Endocarditis: An Ever Increasing Problem in Cardiac Surgery

Background: Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing despite all prophylactic efforts. In recent years particularly device- related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis.

Methods: From 2003 to 2016, a total of 673 patients with endocarditis have been transferred to our cardiosurgical institution (mean age: 65 ± 13 years; mean log ES: 26.4%; 74.9% males predominately). 90.2% of them were surgically treated; 32.1% re-do cases thereof; 9.7% had been operated upon previously for acute endocarditis.

Results: While the total number of cardiosurgical procedures remained relatively stable throughout the years 20 patients were admitted in 2003 and 66 in 2016 yielding a more than 3-fold increase (p < 0.001). Early mortality of all patients was 22.9%. Septic emboli occurred in 22.4%, 9.6% cerebral emboli thereof. New perioperative stroke 2.1%; 29.8% renal failure necessitating dialysis; multi-organ failure 6.3%; wound healing problems 6.7%, AV-block 9.7%, Delirium 7.4%; Pericardial effusion 6.9%. Increase of mitral and tricuspid valve involvement correlated significantly with general increase (p = 0.02; p < 0.001 respectively). An increase of device-related endocarditis was also noted (Pearson Correlation Coefficient (r = 0.9; p < 0.001) while the increase of valve-prosthesis endocarditis correlated with r = 0.78; p = 0.001). Staphylococcus aureus (28.1%, 5.7% MRSA) was mainly and constantly cultured while the percentage of fungal infection steadily decreased.

Conclusion: Despite of all efforts endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. One may speculate that the liberalization of endocarditis prophylaxis in 2007 by the Robert-Koch-Institute may have at least partially contributed to an increase of the individual risk of the patients to suffer from acute endocarditis. In view of the increasing mean age of the patients and the co-morbidities accompanied by an increase of valve and device implantations a renaissance of a more strict endocarditis prophylaxis may be considered.