Preoperative heart failure in infective endocarditis
Heart failure (HF) is the most frequent and most severe complication of infective endocarditis (IE), which rates from 42% to 60% of cases of native IE. Objectives:to review diagnostic criteria and terms of surgical intervention in IE, complicated by HF. Preoperative HF in patients with IE indicates damage of the myocardium and vascular bed with subsequent inability of the cardiovascular system to meet the needs of the patient’s body. Myocardial dysfunction in IE is a complex entity due to the dynamic adaptation of the cardiovascular system to the disease process, the host response, and the effects of medical therapy. Not only myocardial depression leads to the development of HF in patients with IE, but valve structures impairment as well. HF is mainly caused by new or worsening severe aortic or mitral regurgitation, although intracardiac fistulae and, more rarely, valve obstruction may also lead to HF. Presentation of preoperative HF includes clinical and laboratory parameters (New York Heart Association class). Echocardiographic data is of crucial importance for initial evaluation and follow-up. HF in patients with IE causes administration of inotropic support before surgical intervention, greatly complicates intraoperative management and bypass weaning, requires high-doses inotropic support upon admission to the postoperative intensive care unit. This leads to depletion of compromised myocardium and adversely affects the results of surgery. Preoperative HF is an important factor in the international anesthetic and cardiac surgical risk scales (EUROSCORE, APACHE, APACHE II), which significantly impairs the results of treatment. A series of studies revealed reduction in hospital mortality after cardiac surgery in patients with IE, complicated by heart failure, that was reflected in international recommendations on indications and terms of surgical correction in IE. Preoperative HF is the most important predictor of hospital, 6-month and 1-year mortality.
Conclusions. Patients with IE share a special part in the spectrum of cardiac surgery community. Such patients need both timely diagnosis of IE, complicated with HF, and, most importantly, timely surgical intervention. HF is principal indication for urgent surgical intervention in patients with IE. The peculiarities of this pathology include not only the quickness of development and the extent of intracardiac impairment, but also the negative influence of the infective process on the myocardium. Combination of these factors leads to development of preoperative HF, which negatively affects the immediate and long-term results of surgical treatment of infective endocarditis.
2. Hochstadt A, Meroz Y, Landesberg G. Myocardial dysfunction in severe sepsis and septic shock: more questions than answers? J Cardiothorac Vasc Anesth. 2011; 25(3):526–535.
3. De Geer L, Engvall J, Oscarsson A. Strain echocardiography in septic shock – a comparison with systolic and diastolic function parameters, cardiac biomarkers and outcome. Crit Care. 2015; 19:122–122.
4. Klouche K, Pommet S, Amigues L, Bargnoux AS, Dupuy AM, Machado S. Plasma brain natridiuretic peptide and troponin levels in severe sepsis and septic shock: relationships with systolic myocardial dysfunction and intensive care unit mortality . J Intensive Care Med. 2014;29(4):229–237.
5. Landesberg G, Jaffe AS, Gilon D, Levin PD, Goodman S, Abu-Baih A. Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation. Crit Care Med. 2014;42(4):790–800.
6. Fichet J, Sztrymf B, Jacobs FM. Echographic evaluation of ICU patients with tissue Doppler imaging: more studies and more consensus are still needed . Crit Care. 2012;16(3):433–433.
7. Brown SM, Pittman JE, Hirshberg EL, Jones JP, Lanspa MJ, Kuttler KG,, et al. Diastolic dysfunction and mortality in early severe sepsis and septic shock: a prospective observational echocardiography study. Crit Ultrasound J. 2012;4(1):8–18.
8. Landesberg G, Gilon D, Meroz Y, Georgieva M, Levin PD, Goodman S. Diastolic dysfunction and mortality in severe sepsis and septic shock. Eur Heart J. 2012;33(7):895–903.
9. Rolando G, Valenzuela Espinoza ED, Avid E, Welsh S, Del Pozo J, Vasquez AR. Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock. Rev Bras Ter Intensiva. 2015;27(4):333–339.
10. Dantas VC de S, Costa ELV. A look at the diastolic function in severe sepsis and septic shock. Revista Brasileira de Terapia Intensiva. 2015;27(4):307–308. doi:10.5935/0103-507X.20150052.
11. Kahveci G, Bayrak F, Mutlu B, Bitigen A, Karaahmet T, Sonmez K, Izgi A, DegertekinM,BasaranY.Prognostic value of N-terminal pro-B-type natriuretic peptide in patients with active infective endocarditis. Am J Cardiol. 2007. – Vol. 99. – P.1429–1433.
12. Lopez J, Sevilla T, Vilacosta I, Garcia H, Sarria C, Pozo E, Silva J, Revilla A, Varvaro G, delPalacio M, Gomez I, San Roman J A. Clinical significance of congestive heart failure in prosthetic valve endocarditis. A multicenter study with 257 patients. Rev Esp Cardiol (Engl Ed). – 2013. – Vol. 66. – P. 384–390.
13. Hubert S, Thuny F, Resseguier N, Giorgi R, Tribouilloy C, Le Dolley Y, Casalta JP, Riberi A, Chevalier F, Rusinaru D, Malaquin D, Remadi JP, Ammar AB, Avierinos JF, Collart F, Raoult D, Habib G. Prediction of symptomatic embolism in infective endocarditis: construction and validation of a risk calculator in a multicenter cohort. J Am Coll Cardiol. – 2013. – Vol. 62. – P. 1384–1392.
14. Olmos C, Vilacosta I, Fernandez C, Lopez J, Sarria C, Ferrera C, Revilla A, Silva J, Vivas D, Gonzalez I, SanRoman J A. Сontemporary epidemiology and prognosis of septic shock in infective endocarditis. Eur Heart J. – 2013. – Vol. 34. – P. 1999–2006.
15. Mirabel M, Sonneville R, Hajage D, Novy E, Tubach F, Vignon P, Perez P, LavoueS, Kouatchet A, Pajot O, Mekontso-Dessap A, Tonnelier JM, Bollaert PE, Frat JP, Navellou JC, Hyvernat H, Hssain AA, Timsit JF, Megarbane B, Wolff M, Trouillet JL. Long-term outcomes and cardiac surgery in critically ill patients with infective endocarditis. Eur Heart J. – 2014. – Vol. 35. – P. 1195– 1204.
16. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC).
17. Belletti, Alessandro et al. Incidence and Predictors of Postoperative Need for High-Dose Inotropic Support in Patients Undergoing Cardiac Surgery for Infective Endocarditis. Journal of Cardiothoracic and Vascular Anesthesia. – 2017. – pii: S1053-0770(17)31000-5.