Faculty Bibliography

Right-sided infective endocarditis (RSIE) is less common than left-sided infective endocarditis (IE), encompassing only 5-10% of cases of IE. Ninety percent of RSIE involves the tricuspid valve (TV). Given the relatively small numbers of TVIE cases operated on at most institutions, the purpose of this review is to highlight and discuss the current understanding of IE involving the TV. RSIE and TVIE are strongly associated with intravenous drug use (IVDU), although pacemaker leads, defibrillator leads and vascular access for dialysis are also major risk factors. Staphylococcus aureus is the predominant causative organism in TVIE. Most patients with TVIE are successfully treated with antibiotics, however, 5-16% of RSIE cases eventually require surgical intervention. Indications and timing for surgery are less clear than for left-sided IE; surgery is primarily considered for failed medical therapy, large vegetations and septic pulmonary embolism, and less often for TV regurgitation and heart failure. Most patients with an infected prosthetic TV will require surgery. Concomitant left-sided IE has its own surgical indications. Earlier surgical intervention may potentially prevent further destruction of leaflet tissue and increase the likelihood of TV repair. Fortunately, TV debridement and repair can be accomplished in most cases, even those with extensive valve destruction, using a variety of techniques. Valve repair is advocated over replacement, particularly in IVDUs patients who are young, non-compliant and have a higher risk of recurrent infection and reoperation with valve replacement. Excising the valve without replacing, it is not advocated; it has been reported previously, but these patients are likely to be symptomatic, particularly in cases with septic pulmonary embolism and increased pulmonary vascular resistance. Patients with concomitant left-sided involvement have worse prognosis than those with RSIE alone, due predominantly to greater likelihood of invasion and abscess formation in left-sided IE. Patients with isolated TVIE have an operative mortality between 0-15% and excellent survival.

Surgical embolectomy in acute pulmonary embolism is usually reserved for patients with massive pulmonary embolism presenting with cardiogenic shock, or for whom thrombolysis is absolutely contraindicated or has failed. Incomplete removal of thrombotic material lodged in the distal pulmonary arterial bed is considered an important cause of persistent pulmonary hypertension. Retrograde pulmonary embolectomy is an adjunct to conventional pulmonary embolectomy, resulting in more complete embolectomy, specifically of material lodged in the distal pulmonary arterial bed. We describe our simplified technique of retrograde pulmonary embolectomy as a safe adjunct to conventional pulmonary embolectomy.

Embolism to the central nervous system is a frequent and important complication of infective endocarditis. While early surgery improves outcomes in many groups of patients with infective endocarditis, ischemic stroke secondary to septic embolism carries the risk of hemorrhagic transformation and neurological deterioration with heparinization and cardiopulmonary bypass. We review the literature regarding the surgical management of infective endocarditis in patients with cerebral emboli.

Esophageal reconstruction by a substernal route with a colonic conduit after previous esophagectomy and end-cervical esophagostomy in the presence of a patent left internal thoracic artery graft to the left anterior descending coronary artery is a technically challenging procedure. In this case report, we describe a safe approach to this difficult problem. With proper planning and careful dissection, substernal esophageal reconstruction after previous sternotomy in patients with a patent left internal thoracic artery graft is feasible and can be safely performed.

Primary cardiac sarcomas are rare but aggressive tumors and can present a technical challenge with regard to surgical approach and resection. Complete surgical resection, when feasible, remains crucial for palliation of symptoms and for its role as the mainstay of cardiac sarcoma therapy. Surgical resection of recurrent cardiac sarcomas, though formidable, is technically feasible and may provide reasonable survival, especially when the recurrence is local and the metastatic load is limited. In this case report, we describe a successful third cardiac sarcoma resection procedure in a young patient with previous cardiac autotransplantation and excision of left atrial sarcoma.

Aminoglycosides are a mainstay of treatment for enterococcal infective endocarditis. However, the benefit of adding aminoglycosides to cell wall-active agents after surgery is unclear. The aim of this study was to determine if adjunctive aminoglycoside treatment after surgery for enterococcal endocarditis leads to better outcomes. We included patients who underwent surgery for enterococcal endocarditis at our institution between July 2007 and July 2014. Treatment was defined as at least 1 dose of an aminoglycoside after surgery. Propensity to receive aminoglycosides was calculated in a model that included age, native vs prosthetic valve endocarditis, chronic kidney disease, high-level aminoglycoside resistance, metastatic infection, invasive disease, positive valve culture, and creatinine on the day of surgery. A multivariable Cox proportional hazards model was used to compare the primary outcome of death, adjusted for propensity to receive aminoglycosides, among patients who did and did not receive aminoglycosides. A total of 108 patients were identified of whom 37 (34%) received at least 1 dose of an aminoglycoside after surgery, with a median duration of 5 days (interquartile range: 2.5-10). In the multivariable model, patients treated with adjunctive aminoglycoside therapy had better survival than those treated with a cell wall-active agent alone, although the difference did not reach statistical significance (hazard ratio = 0.65, 95% CI: 0.32-1.33). The survival difference was consistently present in subgroups stratified by all-purpose refined diagnosis-related group mortality risk, and with varying definitions of aminoglycoside therapy. In conclusion, antibiotic monotherapy with a cell wall-active agent after surgery for enterococcal endocarditis may be inferior to combination therapy including an aminoglycoside.

BACKGROUND:Rifampin is recommended as adjunctive treatment for staphylococcal prosthetic valve endocarditis (PVE). It is unclear whether this should hold for surgically treated patients. The purpose of this study was to examine whether adjunctive rifampin treatment in addition to cell wall active antimicrobial agents in patients with surgically treated staphylococcal infective endocarditis (IE) results in better outcomes. METHODS:Patients operated on for staphylococcal IE from April 1, 2008, to July 1, 2014, were identified from our institution's IE registry. Rifampin treatment was defined as 3 or more days of rifampin postoperatively. Cox proportional hazards regression was used to compare a composite outcome of death or reoperation for IE relapse, between patients treated and not treated with rifampin, adjusted for propensity to be treated with rifampin, methicillin resistance, all-purpose refined diagnosis related group (APR-DRG) severity score, and APR-DRG mortality risk. RESULTS:In all, 273 patients were identified. The mean age was 56 years, 66% were male, 50% had PVE, 60% had S. aureus or S. lugdunensis infection, 89% had left side involvement, and 57% had invasive disease. Fifty-one (27%) received 3 or more days of rifampin postoperatively. Ninety-two patients died or underwent reoperation for IE relapse at a median of 205 days (interquartile range 56 to 718 days). In a multivariable model, patients treated with rifampin had a similar hazard of death or reoperation for IE relapse as those not treated (hazard ratio 0.76, 95% confidence interval 0.44 to 1.32, p value 0.34). The results were robust to varying definitions of rifampin treatment. CONCLUSIONS:Among patients with surgically treated staphylococcal IE there was insufficient evidence to claim a reoperation-free survival benefit from treatment with rifampin. Rifampin should not be used as adjunctive therapy for staphylococcal IE in patients who have undergone surgical procedures for its treatment.

Acute aortic dissection is a surgical emergency that must be urgently managed, with the primary goal of restoring flow to the dominant true lumen in the downstream aorta. Our preference at the Cleveland Clinic is for an open distal anastomosis technique without aortic clamping, as it permits more accurate approximation of dissected layers and more homeostatically secure anastomosis. During this procedure we employ right axillary end-to-side graft perfusion, followed by deep hypothermic circulatory arrest and antegrade brain perfusion. The distal anastomosis is performed without felt strips or glue. Critical to achieving a successful outcome is meticulous de-airing of the arch, diligent myocardial protection, and a water-tight anastomosis prior to discontinuing cardiopulmonary bypass.