What is the optimal timing for surgery in infective endocarditis with cerebrovascular complications?

Rossi, Michele; Gallo, Alina; Silva, Ravi Joseph De; Sayeed, Rana

doi:10.1093/icvts/ivr010

Cited by 47 publications

(29 citation statements)

References 17 publications

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“…For patients with intracerebral hemorrhage, there is consensus that surgery should be delayed by at least 1 month. For those patients with ischemic stroke, a number of studies (reviewed by Rossi et al [226]) have suggested that surgery does not need to be delayed if there are indications for surgery. Although an analysis of the ICE cohort specifically addressing this question concluded that early surgery is not associated with increased mortality, concerns have been raised regarding the adjusted OR for in-hospital mortality being 2.3 (95% CI, 0.94 to 5.7) for those receiving surgery within 7 days of stroke compared to delayed surgery (227,228).…”

Section: Managementmentioning

confidence: 99%

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

et al. 2015

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SUMMARY Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

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Section: Managementmentioning

confidence: 99%

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

et al. 2015

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“…These findings help guide decisions regarding medical and surgical management, especially timing of possible cardiac valve replacement surgery. 144,147,[159][160][161][162] Some authorities suggest conventional angiography for the detection of ICMAs, especially those <3 mm in diameter. 132,135,163 Some studies have shown that CTA could be as effective as DSA in identifying intracranial aneurysms, but others have reported that CTA had lower sensitivity, especially in detecting small aneurysms (<3 mm).…”

Section: Imaging Modalitiesmentioning

confidence: 99%

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Wilson¹,

Bower²,

Creager³

et al. 2016

Circulation

373

307

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The use of synthetic material for reconstructive vascular surgery was first reported during the early 1950s. Infection involving vascular graft prostheses is an infrequent but devastating complication of reconstructive vascular graft surgery and is associated with a high morbidity and, in some situations, mortality. Improvements in surgical techniques and graft design, including the use of native venous or arterial tissue, have reduced the frequency of infection and severity of complications from vascular graft infection (VGI). However, these advances have also led to more frequent vascular graft procedures occurring in a patient population with multiple underlying comorbidities that would have previously disqualified them as candidates for vascular reconstructive surgery. Underlying comorbidities, such as diabetes mellitus or immune compromise, increase the risk of infection and serious infection-related complications. The major complications of VGI include sepsis, amputation, disruption of infected anastomotic suture line with rupture or pseudoaneurysm formation, embolization of infected thrombi, reinfection of reconstructed vascular grafts, enteric fistulae to the small or large bowel, bacteremic spread of infection to other sites, and death. VGIs can be categorized broadly into those that occur in an extracavitary location, primarily in the groin or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. frequencyThe frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin. [1][2][3][4][5][6][7][8][9] For intracavitary grafts, the infection rate is ≈1% to 5%. 1-6 Graft infection is most common after emergency procedures and after reoperation. [1][2][3][4]10 Aortic graft erosion or fistulous communication into the duodenum or other areas of the bowel reportedly occurs in 1% to 2% of patients after aortic reconstruction. 11,12 MicrobiologyThe microbiological cause of VGI has evolved over the years. 1 In early published studies, Staphylococcus aureus was the predominant microorganism recovered. 1,13 Improvements in surgical technique, administration of prophylactic antistaphylococcal antimicrobial therapy, and other factors have resulted in a changing microbiological epidemiology. Vascular graft surgery performed on patients with multiple underlying comorbidities and the increased frequency of emergency procedures have contributed to the changing spectrum of infection. Other factors such as changes in hospital flora, surgery in patients with complicated vascular anatomy, and multiple revisions of previous vascular surgery have resulted in a more diverse microbio- clInIcal stateMents anD GuIDelInes logical spectrum of infection, which includes multidrugresistant strains, polymicrobial infection, and Candida species. Gram-positive cocci accounts for at least two thirds of VGIs. 1,13 Infections caused by coagulase-negative staphylococ...

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“…7 Specifically, the use of cardiopulmonary bypass and perioperative anticoagulation may worsen neurologic outcomes by causing greater cerebral hemorrhage, hypotension and ischemia, as well as cerebral edema near existing areas of brain injury. 18 However, other studies have not shown poorer neurologic function from cardiac surgery after a stroke. 19 Unfortunately, there is a lack of prospective controlled studies to accurately predict neurologic outcomes and guide treatment decisions in this specific setting.…”

Section: Patients With Neurologic Complicationsmentioning

confidence: 97%

“…18 Although the results of these studies were variable, the severity of neurologic complications and the urgency of surgery appeared to be critical determinants of the outcome.…”

Section: Patients With Neurologic Complicationsmentioning

confidence: 99%

“…Surgery should be delayed by four weeks if intracerebral hemorrhage has occurred, unless there are urgent indications for surgery as previously discussed. 18,21,22 The treatment approach for patients with intracranial mycotic aneurysms must be individualized, given the potential for resolution with conservative treatment alone and the lack of randomized studies. However, cardiac surgery should be postponed after acute aneurysmal rupture, and some recommend delaying valvular surgery by two to three weeks after repair of a ruptured aneurysm.…”

Section: Patients With Neurologic Complicationsmentioning

confidence: 99%

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Fever and multiorgan infarcts in a 35-year-old man

Wong

Chugh

Lee

2012

CMAJ

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A previously healthy 35-year-old man was brought to the emergency department by his family because they were concerned that he was confused. He had experienced five days of flu-like symptoms with fever, progressive swelling of his feet and hands, shortness of breath when lying down, and blurred vision. He had no history of valvular or other cardiac disease. There was no known intravenous drug use or dental or invasive procedures.At presentation, he was febrile (38.7°C) and somnolent, but he was hemodynamically stable. He had generalized pitting edema in all extremities. His cardiac examination was normal with no murmurs, and his lungs were clear with no adventitious sounds. There was mild nonspecific abdominal tenderness on palpation. No obvious skin rashes or lesions were observed. Given the presence of fever, bacteremia with Gram-positive cocci and cerebral hemorrhage, there was a high degree of suspicion for bacterial infective endocarditis (c) despite the absence of obvious risk factors. The lack of other systemic manifestations, as well as the presence of bacteremia, pointed away from vasculitis. Although we could not immediately exclude a cerebral abscess based on the preliminary findings, the presence of peripheral edema and orthopnea in the patient's history supported a heart failure syndrome, which is a common complication of infective endocarditis.1 Illicit drug use should be considered in patients who present with rightsided valvular involvement, signs and symptoms of right heart failure, or septic pulmonary emboli or abscesses. In this case, clinical suspicion of intravenous drug use was low.A magnetic resonance angiogram of the patient's head was obtained to further delineate the intracerebral hemorrhage and to rule out abscess and vascular abnormalities. It confirmed the presence of a hematoma (3.4 × 5.0 cm) in the right parieto-occipital lobe and revealed a mycotic aneurysm as the likely cause of the cerebral hemorrhage. Multifocal hemorrhagic infarcts consistent with cerebral embolism were also seen.The patient was transferred to a tertiary care centre for his intracranial hemorrhage to be assessed by a neurosurgeon. A neurosurgical intervention was not thought to be immediately necessary because the hematoma was stable on repeat CT scans, he remained neurologically unchanged, and his perioperative risk was increased by the concomitant severe thrombocytopenia and renal insufficiency.Empirical intravenous vancomycin therapy was started for treatment of suspected infective endocarditis. However, the antimicrobial therapy was changed to cloxacillin for methicillin-sensitive Staphylococcus aureus, which was grown in the first two blood cultures. Subsequent blood cultures obtained after antibiotic therapy was started were negative.The thrombocytopenia and renal failure were believed to be related to septicemia. There was no evidence to suggest glomerulonephritis. He received a platelet transfusion and intravenous immunoglobulin (IVIg) for two days to stabilize his platelet count, while his renal funct...

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What is the optimal timing for surgery in infective endocarditis with cerebrovascular complications?

Cited by 47 publications

References 17 publications

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

Fever and multiorgan infarcts in a 35-year-old man

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