Heart transplantation for infective endocarditis: Viable option for a limited few?

Abstract

Active infection in the recipient is considered a relative contraindication for solid organ transplantation. However, heart transplantation (HT) can be curative in patients with ventricular assist device infections. For patients with infective endocarditis (IE), valve replacement is part of the management strategy based on emergent, acute, or elective indications. HT has been utilized as an uncommon and sporadic treatment option for carefully selected patients with refractory or recurrent IE after all other surgical treatment options have been exhausted or are not feasible. Herein, we review 19 published cases of IE in whom HT was undertaken in the setting of ongoing active infection with reported good outcomes. We attempt to propose general criteria for HT in the setting of IE and discuss challenges and hurdles that clinicians might encounter when considering HT for active IE in the absence of robust data or clearly defined criteria. K E Y W O R D S endocarditis, heart, transplant, transplantation, ventricular assist device Number Reference Pathogen at time of HT Prior pathogens Prior valve culture Antimicrobial treatment for IE pre-HT Blood cultures at HT Peripheral embolic sites of infection Duration of antimicrobial treatment pre-HT (Approx.) Pathology of explanted heart Explanted heart culture Antimicrobials post-HT Duration antimicrobial treatment post-HT

Infective endocarditis nightmare: A bold solution for a devastating scenario

“…3 HT is the utmost controversial topic, due to the need for immunossupression. 4,5 Although guidelines support its use in extreme cases, there is little experience on the field and recommendations are scarce, being rarely performed in IE. 1,4,5 The patient had recurrent PVIE with major cardiac tissue destruction, making surgery unfeasible.…”

Salvage heart transplantation for Mycoplasma hominis prosthetic valve endocarditis: A case report and review of the literature

“…Overall, HT as salvage therapy for IE remains a rare indication. There are no robust data defining criteria for HT in patients with refractory IE, while the ESC guidelines mentioned HT as a measure of last resort…”

“…Vikram and Murphy have recently proposed general criteria and suggested that, with the availability of effective antibiotic therapy in the post‐transplantation period, HT could be taken into account as a measure of last resort in patients with younger age, without significant comorbidities with persistently negative blood cultures at the time of HT, and without major embolization.…”

“…Galactomannan (GM) and (1,3 )‐beta‐ d ‐glucan (BDG) assay and autoimmunity screening panel were also negative. Transesophageal echocardiogram showed a para‐aortic pseudoaneurysm suggestive of a wide abscess with a mobile hyperechogenic vegetation (16 × 6 mm) attached to the right coronary cusp associated with severe aortic insufficiency …”

A “Cat”‐astrophic Case of Bartonella henselae infective endocarditis followed by cardiac transplantation salvage therapy

“…The European Society of Cardiology suggests it as a last resort in highly vetted candidates . A recent literature review aggregated all published cases—a total of 19—and proposed criteria for evaluating IE patients who may benefit from heart transplant . However, there remains a paucity of literature on this approach, much less in patients with B henselae IE.…”