Surgical treatment and long-term outcome of aortic valve endocarditis with periannular abscess

Multivariate and survival analysis of prognosis and surgical benefits in infective endocarditis

Background. Antibiotic therapy is the primary treatment for infective endocarditis (IE), yet up to 50% of patients still require surgical intervention. However, surgical intervention carries significant risks of mortality and complications for IE patients, and there remains a lack of consensus on which preoperative characteristics of infective endocarditis have a substantial impact on patient prognosis. Particularly, some IE patients develop periannular abscesses, leading to more severe complications. Objectives. The objective of our study is to identify predictors of poor outcomes in infective endocarditis and to further evaluate the impact of surgical intervention on patient prognosis, with the aim of adding value to the existing factors known to affect IE prognosis. Methods. In this retrospective cohort study, we evaluated 210 patients treated for infective endocarditis (IE) at our hospital between December 2016 and June 2023. To analyze short-term outcomes, the patients were divided into two groups based on whether they experienced poor outcomes. We compared demographic characteristics, echocardiographic findings, laboratory test results, surgical details, and postoperative outcomes between the two groups. Patients' long-term outcomes, including survival status and time of death, were assessed through follow-up, which involved telephone contact with the patient or their family. The follow-up period concluded on June 30, 2024. Results. The median age of the patients was 55 years, with most patients ranging from 42 to 64 years. Male patients accounted for 67.1%, and 21.4% had underlying cardiac conditions. During hospitalization, 125 out of 210 patients (59.5%) underwent surgery, with an emergency surgery rate of 6.2% and an in-hospital mortality rate of 13.8%.Regarding short-term outcomes, multivariate logistic regression analysis indicated that surgical treatment (OR 0.211, 95% CI 0.073-0.621) was associated with better patient prognosis. Periannular abscess (OR 4.948, 95% CI 1.005-24.349) and poorer cardiac function (NYHA II [OR 0.041, 95% CI 0.008-0.224], NYHA III [HR 0.207, 95% CI 0.057-0.757], with NYHA IV as the reference group) were significantly associated with poor prognosis in IE patients. For long-term outcomes, multivariate Cox survival analysis showed that surgical treatment (HR 0.200, 95% CI 0.091-0.437) was associated with improved long-term survival. Cerebral infarction (HR 1.939, 95% CI 1.050-3.582) and poorer cardiac function (NYHA II [HR 0.108, 95% CI 0.037-0.313], NYHA III [HR 0.308, 95% CI 0.118-0.805], with NYHA IV as the reference group) were significant factors associated with long-term mortality in IE patients. Conclusions. Surgical treatment was associated with improved short-term prognosis and long-term survival rates in patients with infective endocarditis. In terms of short-term outcomes, the presence of periannular abscesses and poor cardiac function were significant factors associated with poor prognosis. For long-term outcomes, cerebral infarction and poor cardiac function were significant factors associated with increased long-term mortality in these patients.

Aortic Root Replacement Versus Patch Repair for Aortic Valve Endocarditis With Root Abscesses: A Systematic Review and Meta-Analysis of Short- and Long-Term Outcomes

BACKGROUND & AIMS

Complex aortic valve infective endocarditis (IE) is a serious condition requiring surgical intervention. The optimal surgical approach remains a topic of debate. We sought to evaluate and compare the immediate and long-term results of aortic root replacement (ARR) versus patch repair (PR) in patients with aortic valve IE and root abscess.

METHODS

A comprehensive search of multiple electronic databases was completed to identify relevant studies published from inception to April 2023. We included studies reporting outcomes of ARR and PR in patients with aortic valve IE complicated by root abscess. Primary endpoints were short and long-term mortality and re-operation rates. Secondary endpoints included permanent pacemaker implantation, single-arm pooled incidence of mortality, recurrence, and re-operation.

RESULTS

A total of 32 studies met the inclusion criteria (n=2,554). We found no difference in short-term mortality (odds ratio [OR] 1.12; 95% confidence interval [CI] 0.70-1.80; I2=34%). The PR group had superior long-term survival (hazard ratio [HR] 0.69; 95% CI 0.52-0.90; I2=25%), however, they also had a significantly increased need for re-operation (HR 1.79; 95% CI 1.11-2.88; I2=0%). There were no differences in postoperative permanent pacemaker insertion (OR 0.62; 95% CI 0.34-1.12; I2=0%). Using a meta-analysis of proportions, the pooled rate of documented IE recurrence following was 5% after ARR and 8% after PR.

CONCLUSIONS

Our review shows a long-term survival benefit associated with PR for aortic root abscesses. This benefit is offset by a higher incidence of re-operations and IE recurrence. ARR appears to confer better protection against recurrence. However, based on the available weak evidence, individualised approaches should still be considered until further robust data is available to guide treatment decisions.

Atrioventricular conduction disorders in aortic valve infective endocarditis

BACKGROUND

Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases.

AIM

To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis.

METHODS

Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year.

RESULTS

High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up.

CONCLUSIONS

High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

Results of the inoperable and operable with aortic valve endocarditis

Objectives

To evaluate the results of the inoperable and operable with aortic valve endocarditis, focus on risk factors, significance, and management of destruction of the aortic annulus in aortic valve endocarditis.

Methods

The retrospective study was completed to investigate patients with aortic valve endocarditis undergoing cardiac surgery between January 2006 and November 2022 at our hospital.

Results

512 patients were divided into group with destruction of the aortic annulus (n = 80) and without destruction of the aortic annulus (n = 432). There were 32 operative deaths (6.3%, 32/512). By univariate and multivariate analysis, destruction of the aortic annulus is found to be statistically significantly associated with in-hospital mortality (P < 0.001), prolonged mechanical ventilation time (mechanical ventilation time > 96 h, P = 0.018), early aortic paravalvular leak (P < 0.001), and 1-year mortality following cardiac surgery (P < 0.001), respectively.

Conclusions

In our study, destruction of the aortic annulus increases mortality and health care costs. Optimization of pre-, peri-, and postoperative factors can reduce mortality and morbidity in aortic valve endocarditis. Aortic root replacement could be recommended as the best practice choice for aortic valve endocarditis with periannular abscess and destruction of the aortic annulus.

Surgical Challenges in Infective Endocarditis: State of the Art

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Early Mortality Predictors in İnfective Endocarditis Patients: A Single-Center Surgical Experience

INTRODUCTION

Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis.

METHODS

In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared.

RESULTS

Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all).

CONCLUSION

The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results

The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.

Incidental Diagnosis of Healed Aortic Abscess Cavity

In infective endocarditis, the perivalvular abscess is a known complication with an incidence of more than 22%-29%, but the primary presentation of a healed aortic abscess without any clinical features of infective endocarditis is very rare. These sorts of cases are scarcely documented throughout literature. We present a successful surgical closure of healed perivalvular abscess cavity with aortic valve replacement and mitral valve repair.

PR interval prolongation is significantly associated with aortic root abscess: An age- and gender-matched study

BACKGROUND

Electrocardiographic abnormalities, such as PR interval prolongation, have been anecdotally reported in patients with aortic root abscess (ARA). An electrocardiographic marker may be useful in identifying those patients with aortic valve endocarditis who may progress to ARA. The objective of this study is to evaluate the change in the PR interval in patients with surgically confirmed ARA and compare it to age- and gender-matched controls with echocardiographically or surgically confirmed aortic valve endocarditis but without aortic root abscess and those hospitalized with diagnoses other than endocarditis.

METHODS

Patients were eligible for enrollment if they were 18 years or older and were hospitalized for either ARA, aortic valve endocarditis, or for unrelated reasons and had at least one 12-lead electrocardiogram (ECG) prior to or on the day of hospitalization and at least one ECG after hospitalization but prior to any cardiac surgical procedure. Delta PR interval, defined as the difference between the pre- and post-admission PR interval, was the primary outcome of interest. The patients in the ARA group were age- and gender-matched to patients with aortic valve endocarditis and to those without endocarditis. Comparisons of demographic variables and study outcomes were performed.

RESULTS

Eighteen patients with surgically confirmed ARA were enrolled. These patients were age- and gender-matched to 19 patients with aortic valve endocarditis and 18 patients with no past history or evidence of endocarditis during hospitalization. No difference was noted in the baseline PR interval between the groups. However, the PR interval following admission in the aortic root abscess group (201 ± 66 ms) was significantly longer than the PR interval in both the aortic valve endocarditis (162 ± 27 ms) (24%, p = .009) and no endocarditis (143 ± 24 ms) (40%, p < .001) groups. The primary outcome measure, delta PR interval, was significantly longer in the ARA group (35 ± 51 ms) than no endocarditis (-5 ± 17 ms) (p = .001) and aortic valve endocarditis groups (0.2 ± 18) (p = .003).

CONCLUSIONS

The findings of our study support the notion that the PR interval is more likely to be prolonged in patients with ARA. Since ARA is associated with a high morbidity and mortality, PR interval prolongation in a patient with aortic valve endocarditis should prompt a thorough evaluation for aortic root involvement.