = 0.03).

Conclusions

In patients with AAG and prosthetic aortic valve IE, mortality is not higher than in other patients with prosthetic IE. Multimodality imaging plays an important role in the diagnosis and management of these patients. Heart failure and the type of surgery were risk factors associated with in-hospital mortality. Although surgical treatment is usually recommended, a conservative management might be a valid alternative treatment in selected patients.

Graphical abstract

TEE: transesophageal echocardiography; PET-CT: positron emission tomography/computed tomography; CT: computed tomography.

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Introduction

Infective endocarditis (IE) involving an aortic valve prosthesis and extending to an ascending aortic graft (AAG) is a rare clinical scenario occurring at a rate of 0.2%/year [1]. The diagnosis of this entity remains challenging [2]. A high clinical suspicion, and the contribution of latest imaging techniques, are of paramount importance. Transesophageal echocardiography (TEE) remains the main imaging technique in this setting [3], although 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is emerging as a useful complementary diagnostic tool in recent years [4].

AAG IE has been classically associated with bad prognosis, mainly due to difficulties in the diagnosis, but also because surgical treatment, which is considered necessary in most cases, is technically challenging and has been associated to high mortality and morbidity [5,6]. However, to date, only small series have been published [1,3,[5], [6], [7], [8], [9]], and no previous studies have analyzed patients outcome according to the type of graft surgery.

The aim of our study was to assess the epidemiological, microbiological and clinical characteristics, and outcome of patients with aortic prosthetic valve and AAG infection, comparing patients with a composite valve graft and those with prosthetic aortic valve and a supracoronary aortic graft.

Section snippets

Patient population

This is a multicentriccohort study performed at three tertiary care centres with surgical facilities that have been working together in the field of IE since the beginning of the study, with uniform protocols and data collection, and identical diagnostic and therapeutic criteria. From January 1996 to April 2019, a total of 1654 episodes of IE that fulfilled the diagnosis of possible or definite IE according to the Duke criteria (until 2002) [10] or the modified Duke criteria (since 2003) [11]

Patients

There were 37 patients with an AAG infection (2.2% of all IE episodes). Mean time from surgery to diagnosis of IE was 1540 [1544] days. Twenty one cases had a composite valve graft (Group A) and 16 had a supracoronary aortic graft (Group B; Fig. 1). Mean age of our patient population was 67.7 [14.6] years, and 34 (91.9%) were male. A total of 33 patients (89.2%) met criteria for definite IE, whereas 4 (10.8%) had possible IE. Epidemiological, clinical and microbiological features comparing both

Discussion

This study comprises one of the largest series of patients with ascending aortic graft infections reported to date. In this multicenter series, valve-tube graft infections represented 2.2% of all IE episodes, and, as already reported [6,8,9,18,19], it seems to be a disease mainly of men. The main findings of our study highlight the complementary role of PET/CT together with TEE in the diagnostic assessment and follow-up of these patients, and show that in-hospital mortality is not higher than

Conclusions

In patients with ascending aortic prosthetic graft infections: 1- Multimodality imaging, has an important role, not only when diagnosis remains uncertain, but also to assess the extension of the infection and to monitor the effectiveness of antibiotic treatment; 2- Heart failure is a frequent complication and is associated with an increased in-hospital mortality; 3- Prompt radical debridement and graft replacement when clinically indicated, especially if abscesses or pseudoaneurysms are

Funding sources and Declaration of Competing Interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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