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Indicações para intervenção cirúrgica precoce na endocardite infecciosa
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A endocardite infecciosa é uma doença que, apesar de rara nos países desenvolvidos, apresenta uma taxa de mortalidade elevada, em grande parte devido às suas complicações como a insuficiência cardíaca e os eventos cerebrovasculares. Por este motivo, são importantes o diagnóstico e tratamento precoces. Para além da antibioterapia, a cirurgia tem vindo a estabelecer-se como uma opção terapêutica desde a década de 1960 e, actualmente, as indicações cirúrgicas estão definidas nas recomendações internacionais. Contudo, ainda não se chegou a um consenso sobre a existência de benefício em intervir cirurgicamente durante a fase activa da infecção, nem sobre o tempo mais apropriado para operar em cada uma das indicações cirúrgicas. Objectivos: determinar se existe, ou não, benefício em operar durante a fase activa da infecção e qual o momento mais adequado para essa intervenção cirúrgica, para cada uma das indicações apresentadas nas recomendações internacionais. Métodos: realizou-se a pesquisa inicial na base de dados PubMed, com as palavras infective, endocarditis, surgery e timing. Foram seleccionados para revisão os artigos relevantes publicados nos últimos dez anos. A bibliografia destas publicações também foi analisada e algumas referências foram incluídas neste trabalho. Resultados: a larga maioria dos trabalhos publicados são estudos observacionais retrospectivos ou prospectivos, com os vieses intrínsecos a estes modelos, apesar de muitos estudos utilizarem propensity scores para diminuir o viés. Apenas foi publicado um ensaio clínico randomizado de pequena escala. A melhor evidência existente provém de várias meta-análises realizadas nos últimos anos. No futuro, novos ensaios clínicos randomizados poderão fornecer evidência mais sólida sobre este tema. Conclusões: segundo a evidência existente, a intervenção cirúrgica precoce parece apresentar benefícios face ao tratamento conservador, reduzindo a mortalidade a curto e a longo prazo. Só há benefício em protelar a cirurgia após eventos cerebrovasculares, uma vez que o risco de agravamento neurológico intra-operatório é elevado. Como tal, a cirurgia só deve ser realizada após o restabelecimento da auto-regulação da circulação cerebral.
Infective endocarditis is a rare disease in developed countries. Nevertheless, it has a high mortality rate, mostly due to its complications such as heart failure and stroke. Therefore, early diagnosis and treatment are of paramount importance. Surgery, alongside antibiotic therapy, has been established as a therapeutic option since the 1960s and, nowadays, the main surgical indications are defined in the international guidelines. However, a consensus has not been reached regarding the effect of early surgery (i.e. during the active phase of infection), or the best time to operate for each indication. Objectives: to determine whether there is benefit in performing early surgery and what is the best time to operate in each situation presented as a surgical indication in the international guidelines. Methods: the initial search was conducted in the PubMed database using the words “infective”, “endocarditis”, “surgery” and “timing”. Relevant articles published in the last ten years were selected for review. The references presented in these articles were also reviewed and some articles were included. Results: the vast majority of published articles are retrospective or prospective observational studies, which have inherent bias. Most of those studies, though, apply a propensity score in order to reduce it. Only one small scale randomized controlled trial has been published. The best available evidence is provided by several meta-analyses published in the past few years. In the future, new randomized controlled trials may provide more solid evidence on this subject. Conclusions: according to the available evidence, early surgery appears to provide a significant benefit when compared to conservative treatment, reducing both short and long-term mortality. After a stroke or intracranial hemorrhage, the risk of intra-operatory neurological deterioration is high; as such, surgery should be delayed until the autoregulation of cerebral circulation is reestablished.
Infective endocarditis is a rare disease in developed countries. Nevertheless, it has a high mortality rate, mostly due to its complications such as heart failure and stroke. Therefore, early diagnosis and treatment are of paramount importance. Surgery, alongside antibiotic therapy, has been established as a therapeutic option since the 1960s and, nowadays, the main surgical indications are defined in the international guidelines. However, a consensus has not been reached regarding the effect of early surgery (i.e. during the active phase of infection), or the best time to operate for each indication. Objectives: to determine whether there is benefit in performing early surgery and what is the best time to operate in each situation presented as a surgical indication in the international guidelines. Methods: the initial search was conducted in the PubMed database using the words “infective”, “endocarditis”, “surgery” and “timing”. Relevant articles published in the last ten years were selected for review. The references presented in these articles were also reviewed and some articles were included. Results: the vast majority of published articles are retrospective or prospective observational studies, which have inherent bias. Most of those studies, though, apply a propensity score in order to reduce it. Only one small scale randomized controlled trial has been published. The best available evidence is provided by several meta-analyses published in the past few years. In the future, new randomized controlled trials may provide more solid evidence on this subject. Conclusions: according to the available evidence, early surgery appears to provide a significant benefit when compared to conservative treatment, reducing both short and long-term mortality. After a stroke or intracranial hemorrhage, the risk of intra-operatory neurological deterioration is high; as such, surgery should be delayed until the autoregulation of cerebral circulation is reestablished.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2017
Palavras-chave
Endocardite infeciosa Cirurgia precoce Auto-regulação cerebral Doenças transmissíveis