Portal de Periódicos da CAPES

Surgical Treatment of Infective Endocarditis in Elderly Patients: The Importance of Shared Decision Making

2021; Wiley; Volume: 10; Issue: 19 Linguagem: Inglês

10.1161/jaha.121.022186

2047-9980

Ravi K. Ghanta, Gösta Pettersson,

Streptococcal Infections and Treatments

HomeJournal of the American Heart AssociationVol. 10, No. 19Surgical Treatment of Infective Endocarditis in Elderly Patients: The Importance of Shared Decision Making Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toOpen AccessEditorialPDF/EPUBSurgical Treatment of Infective Endocarditis in Elderly Patients: The Importance of Shared Decision Making Ravi K. Ghanta, MD and Gosta B. Pettersson, MD, PhD Ravi K. GhantaRavi K. Ghanta * Correspondence to: Ravi K. Ghanta, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MC‐390, Houston, TX 77030. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0003-3299-2668 Michael E. DeBakey Department of Surgery, , Baylor College of Medicine, , Houston, , TX and Gosta B. PetterssonGosta B. Pettersson Department of Thoracic and Cardiovascular Surgery, , Heart, Vascular, and Thoracic Institute, , Cleveland Clinic, , Cleveland, , OH Originally published24 Sep 2021https://doi.org/10.1161/JAHA.121.022186Journal of the American Heart Association. 2021;10:e022186This article is a commentary on the followingSurgery Is Underused in Elderly Patients With Left‐Sided Infective Endocarditis: A Nationwide Registry StudyInfective endocarditis (IE) is increasing in prevalence and severity in most countries in the industrialized world, fueled by increasing comorbidities, intravenous drug abuse, medical interventions, and indwelling devices.1 Despite advances made over the past 2 decades in the management of valvular heart disease, outcomes for IE remain essentially unchanged, with 20% in‐hospital and 40% 1‐year mortality.2 Surgical valve repair or replacement is the recommended therapy for patients with IE who have severe valve dysfunction, heart failure, unresolving sepsis, and high embolic risk.3, 4, 5 However, as the operative risk for valve surgery with IE is at least 2‐fold greater than for degenerative valve disease, clinical decision making in some patients, particularly in older patients, can be vexing. Moreover, multivalve or invasive aortic root IE can be especially complex and requires experienced surgeons with a good support system. Elderly individuals are increasingly afflicted with IE and now represent nearly one third of patients with IE, but few studies have evaluated the "real‐world" use of surgery among the octogenarian and nonagenarian population.6, 7, 8In this issue of the Journal of the American Heart Association (JAHA), Ragnarsson and colleagues present an analysis of 2186 patients with aortic and mitral valve IE in the Swedish Registry on Infective Endocarditis, which evaluates surgical use and outcomes stratified by age.9 They found that only 6% of patients aged >80 years received surgery compared with 46% of patients aged 60 years as a statistically significant risk factor for major morbidity or mortality, yet it is a relatively low overall contributor toward risk compared with clinical status and other comorbidities.12 Aging is a heterogeneous process, with some older patients being more fit than some younger patients. Functional status and frailty assessment have become the norm when considering intervention for older patients with structural valve disease.13 Similarly, comprehensive geriatric assessment and use of multidisciplinary endocarditis teams are essential in IE.14One limitation of the analysis by Ragnarsson and colleagues is the inability to identify patients in their data set with clear surgical indications nor identify the reason for nonsurgical management. In an analysis of 2160 patients with IE in the European Infective Endocarditis Registry (EURO‐ENDO) registry, Habib and colleagues found that 69% of patients met surgical indications, but surgery was only performed in 51% of patients, with high operative risk being the most common reason for refusal.15 We certainly agree that surgery should only be performed in reasonable operative candidates. However, "risk aversion" is an observed phenomenon that may contribute to denial of surgery, resulting in a risk‐treatment paradox, where patients at higher risk for adverse events receive less intensive treatment despite possibly obtaining greater benefit.16, 17 Risk aversion may be mitigated by referral to experienced valve surgeons at centers with access to the multidisciplinary team, including infectious disease, neurology, nephrology, geriatrics, and critical care, needed to handle IE‐related complications.3Notably, in the EURO‐ENDO registry, patients refused surgery despite indications in 19% of cases. Surgical hesitancy among elderly patients is also present in patients with structural valve disease.18, 19 Shared decision making requires effective communication with patients and families about the risks and benefits of surgery. In the analysis by Ragnarsson and colleagues, patients who underwent surgery had a high 20% operative mortality, which was similar to the hospital mortality for the nonoperative patients. Still, in their propensity‐matched comparison, 1‐ and 5‐year survival was better in patients who underwent surgery compared with medically managed patients in all age groups. This may be attributable to ongoing valve dysfunction and heart failure in the nonoperated on patients: if you were not offered surgery for your valve dysfunction when you were infected, you are probably less likely to be referred for surgery later. Quality of life is an important decision‐making factor in the elderly population, and freedom from heart failure is an important factor for survivors of endocarditis. Although there is an inherent selection bias in this data set, one can reasonably conclude that although operative risk may be high, midterm survival is improved in patients who receive surgery versus those who do not.Surgery to remove infected prosthetic valves, to remove high‐risk sources of embolism, and to restore functioning valve and cardiac integrity remains the cornerstone therapy for patients with advanced IE for survival and recovery. Elderly patients are increasingly afflicted with IE and should not be denied surgery on the basis of age alone. Shared decision making and experienced multidisciplinary teams are required for best evidence‐based practice in these complex patients.DisclosuresNone.Footnotes* Correspondence to: Ravi K. Ghanta, MD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MC‐390, Houston, TX 77030. E‐mail: ravi.[email protected]eduThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 2.See Article by Ragnarsson et al.References1 Cahill TJ, Baddour LM, Habib G, Hoen B, Salaun E, Pettersson GB, Schafers HJ, Prendergast BD. Challenges in infective endocarditis. J Am Coll Cardiol. 2017; 69:325–344. DOI: 10.1016/j.jacc.2016.10.066.CrossrefMedlineGoogle Scholar2 Pettersson GB, Hussain ST. Current AATS guidelines on surgical treatment of infective endocarditis. Ann Cardiothorac Surg. 2019; 8:630–644. DOI: 10.21037/acs.2019.10.05.CrossrefMedlineGoogle Scholar3 Pettersson GB, Coselli JS, Pettersson GB, Coselli JS, Hussain ST, Griffin B, Blackstone EH, Gordon SM, LeMaire SA, Woc‐Colburn LE. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: executive summary. J Thorac Cardiovasc Surg. 2017; 153:1241–1258.e29. DOI: 10.1016/j.jtcvs.2016.09.093.CrossrefMedlineGoogle Scholar4 Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Lung B, et al. 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). Endorsed by: European Association for Cardio‐Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015; 36:3075–3128. DOI: 10.1093/eurheartj/ehv319.CrossrefMedlineGoogle Scholar5 Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021; 143:e35–e71.LinkGoogle Scholar6 Slipczuk L, Codolosa JN, Davila CD, Romero‐Corral A, Yun J, Pressman GS, Figueredo VM. Infective endocarditis epidemiology over five decades: a systematic review. PLoS One. 2013; 8:e82665. DOI: 10.1371/journal.pone.0082665.CrossrefMedlineGoogle Scholar7 Forestier E, Fraisse T, Roubaud‐Baudron C, Selton‐Suty C, Pagani L. Managing infective endocarditis in the elderly: new issues for an old disease. Clin Interv Aging. 2016; 11:1199–1206. DOI: 10.2147/CIA.S101902.CrossrefMedlineGoogle Scholar8 Kiriyama H, Kaneko H, Itoh H, Kamon T, Morita K, Jo T, Fujiu K, Daimon M, Takeda N, Morita H, et al. Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan. Open Heart. 2021; 8:e001627. DOI: 10.1136/openhrt‐2021‐001627.CrossrefMedlineGoogle Scholar9 Ragnarsson S, Salto‐Alejandra S, Ström A, Olaison L, Rasmussen M. Surgery is underused in elderly patients with left‐sided infective endocardits: a nationwide registry study. J Am Heart Assoc. 2021; 10:e020221. DOI: 10.1161/JAHA.120.020221.LinkGoogle Scholar10 Ghanta RK, Shekar PS, McGurk S, Rosborough DM, Aranki SF. Nonelective cardiac surgery in the elderly: is it justified?J Thorac Cardiovasc Surg. 2010; 140:103–109, 109.e1.CrossrefMedlineGoogle Scholar11 Ghanta RK, Shekar PS, McGurk S, Rosborough DM, Aranki SF. Long‐term survival and quality of life justify cardiac surgery in the very elderly patient. Ann Thorac Surg. 2011; 92:851–857. DOI: 10.1016/j.athoracsur.2011.04.083.CrossrefMedlineGoogle Scholar12 Gaca JG, Sheng S, Daneshmand MA, O'Brien S, Rankin JS, Brennan JM, Hughes GC, Glower DD, Gammie JS, Smith PK. Outcomes for endocarditis surgery in North America: a simplified risk scoring system. J Thorac Cardiovasc Surg. 2011; 141:98–106.e1–2. DOI: 10.1016/j.jtcvs.2010.09.016.CrossrefMedlineGoogle Scholar13 Afilalo J, Mottillo S, Eisenberg MJ, Alexander KP, Noiseux N, Perrault LP, Morin J‐F, Langlois Y, Ohayon SM, Monette J, et al. Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes. 2012; 5:222–228. DOI: 10.1161/CIRCOUTCOMES.111.963157.LinkGoogle Scholar14 Forestier E, Roubaud‐Baudron C, Fraisse T, Patry C, Gavazzi G, Hoen B, Carauz‐Paz P, Moheb‐Khosravi B, Delahaye F, Sost G, et al. Comprehensive geriatric assessment in older patients suffering from infective endocarditis: a prospective multicentric cohort study. Clin Microbiol Infect. 2019; 25:1246–1252. DOI: 10.1016/j.cmi.2019.04.021.CrossrefMedlineGoogle Scholar15 Habib G, Lancellotti P, Erba P‐A, Sadeghpour A, Meshaal M, Sambola A, Furnaz S, Citro R, Ternacle J, Donal E, et al. The ESC‐EORP EURO‐ENDO (European Infective Endocarditis) registry. Eur Heart J Qual Care Clin Outcomes. 2019; 5:202–207. DOI: 10.1093/ehjqcco/qcz018.CrossrefMedlineGoogle Scholar16 Shahian DM, Jacobs JP, Badhwar V, D'Agostino RS, Bavaria JE, Prager RL. Risk aversion and public reporting, part 1: observations from cardiac surgery and interventional cardiology. Ann Thorac Surg. 2017; 104:2093–2101. DOI: 10.1016/j.athoracsur.2017.06.077.CrossrefMedlineGoogle Scholar17 Hawkins RB, Mehaffey JH, Chancellor WZ, Fonner CE, Speir AM, Quader MA, Rich JB, Kron IL, Ailawadi G; Investigators for the Virginia Cardiac Services Quality Initiative . Risk aversion in cardiac surgery: 15‐year trends in a statewide analysis. Ann Thorac Surg. 2020; 109:1401–1407. DOI: 10.1016/j.athoracsur.2019.08.027.CrossrefMedlineGoogle Scholar18 Bach DS, Siao D, Girard SE, Duvernoy C, McCallister BD, Gualano SK. Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk. Circ Cardiovasc Qual Outcomes. 2009; 2:533–539. DOI: 10.1161/CIRCOUTCOMES.109.848259.LinkGoogle Scholar19 Tang L, Gössl M, Ahmed A, Garberich R, Bradley SM, Niikura H, Witt D, Pedersen WR, Bae R, Lesser JR, et al. Contemporary reasons and clinical outcomes for patients with severe, symptomatic aortic stenosis not undergoing aortic valve replacement. Circ Cardiovasc Interv. 2018; 11:e007220. DOI: 10.1161/CIRCINTERVENTIONS.118.007220.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesSurgery Is Underused in Elderly Patients With Left‐Sided Infective Endocarditis: A Nationwide Registry StudySigurdur Ragnarsson, et al. Journal of the American Heart Association. 2021;10 October 5, 2021Vol 10, Issue 19Article InformationMetrics Download: 752 Copyright © 2021 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.121.022186PMID: 34558288 Originally publishedSeptember 24, 2021 Keywordsheart valve surgeryEditorialsagingsurvivalinfective endocarditisPDF download SubjectsRisk FactorsInfectious EndocarditisMortality/SurvivalCardiovascular SurgeryAging