Surgical Results for Infective Endocarditis Complicated With Cardiogenic Shock

Abstract

Background: Infective endocarditis remains associated with substantial mortality and morbidity rates, and the presence of acute heart failure (AHF) compromises clinical results after valve surgery; however, little is known in cardiogenic shock (CGS) patients. This study evaluated the clinical results and risk of mortality in CGS patients after valve surgery. Methods and Results: This study enrolled 585 patients who underwent valve surgery for active endocarditis at 14 institutions between 2009 and 2017. Of these patients, 69 (12%) were in CGS, which was defined as systolic blood pressure <80 mmHg and severe pulmonary congestion, requiring mechanical ventilation and/or mechanical circulatory support, preoperatively. The predictors of CGS were analyzed, and clinical results of patients with non-CGS AHF (n=215) were evaluated and compared. Staphylococcus aureus infection (odds ratio [OR] 2.19; P=0.044), double valve involvement (OR 3.37; P=0.003), and larger vegetation (OR 1.05; P=0.036) were risk factors for CGS. Hospital mortality occurred in 27 (13%) non-CGS AHF patients and in 15 (22%) CGS patients (P=0.079). Overall survival at 1 and 5 years in CGS patients was 76% and 69%, respectively, and there were no significant differences in overall survival compared with non-CGS AHF patients (P=1.000). Conclusions: Clinical results after valve surgery in CGS patients remain challenging; however, mid-term results were equivalent to those of non-CGS AHF patients.

Case Report: Can preoperative implantation of veno-arterial extracorporeal membrane oxygenation lead to embolic events in infective endocarditis?

“…In the case reports in which patients received ECMO support before surgery, individual cases were also successful ( 12 , 14 , 16 , 17 ). The only multicenter retrospective case study was published by Handa K et al ( 8 ), in which two patients needed ECMO support before surgery due to cardiogenic shock and 10 patients needed ECMO support due to postoperative cardiogenic shock. The final prognosis of these patients was not described in the article.…”

“…This can increase the probability of embolic complications. Common ECMO complications in a patient's body include bleeding from surgical wounds and intubation sites, embolism, hemolysis, renal dysfunction, infection, and abnormal nervous system function ( 8 , 20 ). Among them, the probable cause of embolism in ECMO patients is that ECMO flow is too high, leading to insufficient blood flow to the left ventricle.…”

“…In a review of the Osaka Cardiovascular Research (OSCAR) group database, Kazuma Handa et al discovered that from 2009 to 2017, only two patients required VA-ECMO mechanical-assisted support (due to cardiogenic shock) before surgery, and 10 patients received ECMO support following surgery ( 8 ). The current guidelines recommend early surgical intervention for AHF patients, especially those with cardiogenic shock ( 21 , 22 ).…”

“…However, since the site of attachment of the neoplasm was on the mitral valve and there were larger valvular neoplasms with a high risk of shedding, we were not able to determine whether we promoted shedding of the neoplasm after applying ECMO. In a review of the Osaka Cardiovascular Research (OSCAR) group database, Kazuma Handa et al discovered that from 2009 to 2017, only two patients required VA-ECMO mechanicalassisted support (due to cardiogenic shock) before surgery, and 10 patients received ECMO support following surgery (8). The current guidelines recommend early surgical intervention for AHF patients, especially those with cardiogenic shock (21, 22).…”