Intracranial hemorrhage (ICH) represents a severe complication of infective endocarditis (IE) and stands as a significant contributor to the poor prognosis associated with IE. Current guidelines suggested a delay of 4 weeks for cardiac surgery in patients with ICH, but these recommendations were based on insufficient clinical evidence, and recent studies have yielded different opinions. In this paper, we thoroughly reviewed relevant guidelines and their references in conjunction with 3 typical cases with IE and ICH, discussed the recommendations with controversy, and proposed a process for the management of IE with ICH.
Infective endocarditis (IE) is a potentially fatal disease. Although pathological examination is the gold standard for the diagnosis of IE, only a small number of patients undergo this examination. The clinical diagnosis of IE still mainly relies on its clinical symptoms. However, the systemic manifestations of IE are diverse and often non-cardiac specific, which poses a great challenge to diagnosis. Based on the clinical presentations, imaging characteristics, and etiological data of IE, experts at home and abroad have developed a variety of diagnostic tools. Over the past thirty years, there have been significant changes in the microbiological and epidemiological characteristics of IE, and at the same time, the advancement of imaging and laboratory diagnostic technologies has also had an important impact on diagnostic methods, leading to the continuous evolution of diagnostic criteria and tools. This article reviews and interprets the main diagnostic criteria for IE, analyzes its development history, current changes, and efficacy, aiming to provide a perspective on the historical evolution of diagnostic tools and to offer prospects for future research directions.
Infective endocarditis is one of the severest valvar diseases, commonly affecting the mitral valve. Currently, valve repair and replacement are the main surgical options for mitral infective endocarditis. However, the complexity of the unique nature of infective pathological changes has caused a raging debate on the most appropriate surgery for mitral infective endocarditis. With the development of surgical treatment for endocarditis, mitral valve repair could be considered as a relatively effective solution, and it has the advantages of preserving left ventricular function effectively and avoiding the inherent risks of prosthetic heart valve, but it is required on further evidence-based support. Furthermore, the controversies of the surgical timing, repair technique, and artificial materials of mitral valve repair have never stopped. By summarizing the relevant existing research results, this review aims to help clinicians make optimal treatment decisions for mitral endocarditis.
ObjectiveTo compare the clinical outcomes of mitral valvuloplasty (MVP) and mitral valve replacement (MVR) for infective endocarditis, and to investigate the effect of MVP under different surgical risks. MethodsA retrospective study was done on the patients with mitral infective endocarditis, who underwent surgical treatment in our department from January 2018 to March 2022. Among them, the patients receiving mitral valve repair were divided into a MVP group, and the patients receiving mitral valve replacement were divided into a MVR group. Propensity score matching method was applied with a ratio of 1∶1 to eliminate the biases. The early and midterm outcomes were compared between the two groups after matching. According to the European System for Cardiac Operative Risk Evaluation Ⅱ(EuroSCORE-Ⅱ), the effect of MVP was compared between high and low risk patients. ResultsA total of 195 patients were collected. There were 141 patients in the MVP group (102 males, 85.1%) and 54 patients in the MVR group (41 males, 75.9%). Patients in the MVP group were younger (43.0±14.6 years vs. 57.0±13.0, P<0.001) and had better preoperative conditions. The mean follow-up time was 30.4±16.1 months. The patients in the MVP group had a shorter ICU stay (5.0±5.4 d vs. 7.0±7.0 d, P=0.037), and lower incidences of low cardiac output syndrome (0.7% vs. 9.3%, P=0.007), in-hospital mortality (0.0% vs. 3.7%, P=0.023), and follow-up mortality (4.3% vs. 15.4%, P=0.007). However, after 1∶1 propensity score matching, there were no statistical differences in the postoperative and follow-up adverse events between the two groups (P>0.05). Also, there was no statistical difference in the mortality of high-risk patients between MVP and MVR group (P>0.05). There was no statistical difference in the reoperation and recurrent severe mitral regurgitation between high and low-risk patients in the MVP group (P>0.05). Conclusion MVP is feasible for treating mitral lesions caused by infective endocarditis with good early and midterm outcomes. For patients who have severe preoperative conditions without serious valvular lesions, surgeons could try MVP.
ObjectiveTo analyze the short- and mid-term outcomes of patients undergoing reconstruction of intervalvular fibrous body (IVFB) via double valve replacement (Commando procedure) or aortic valve replacement and mitral valve repair (Hemi-Commando procedure). MethodsThe patients who underwent Commando or Hemi-Commando procedure between September 2014 and September 2022 in Guangdong Provincial People’s Hospital were collected. The perioperative and follow-up data were reviewed and analyzed for the assessment of short- and mid-term outcomes. Results Eleven patients received Commando procedure (a Commando group), including 4 males and 7 females with a median age of 61 (33, 68) years; 7 patients received Hemi-Commando procedure (a Hemi-Commando group), including 5 males and 2 females with a median age of 50 (36, 58) years. Two patients died in the postoperative 30 days (1 patient in the Commando group and 2 patients in the Hemi-commando group). Low cardiac output syndrome complicated with multiple organ dysfunction syndrome was the main cause of death. Fifteen patients were discharged and followed up for 13 (6, 42) months, with a survival rate of 100%. The rates of free from recurrent endocarditis or re-operation were both 100%. ConclusionCommando and Hemi-Commando procedures are effective strategies for IVFB reconstruction, and can achieve excellent mid-term outcomes if patients survive from the frailest period of early postoperative stage.
Objective To summarize the clinical characteristics of patients with infectious endocarditis (IE) associated infectious aneurysm (IIA) and share the experience in diagnosis and treatment. Methods A retrospective analysis was conducted on the clinical data of 554 patients who underwent cardiac surgery for IE at the Department of Cardiology, Guangdong Provincial People's Hospital from September 2018 to August 2023. Patients with secondary IIA were screened. According to the treatment plan of IIA, patients are divided into a simple anti infection group and an endovascular treatment group. Results Finally, 31 patients with IE secondary IIA were included, including 21 males and 10 females, with a median age of 33 (26, 53) years. Fifteen patients had no obvious neurological symptoms before diagnosis of IIA. The IIA treatment plan for 7 patients was simple anti infective therapy; 24 patients received anti infection and endovascular embolization treatment, of which 23 patients achieved technical success. Nine patients underwent simultaneous combined surgery with an interval of 2 (0, 6) days between IIA endovascular embolization and open heart surgery. Three patients in the simple anti infection group experienced IIA rupture and bleeding, and died on the day of automatic discharge. One patient in the endovascular treatment group experienced aneurysm rupture and died. All patients recovered well after surgery and did not show any new neurological symptoms. Conclusion IE patients should pay attention to head imaging examination to screen for IIA. In addition to regular anti infection measures, intracavitary therapy can be considered as a reasonable treatment plan for IIA in IE patients with indications for cardiac surgery.
ObjectiveTo evaluate the effectiveness of preoperative immunosuppressive therapy combined with surgical intervention. MethodsA retrospective study was conducted on Behçet's disease patients who underwent cardiac surgery at Guangdong Provincial People's Hospital from 2012 to 2021. Patients were divided into immunosuppressive group and non-immunosuppressive group based on whether they received immunosuppressive therapy before surgery. The complications and long-term survival rates of the two groups were analyzed. ResultsA total of 28 patients were included, among which 2 patients underwent reoperation, a total of 30 surgeries were performed, including 16 males (53.3%), and the confirmed age was 37 (31, 45) years old. There were 15 surgeries in the immunosuppressive group and 15 surgeries in the non-immunosuppressive group. Compared with the non-immunosuppressive group, the incidence of complications during hospitalization in the immunosuppressive group was lower (13.3% vs. 53.3%, P=0.008). One patient died in hospital, and the rest were discharged and followed up, with a median follow-up time of 38.7 (15.1, 57.3) months, and there was no statistically significant difference in long-term survival rate between the two groups (26.7% vs. 6.7%, P=0.158). There was no statistically significant difference in the cumulative incidence of complications one month (20% vs. 53%, P=0.058) and one year (27% vs. 60%, P=0.065) after surgery between the immunosuppressive group and the non-immunosuppressive group, but there was a statistically significant difference in the cumulative incidence of complications three years after surgery (47% vs. 92%, P=0.002). ConclusionSurgical treatment can save lives in Behçet's disease patients with cardiovascular diseases, but the incidence of postoperative complications is high. Timely use of immunosuppressants before cardiovascular surgery can reduce the incidence of postoperative complications.
Objective To investigate the preliminary experience, the evolution of surgical approach of multidisciplinary therapy for atrial fibrillation and the advantages and disadvantages of each procedure. Methods We retrospectively analyzed the clinical data of 69 patients with stand-alone surgical ablation with or without transcatheter radiofrequency ablation for atrial fibrillation in our center from January 2015 to May 2017. There were 50 males and 19 females at average age of 57.2 years. The patients were divided into three groups according to the surgical approach including a median sternotomy group (n=9), a left unilateral thoracoscopy group (n=7) and a bilateral thoracoscopy group (n=53). One (11.1%) patient, 3 (42.9%) patients and 26 (49.1%) patients received transcatheter mapping and radiofrequency ablation after surgical ablation in each group, respectively. Results The mean follow-up time in the median sternotomy group was 10.2 months. All 9 patients maintained sinus rhythm. The mean follow-up time of the left unilateral thoracoscopy group was 7.4 months. Five (71.4%) patients maintained sinus rhythm. While the mean follow-up time of the bilateral thoracoscopy group was 5.0 months. Forty-seven (88.7%) patients maintained sinus rhythm. There was no perioperative death, or death, stroke, major bleeding nor pulmonary vein stenosis during follow-up. Conclusion The classic Cox-Maze Ⅳ procedure with high success rate is still the basic operation for the surgical treatment of atrial fibrillation, while the thoracoscopic mini maze procedure has the advantages of minimally invasiveness, repeatibility, and can achieve similar results as Cox-Maze Ⅳ procedure when combined with transcatheter radiofrequency ablation. Multidisciplinary therapy could be the best solution for non-paroxysmal atrial fibrillation.