Preface

Chapter 7 **Surgical Treatment for Tricuspid Valve Infective**

Chapter 10 **Septic Embolism in Endocarditis: Anatomic and Pathophysiologic Considerations 149**

Chapter 11 **Left Ventricular Assist Device Infections 171**

Ahmed Fayaz, Medhat Reda Nashy, Sarah Eapen and Michael S.

Julie M. Aultman, Emanuela Peshel, Cyril Harfouche and Michael S.

Vikas Yellapu, Daniel Ackerman, Santo Longo and Stanislaw P.

Chapter 9 **The Ethics in Repeat Heart Valve Replacement Surgery 133**

**Endocarditis 103** Takashi Murashita

Firstenberg

**VI** Contents

Firstenberg

Stawicki

Marion J. Skalweit

**Section 4 Advanced Problems 131**

Chapter 8 **Prosthetic Valve Endocarditis 115**

Endocarditis is an infection of the heart and is often characterized by the involvement of the cardiac valves, other intracardiac structures, or implantable devices that support cardiac function. Infections are defined by the involvement of either native cardiac structures or prosthetic or artificial materials or implants. Systemic complications, acute heart failure, and sepsis are common presenting signs and symptoms. The advances in imaging technologies such as echocardiography, computed tomography, and magnetic resonance imaging have facilitated the diagnosis and management of patients with suspected and proven infections. Nevertheless, the management of infected patients remains a formidable challenge. While patients often require a prolonged course of antibiotic (or antifungal) therapy, many cases require surgical intervention to appropriately "cure" them of their infections. The difficulty is in determining the timing of surgical intervention, often in the setting of recent or ongoing bacteremia, embolic complications such as recent stroke, acute heart failure, or evidence on worsening infection despite appropriate medical antibiotic therapy. Historical paradigms of care suggested a prolonged period of antibiotics with the goal of sterilization of the infected structures prior to surgery; however, this often resulted in substantial morbidity and/or mortality in those awaiting surgery. The obvious selection bias that occurs from withhold‐ ing surgical therapy, while reasonable in patients for whom surgery is deemed to be too high risk or who show signs of improvement, has been shown to potentially deprive some patients of the chance of a definitive cure. Hence, currently, treatment plans will often con‐ sider early surgical intervention‑even in those patients historically viewed as having highrisk characteristics. In fact, it is often those high-risk factors (as mentioned above) that serve as strong indicators that surgery should be considered. The growing difficulty in the current era of endocarditis management is the ethical dilemma in dealing with patients with infec‐ tions, and sometimes reinfections, that are the result of "undesirable" (as viewed by some) social habits or lifestyle choices, such as intravenous substance abuse (IVDA). Such patients can be extremely difficult to manage in the acute (or perioperative) phase and their endocar‐ ditis can be very difficult to eradicate long-term. Without a doubt, patients with IVDA are at an extremely high risk for recurrence of their infections. Regardless of whether such abuse is viewed as a medical problem, a social problem, or a lifestyle decision, much debate is fo‐ cused on how much time, energy, and resources should be devoted to treat a patient who many view as having an incurable problem‑namely, their substance abuse and tendencies toward noncompliance.

In addition, there is a growing recognition of unusual causes of cardiac infections. Historically, a small subset of patients, despite imaging and clinical evidence of an infection, does not have positive cultures that can be used to guide antimicrobial therapy. With advances in genetic testing, molecular and biological markers, and other sophisticated techniques for growing and detecting unusual organisms, clinicians have better tools to use in adequately identifying caus‐ ative agents and, therefore, allowing for more appropriate and targeted therapies.

As experience grows in the diagnosis and management of cardiac infections, there has also been a greater recognition of the presenting acute and chronic comorbidities that can be used to predict short- and long-term outcomes. While certain populations, such as those with im‐ plantable cardiac devices such as pacemakers, defibrillators, and left ventricular assist devi‐ ces or those with advanced end-organ dysfunction, such as end-stage renal disease, have long since been recognized as being at high risk for poor outcomes, there is a growing recog‐ nition (as referenced above) that those patients with right-sided disease involving the tricus‐ pid valve might warrant a change in how their disease has been traditionally managed. Historically, tricuspid disease has rarely been viewed as a surgical problem and most pa‐ tients who underwent prolonged medical treatments — and often as a function of the base‐ line comorbidities (i.e., IVDA) or untreated, or undertreated, right-sided heart failure or pulmonary septic complication‑did very poorly. As such, with greater recognition of the catastrophic complications associated with right-sided disease, there has been growing inter‐ est in better defining the guidelines for both medical and surgical management. In addition, as more patients, with more comorbidities, who are older, sicker, frailer, are offered surgical or catheter-based therapies for their structural heart disease, combined with better diagnostic tools, the incidence and sheer number of endocarditis cases are increasing rapidly.

The challenges in the diagnosis and medical and surgical management of patients with en‐ docarditis clearly illustrate the value of developing and engaging a multidisciplinary team. Such a team of dedicated providers, as with many areas of cardiovascular case, help navi‐ gate a patient through a very difficult, and often unpredictable, disease course. Effective and efficient team communication is critical and can often be the definitive factor in achieving clinical success. The topic of "endocarditis" in itself can be overwhelming and, almost by definition, a singular book would quickly become both out of date and incomplete. It is hence the goal of this book, as a continuation of the previous volume on this topic, to high‐ light some of the current controversies and difficulties in this extremely complex topic.

As the Editor of this book, I want to extend my deepest appreciation to not only those who contributed to this volume, but also to the countless providers who care for, what are often, very sick, complex, and difficult patients. In addition, most importantly, I want to thank my family and close friends who supported me during the countless hours needed not only to manage these patients but also to share my interests in educating, mentoring, and support‐ ing those who contributed to this text.

#### **Michael S. Firstenberg, MD FACC**

**Section 1**

**Introduction**

Adjunct Graduate Faculty College of Graduate Studies Northeast Ohio Medical University

Adjunct Associate Professor of Surgery and Integrative Medicine Northeast Ohio Medical University

The Department Cardiothoracic and Cardiovascular Surgery The Medical Center of Aurora Aurora, Colorado, USA

**Section 1**
