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Mestres CA, Quintana E. Partial heart transplantation for destructive infective endocarditis. Indian J Thorac Cardiovasc Surg 2024; 40:155-159. [PMID: 38827554 PMCID: PMC11139832 DOI: 10.1007/s12055-024-01728-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 06/04/2024] Open
Abstract
Infective endocarditis frequently spreads beyond the valve tissue, especially in the aortic location. Invasive endocarditis may lead to abscess formation or fistula, with substantial tissue loss. Here, the case of a 31-year-old male patient with destructive aortic and pulmonary valve endocarditis and a subaortic mural defect who underwent patch closure of the ventricular septal defect and aortic and pulmonary root replacement and right coronary artery bypass graft is presented. This is an uncommon condition and stress is placed on imaging of the technical aspects of the case.
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Affiliation(s)
- Carlos A. Mestres
- Department of Cardiothoracic Surgery and The Robert WM Frater Cardiovascular Research Institute, The University of the Free State, PO Box 339 (Internal Box G32), Bloemfontein, 9300 South Africa
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic, University of Barcelona, Barcelona, Spain
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2
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Brown JA, Verghis NM, Yousef S, Serna-Gallegos D, Zhu J, Thoma F, Kaczorowski D, Chu D, Bonatti J, Yoon P, Phillippi J, Sultan I. Outcomes of Aortomitral Continuity Reconstruction During Concomitant Aortic and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2024; 38:905-910. [PMID: 38350743 DOI: 10.1053/j.jvca.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/16/2023] [Accepted: 01/10/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVES To describe outcomes of reconstruction of the aortomitral continuity (AMC) during concomitant aortic and mitral valve replacement (ie, the "Commando" procedure). DESIGN A retrospective study of consecutive cardiac surgeries from 2010 to 2022. SETTING At a single institution. PARTICIPANTS All patients undergoing double aortic and mitral valve replacement. INTERVENTIONS Patients were dichotomized by the performance (or not) of AMC reconstruction. MEASUREMENTS AND MAIN RESULTS A total of 331 patients underwent double-valve replacement, of whom 21 patients (6.3%) had a Commando procedure. The Commando group was more likely to have had a previous aortic valve replacement (AVR) or mitral valve replacement (MVR) (66.7% v 27.4%, p < 0.001), redo cardiac surgery (71.4% v 31.3%, p < 0.001), and emergent/salvage surgery (14.3% v 1.61%, p = 0.001), whereas surgery was more often performed for endocarditis in the Commando group (52.4% v 22.9%, p = 0.003). The Commando group had higher operative mortality (28.6% v 10.7%, p = 0.014), more prolonged ventilation (61.9% v 31.9%, p = 0.005), longer cardiopulmonary bypass time (312 ± 118 v 218 ± 85 minutes, p < 0.001), and longer ischemic time (252 ± 90 v 176 ± 66 minutes, p < 0.001). Despite increased short-term morbidity in the Commando group, Kaplan-Meier survival estimation showed no difference in long-term survival between each group (p = 0.386, log-rank). On multivariate Cox analysis, the Commando procedure was not associated with an increased hazard of death, compared to MVR + AVR (hazard ratio 1.29, 95% CI: 0.65-2.59, p = 0.496). CONCLUSIONS Although short-term postoperative morbidity and mortality were found to be higher for patients undergoing the Commando procedure, AMC reconstruction may be equally durable in the long term.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Nina M Verghis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - David Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Johannes Bonatti
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pyongsoo Yoon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Julie Phillippi
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
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3
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Kakavand M, Stembal F, Chen L, Mahboubi R, Layoun H, Harb SC, Xiang F, Elgharably H, Soltesz EG, Bakaeen FG, Hodges K, Vargo PR, Rajeswaran J, Firth A, Blackstone EH, Gillinov M, Roselli EE, Svensson LG, Pettersson GB, Unai S, Koprivanac M, Johnston DR. Contemporary experience with the Commando procedure for anterior mitral anular calcification. JTCVS OPEN 2024; 18:12-30. [PMID: 38690415 PMCID: PMC11056448 DOI: 10.1016/j.xjon.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/22/2023] [Accepted: 10/10/2023] [Indexed: 05/02/2024]
Abstract
Objective Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.
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Affiliation(s)
- Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Filip Stembal
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge C. Harb
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Austin Firth
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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4
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Matsuzaki K, Mitomi K, Imai A, Sato M, Watanabe Y. Modified Commando procedure using a double valve composite through an aorto-annulo-septotomy. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivad213. [PMID: 38180849 PMCID: PMC10911401 DOI: 10.1093/icvts/ivad213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/01/2023] [Accepted: 01/04/2024] [Indexed: 01/07/2024]
Abstract
Double valve replacement of aortic and mitral valves with intervalvular fibrous body reconstruction (Commando procedure) is a challenging operation. Particularly in redo surgery for prosthetic valve endocarditis, special techniques are needed for approaching and reconstructing the valve complex. We performed a modified Commando procedure using a double valve composite through an aorto-annulo-septotomy. This approach provided a good field of vision at the combined aortic and mitral annuli without incising the left atrial roof. The double valve composite with four-layer patch wings was useful for performing double valve replacement en bloc and aorto-annulo-septotomy closure serially. Using these techniques, we successfully performed the Commando procedure for complicated prosthetic valve endocarditis.
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Affiliation(s)
- Kanji Matsuzaki
- Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Japan
| | - Kisato Mitomi
- Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Japan
| | - Akito Imai
- Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Japan
| | - Masataka Sato
- Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Japan
| | - Yasunori Watanabe
- Department of Cardiovascular Surgery, Hitachi General Hospital, Hitachi, Japan
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5
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Navia JL, Aleman R. The hemi-commando procedure. JTCVS Tech 2023; 22:88-89. [PMID: 38152195 PMCID: PMC10750983 DOI: 10.1016/j.xjtc.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/20/2023] [Accepted: 10/03/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Jose L. Navia
- Heart, Vascular, & Thoracic Institute, Cleveland Clinic Florida, Weston, Fla
| | - Rene Aleman
- Heart, Vascular, & Thoracic Institute, Cleveland Clinic Florida, Weston, Fla
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6
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Zaki A, Witten JC, Pettersson GB, Elgharably H. Patch reconstruction of the aorto-mitral curtain without posterior extension: Alternative to the Commando procedure for double valve replacement. JTCVS Tech 2023; 22:181-184. [PMID: 38152184 PMCID: PMC10750764 DOI: 10.1016/j.xjtc.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/29/2023] [Accepted: 08/07/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James C. Witten
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gosta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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7
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Nappi F, Avtaar Singh SS, Jitendra V, Fiore A. Bridging Molecular and Clinical Sciences to Achieve the Best Treatment of Enterococcus faecalis Endocarditis. Microorganisms 2023; 11:2604. [PMID: 37894262 PMCID: PMC10609379 DOI: 10.3390/microorganisms11102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Enterococcus faecalis (E. faecalis) is a commensal bacterium that causes various infections in surgical sites, the urinary tract, and blood. The bacterium is becoming a significant concern because it tends to affect the elderly population, which has a high prevalence of undiagnosed degenerative valvular disease and is often subjected to invasive procedures and implanted medical devices. The bacterium's actions are influenced by specific characteristics like pili activity and biofilm formation. This resistance significantly impedes the effectiveness of numerous antibiotic therapies, particularly in cases of endocarditis. While current guidelines recommend antimicrobial therapy, the emergence of resistant strains has introduced complexity in managing these patients, especially with the increasing use of transcatheter therapies for those who are not suitable for surgery. Presentations of the condition are often varied and associated with generalised symptoms, which may pose a diagnostic challenge. We share our encounter with a case study that concerns an octogenarian who had a TAVI valve and developed endocarditis. We also conducted a literature review to identify the essential treatment algorithms for such cases.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | | | - Vikram Jitendra
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK;
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France;
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 242] [Impact Index Per Article: 242.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Nappi F, Schoell T, Spadaccio C, Acar C, da Costa FDA. A Literature Review on the Use of Aortic Allografts in Modern Cardiac Surgery for the Treatment of Infective Endocarditis: Is There Clear Evidence or Is It Merely a Perception? Life (Basel) 2023; 13:1980. [PMID: 37895362 PMCID: PMC10608498 DOI: 10.3390/life13101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Infective valve endocarditis is caused by different pathogens and 60% of those involve the aortic valve with valve failure. Although S. aureus is recognized as the most frequently isolated causative bacterium associated with IE in high-income countries, Gram-positive cocci nevertheless play a crucial role in promoting infection in relation to their adhesive matrix molecules. The presence of pili on the surface of Gram-positive bacteria such as in different strains of Enterococcus faecalis and Streptococcus spp., grants these causative pathogens a great offensive capacity due to the formation of biofilms and resistance to antibiotics. The indications and timing of surgery in endocarditis are debated as well as the choice of the ideal valve substitute to replace the diseased valve(s) when repair is not possible. We reviewed the literature and elaborated a systematic approach to endocarditis management based on clinical, microbiological, and anatomopathological variables known to affect postoperative outcomes with the aim to stratify the patients and orient decision making. From this review emerges significant findings on the risk of infection in the allograft used in patients with endocarditis and no endocarditis etiology suggesting that the use of allografts has proved safety and effectiveness in patients with both pathologies.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK;
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France;
| | - Francisco Diniz Affonso da Costa
- Department of Cardiovascular Surgery, Instituto de Neurologia e Cardiologia de Curitiba—INC Cardio, Curitiba 81210-310, Parana, Brazil;
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Marin-Cuartas M, De La Cuesta M, Davierwala PM, Kang J, Stöger G, Misfeld M, Kiefer P, Leontyev S, Verevkin A, Pfanmüller B, Saaed D, Borger MA, Noack T. Mid-term outcomes following the Hemi-Commando procedure for complex infective endocarditis involving the aortomitral junction. Eur J Cardiothorac Surg 2023; 64:ezad208. [PMID: 37228088 DOI: 10.1093/ejcts/ezad208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES Perivalvular abscesses with destruction of the aortomitral junction (AMJ) are a severe complication of infective endocarditis (IE) and are associated with high mortality and complex management. The Hemi-Commando procedure is a mitral valve-sparing alternative to the Commando procedure in suitable patients with complex IE and paravalvular destruction. This study reviews the mid-term outcomes in patients undergoing the Hemi-Commando procedure for treating IE with destruction of the AMJ. METHODS The clinical outcomes of patients with IE and AMJ involvement who underwent the Hemi-Commando procedure between 2015 and 2021 at the Leipzig Heart Center were retrospectively analysed. Primary outcomes were 30-day mortality and 1-year survival. Secondary outcome was 1-year freedom from reoperation. RESULTS A total of 22 patients underwent the Hemi-Commando procedure during the study period. The patients' mean age was 59.8 ± 18.3 years. The study population was predominantly male (86.4%). Preoperative sepsis was present in 6 (27.3%) patients, and the median EuroSCORE II was 28.5%. Almost two-thirds (N = 14; 63.6%) of the patients presented with native IE. Streptococci were the most common pathogens (N = 8; 36.4%). Paravalvular abscess was found intraoperatively in 16 (72.7%) patients. The 30-day mortality was 13.6%. The estimated 1- and 3-year survival rates were 77.5% and 66.4%, respectively. The estimated freedom from reoperation at 1 and 3 years was 92.3%. CONCLUSIONS The Hemi-Commando procedure offers an acceptable mid-term survival chance with low reoperation rates and is, therefore, a reasonable mitral valve-sparing alternative to the Commando procedure in suitable patients with extensive IE and perivalvular involvement.
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Affiliation(s)
- Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Manuela De La Cuesta
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Piroze M Davierwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jagdip Kang
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Guillermo Stöger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Institute of Academic Surgery, RPAH, Sydney, NSW, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Philipp Kiefer
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Sergey Leontyev
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Alexander Verevkin
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Bettina Pfanmüller
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Diyar Saaed
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Thilo Noack
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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11
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Nappi F, Nenna A, Spadaccio C, Avtaar Singh SS, Almazil A, Acar C. The Use of the Cryopreserved Aortic Homograft for Aortic Valve Replacement: Is It Still an Option? J Cardiovasc Dev Dis 2023; 10:248. [PMID: 37367413 DOI: 10.3390/jcdd10060248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The indications for cryopreserved allografts in aortic valve replacement are still debatable. We aim to identify factors influencing early and long-term durability of the aortic homograft and to define subgroups of patients with an improved long-term quality of life, survival, and freedom from structural valve degeneration (SVD). We evaluated our series of 210 patients who underwent allograft implantation with a retrospective cohort study design over a period of 20 years. Endpoints were overall mortality, cardiac mortality related to SVD, the incidence of SVD, reoperation, and a composite endpoint comprising major adverse cardiac and cerebrovascular events (MACCEs), which includes cardiac death both related and not related to SVD, subsequent aortic valve surgery, new or recurrent infection of implanted allograft, recurrent aortic regurgitation, rehospitalization for heart failure, an increase in New York Heart Association (NYHA) class of ≥1, or cerebrovascular events. The primary indication for surgery was endocarditis (48%), which was also a predisposing factor for increased cardiac mortality. Overall mortality was 32.4% with a 27% incidence of SVD and mortality associated with SVD of 13.8%. Reoperation occurred in 33.8% and MACCEs in 54.8%. Long-term NYHA functional class and echocardiographic parameters improved over time. Statistical analysis demonstrated that root replacement technique and adult age were protective factors for SVD. We found no statistically significant difference in the clinical outcomes analyzed between women of childbearing age who had children after surgery and the rest of the women. The cryopreserved allograft is still a valid option in aortic valve replacement, providing acceptable durability and clinical outcomes with optimal hemodynamic performance. SVD is influenced by the implantation technique. Women of childbearing age might have additional benefits from this procedure.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK
| | | | - Almothana Almazil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France
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12
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Tomšič A, Palmen M, de Jong ML, Hjortnaes J, Driessen AGH, Braun J, Marsan NA, Klautz RJM. Extensive aortic root endocarditis with extension into the intervalvular fibrous body: an updated report of a mitral valve sparing approach. Eur J Cardiothorac Surg 2023; 63:ezad114. [PMID: 36951528 PMCID: PMC10290551 DOI: 10.1093/ejcts/ezad114] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/09/2023] [Accepted: 03/22/2023] [Indexed: 03/24/2023] Open
Abstract
OBJECTIVES Aortic root abscess can spread to include adjacent cardiac structures, including the central or intervalvular fibrous body and mitral valve. After radical debridement, complex surgical correction is needed. We describe the results of our mitral valve sparing approach. METHODS Between January 2004 and December 2020, 60 patients underwent operation for infective endocarditis of the aortic root with extension towards the mitral valve at 2 centres in the Netherlands. Early and late clinical and echocardiographic outcomes were studied. RESULTS Prosthetic valve endocarditis was present in 42 (70%) patients and emergent or salvage surgery was performed in 8 (13%) patients. After radical debridement of all infected tissue, mitral valve repair was feasible in 48 (80%) patients. Early mortality occurred in 11 (18%) patients while mechanical circulatory support was needed in 8 (13%) patients. At 10 years after surgery, the estimated reintervention-free survival rate was 51.9% (95% confidence interval 37.0-66.8%). Eight patients underwent reintervention; this was more common in patients who underwent aortic valve rather than root replacement and in patients in whom mitral valve repair was performed without ring annuloplasty. For 48 patients who underwent mitral valve repair, the estimated freedom from recurrent mitral regurgitation rate was 64.4% (95% confidence interval 40.1-88.7%) at 10 years after surgery. CONCLUSIONS Surgical intervention for extensive infective endocarditis of the aortic root is related to reasonable perioperative morbidity and mortality. Optimal surgical technique is crucial to lower the risk of late reintervention. Mitral valve repair is feasible in the majority of patients with satisfactory durability.
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Affiliation(s)
- Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Mylene Loncq de Jong
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Antoine G H Driessen
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centre, Amsterdam, Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centre, Amsterdam, Netherlands
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13
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Vobornik M, Timbilla S, Gofus J, Smolak P, Chek JL, Pojar M, Cermakova E, Zacek P, Vojacek J. Aorto-mitral curtain reconstruction in invasive double-valve endocarditis: mid-term outcomes. Front Cardiovasc Med 2023; 10:1154129. [PMID: 37234378 PMCID: PMC10206113 DOI: 10.3389/fcvm.2023.1154129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
Background Invasive double-valve endocarditis with structural damage (abscess or perforation) of the aorto-mitral curtain is a relatively rare but fatal diagnosis requiring complex surgical reconstruction. This study presents the short-term and mid-term outcomes from a single center. Methods From 2014 to 2021, 20 patients with double-valve endocarditis with structural damage of the aorto-mitral curtain underwent surgical reconstruction (Hemi-Commando procedure n = 16 and Commando procedure n = 4). Data were obtained retrospectively. Results In 13 cases, the procedure was a reoperation. The mean cardiopulmonary bypass time was 239 ± 47 min and the mean cross-clamp time was 186 ± 32 min. Concomitant procedures were tricuspid valve repair in two, coronary revascularization in one, closure of a ventricular septal defect in one and hemiarch (using circulatory arrest) in one patient. Eleven patients (55%) required surgical revision for bleeding. Thirty-day mortality was 30% (6 patients)-3 patients from the Hemi-Commando group (19%) and 3 patients from the Commando group (75%). Overall survival at 1, 3 and 5 years was 60%, 50% and 45% respectively. Reoperation was required by 4 patients. Freedom from reoperation at 1, 3 and 5 years was 86%, 71% and 71% respectively. Conclusion Despite the high postoperative morbidity and mortality, complex surgical reconstruction of the aorto-mitral continuity of patients with double-valve endocarditis represents the only real chance for survival. Mid-term outcomes are acceptable, but strict follow-up is required due to the risk of valve failure.
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Affiliation(s)
- Martin Vobornik
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Salifu Timbilla
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Jan Gofus
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Petr Smolak
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - James Lago Chek
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Marek Pojar
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Eva Cermakova
- Department of Medical Biophysics, Faculty of Medicine Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Pavel Zacek
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
| | - Jan Vojacek
- Department of Cardiac Surgery, Faculty of Medicine and University Hospital in Hradec Kralove, Charles University, Hradec Kralove, Czechia
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14
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Wang S, Zhou T, Bian J, Li G, Zhang W, Chen S, Jiang Y. Clinical outcomes following surgical mitral valve plasty or replacement in patients with infectious endocarditis: A meta-analysis. Front Surg 2023; 9:1048036. [PMID: 36700028 PMCID: PMC9869952 DOI: 10.3389/fsurg.2022.1048036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023] Open
Abstract
Background For degenerative mitral disease, more and more evidences support that mitral valve plasty (MVP) has much better clincial outcomes than mitral valve replacement (MVR). However, the advantages of MVP in patients suffering from infectious endocarditis (IE) are unclear. To evaluate the appropriateness of MVP in IE patients, we conducted this meta-analysis. Based on the difference between active and healed phase, we not only compared the result of patients with IE, but also identified the subgroup with active IE. Methods We systematically searched the clinical trials comparing clinical outcomes of MVP and MVR in patients suffering from IE. Relevant articles were searched from January 1, 2000 to March 18, 2021 in Pubmed and Cochrane Library. Studies were excluded if they were with Newcastle-Ottawa Scale (NOS) score less than 6 or lacking of direct comparisons between MVP and MVR. Results 23 studies were involved and 25,615 patients were included. Pooled analysis showed fewer adverse events and early or long-term death in the MVP group. However, more reoperations existed in this patient group. And the reinfection rate was close between two groups. Similar results were observed after identifying active IE subgroup, but there is no difference in the freedom from reoperation due to all-events. Conclusions Although limitimations exited in this study, patients suffering from IE can benefit from both MVP and MVR. For surgeons with consummate skills, MVP can be the preferred choice for suitable IE patients.
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Affiliation(s)
- Song Wang
- Department of Cardiovascular Surgery, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Nanjing, China,Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ting Zhou
- Health Management Center, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinhui Bian
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Geng Li
- Department of Cardiovascular Surgery and Heart Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenjing Zhang
- Department of Ultrasound Medicine, The Second Afliated Hospital of Harbin Medical University, Harbin, China,Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Correspondence: Yefan Jiang Si Chen Wenjing Zhang
| | - Si Chen
- Department of Cardiovascular Surgery and Heart Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Correspondence: Yefan Jiang Si Chen Wenjing Zhang
| | - Yefan Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Department of Cardiovascular Surgery and Heart Transplantation, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Correspondence: Yefan Jiang Si Chen Wenjing Zhang
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15
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Bojko M, Hershenhouse KS, Elsayed RS, Abt B, Cohen RG, Lee R, Bowdish ME, Starnes VA. Surgical Outcomes After Reconstruction of the Aortomitral Curtain. Semin Thorac Cardiovasc Surg 2022; 36:158-166. [PMID: 36481412 DOI: 10.1053/j.semtcvs.2022.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.
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Affiliation(s)
- Markian Bojko
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Korri S Hershenhouse
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Ramsey S Elsayed
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Brittany Abt
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Robbin G Cohen
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Raymond Lee
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California
| | - Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vaughn A Starnes
- Department of Surgery, Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California..
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16
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Berger T, Dees D, Siepe M, Pingpoh C, Fagu A, Zeh W, Beyersdorf F, Neumann FJ, Czerny M, Kreibich M. Invasive Coronary Angiography in Patients with Native or Prosthetic Aortic Valve Endocarditis. Thorac Cardiovasc Surg 2022. [PMID: 36257543 DOI: 10.1055/s-0042-1757600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Invasive coronary angiography (ICA) is essential to detect significant coronary artery disease (CAD) but is generally not recommended in patients with infective aortic valve endocarditis. This study aimed to evaluate the risks and benefits of preoperative ICA in patients before aortic valve replacement. METHODS Between March 2008 and September 2020, 232 patients were surgically treated for infectious endocarditis of the aortic valve. Sixty-seven (29%) of them underwent preoperative diagnostic ICA and were compared with the patients without preoperative ICA. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the ICA data. The intraoperative data and clinical outcomes after ICA and after surgery were evaluated. RESULTS ICA revealed a CAD in the majority of our patients (n = 36; 54%): One-vessel disease n = 19 (28%), two-vessel disease n = 6 (9%), and three-vessel disease n = 11 (16%). We observed no adverse events following preoperative diagnostic ICA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischemia were detected. During surgical aortic valve replacement, concomitant coronary artery bypass grafting was performed in 20 patients (30%). In patients with preoperative ICA, postoperative in-hospital mortality was significantly lower (n = 8 [12%] vs. n = 30 [18%]; p < 0.001), while the incidence of postoperative bleeding was higher (n = 18 [27%] vs. n = 22 [13%]; p = 0.022). The new-onset stroke incidence was 5% in each group. CONCLUSION Taking a multidisciplinary team approach, ICA is safe in selected patients with aortic valve infectious endocarditis with no adverse clinical outcomes, but significant clinical implications.
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Affiliation(s)
- Tim Berger
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dominik Dees
- Department of Cardiology and Angiology, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Clarence Pingpoh
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Albi Fagu
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolfgang Zeh
- Department of Cardiology and Angiology, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Kreibich
- Department of Cardiovascular Surgery, University Hospital Freiburg, Heart Centre, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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17
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Shavit R, Orvin K, Toledano R, Shaked H, Rubchevsky V, Shapira Y, Kornowski R, Aravot D, Sharony R. Does Perivalvular Involvement Affect the Long-Term Surgical Outcomes of Primary Left-Sided Endocarditis? Am J Cardiol 2022. [DOI: 10.1016/j.amjcard.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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18
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Tanaka D, Zulfiqar A, Mazine A. Going all in: left ventricular outflow tract, aortic root and intervalvular fibrous body reconstruction for extensive infective endocarditis. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6619558. [PMID: 35766862 DOI: 10.1093/ejcts/ezac367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/27/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Dustin Tanaka
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Amna Zulfiqar
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Amine Mazine
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
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19
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20
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Reply to Chen et al. Improvements in Outcomes and Expanding Indications for the Commando Procedure. Comment on "Giambuzzi et al. Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J. Clin. Med. 2021, 10, 3163". J Clin Med 2022; 11:jcm11061601. [PMID: 35329926 PMCID: PMC8949991 DOI: 10.3390/jcm11061601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 01/27/2023] Open
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21
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Chen L, Mahboubi R, Kakavand M, Erten O, Blackstone EH, Johnston DR. Improvements in Outcomes and Expanding Indications for the Commando Procedure. Comment on Giambuzzi et al. Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J. Clin. Med. 2021, 10, 3163. J Clin Med 2022; 11:jcm11041125. [PMID: 35207398 PMCID: PMC8877058 DOI: 10.3390/jcm11041125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/17/2022] [Indexed: 02/01/2023] Open
Abstract
We read with interest the authors' review and metanalysis of the Commando procedure in "Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results" [...].
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Affiliation(s)
- Lin Chen
- Case Western Reserve University School of Medicine, 9501 Euclid Ave., Cleveland, OH 44106, USA
- Correspondence:
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (R.M.); (M.K.); (O.E.); (E.H.B.); (D.R.J.)
| | - Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (R.M.); (M.K.); (O.E.); (E.H.B.); (D.R.J.)
| | - Ozgun Erten
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (R.M.); (M.K.); (O.E.); (E.H.B.); (D.R.J.)
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (R.M.); (M.K.); (O.E.); (E.H.B.); (D.R.J.)
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA; (R.M.); (M.K.); (O.E.); (E.H.B.); (D.R.J.)
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22
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Marshall WH, Henn MC, Harfi TT. Left ventricular outflow tract to left atrial fistula: A rare long-term complication of the commando procedure. Echocardiography 2021; 39:140-145. [PMID: 34923674 DOI: 10.1111/echo.15279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022] Open
Abstract
The commando procedure involves aortic and mitral valve replacement with complete reconstruction of the aorto-mitral curtain. It is often a surgical treatment for invasive infective endocarditis with abscess, or less commonly for radiation-induced heart disease with extensive calcification extending from the aortic valve onto the anterior mitral leaflet. Prosthetic valve endocarditis is a known long-term complication of this surgery; however, reports of other long-term outcomes are limited. We report the case of a 59-year-old male who developed a non-infectious left ventricular outflow tract to left atrial fistula, incidentally found 5 years after undergoing a commando procedure for radiation-induced heart disease.
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Affiliation(s)
- William H Marshall
- The Ohio State University, Department of Internal Medicine, Division of Cardiovascular Medicine, Columbus, Ohio, USA
| | - Matthew C Henn
- The Ohio State University, Department of Surgery, Division of Cardiothoracic Surgery, Columbus, Ohio, USA
| | - Thura T Harfi
- The Ohio State University, Department of Internal Medicine, Division of Cardiovascular Medicine, Columbus, Ohio, USA
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23
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Girardi LN, Lau C. Commentary: Multivalve infective endocarditis: Further support for radical debridement and complex reconstruction. JTCVS Tech 2021; 10:307-308. [PMID: 34984390 PMCID: PMC8691922 DOI: 10.1016/j.xjtc.2021.10.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 10/10/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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24
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Mullan CW, Geirsson A, Assi R. Commentary: Radical root resection for prosthetic valve endocarditis. JTCVS Tech 2021; 9:28-29. [PMID: 34647048 PMCID: PMC8501240 DOI: 10.1016/j.xjtc.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Clancy W. Mullan
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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25
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David TE, Lafreniere-Roula M, David CM, Issa H. Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart. J Thorac Cardiovasc Surg 2021; 164:1474-1484. [PMID: 34627607 DOI: 10.1016/j.jtcvs.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/25/2021] [Accepted: 09/02/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objectives of this study were to examine operative and long-term results of combined aortic and mitral valve replacement when reconstruction of the fibrous skeleton of the heart is needed because of calcification, abscess, previous operations, or patient-prosthesis mismatch. METHODS From 1985 to 2020, 182 consecutive patients underwent combined aortic and mitral valve replacement with reconstruction of the intervalvular fibrous skeleton in all cases and also the posterior mitral annulus in 63 patients. Bovine pericardium or Dacron grafts were used for the reconstructions. Median follow-up was 7.5 (interquartile range, 2.1-12.6) years and 98% complete. RESULTS Patient mean age was 62 years; 69% had 1 or more previous valve operations, and 92% were functional class III or IV. The indications for reconstruction were extensive calcification of the fibrous skeleton in 34%, abscess in 13%, tissue damage secondary to previous operations in 39%, and patient-prosthesis mismatch of the mitral valve in 13%. Bovine pericardium was used in two-thirds of cases and Dacron grafts in one-third. Operative mortality was 13.2% and postoperative complications were common. Survival at 1, 10, and 20 years was 81.8%, 51.1%, and 23.7%, respectively. Fourteen patients required reoperation and 3 transcatheter interventions. The cumulative probability of reinterventions at 1, 10, and 20 years were 3.3%, 5.8%, and 9.1%, respectively. Most patients experienced symptomatic improvement postoperatively. CONCLUSIONS Reconstructions of the fibrous skeleton of the heart are associated with high operative mortality but the long-term results are satisfactory because most patients would not have survived without surgical intervention.
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Affiliation(s)
- Tirone E David
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
| | - Myriam Lafreniere-Roula
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Carolyn M David
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Hugo Issa
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
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26
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Huuskonen A, Kaarne M, Vento A, Juvonen T, Raivio P. Outcomes of surgery for extensive infective endocarditis. J Card Surg 2021; 36:4675-4681. [PMID: 34547124 DOI: 10.1111/jocs.16005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 07/29/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Extensive infective endocarditis (EIE) involving the valve annulus or the intervalvular fibrous body (IFB) is a treatment challenge. We sought to clarify the outcomes of patients undergoing surgery for EIE. METHODS We retrospectively reviewed all 197 consecutive patients who underwent an operation for infective endocarditis (IE) between 2005 and 2016 in the Helsinki University Hospital. Thirty-five (18%) patients had EIE, of which 17 (9%) infection extended to IFB. RESULTS Patients with EIE had higher EuroSCORE II (24.4% vs. 12.4% p < .001), higher frequency of diabetes (29% vs. 13% p = .017), more often NYHA Class IV (83% vs. 56% p = .02), aortic (97% vs. 45% p < .001), multivalve (40% vs. 11% p < .001), and prosthetic valve IE (37% vs. 9% p < .001), and underwent more often emergency surgery (46% vs. 29% p = .042). Thirty-day mortality was 9% in the EIE group and 7% in the non-EIE group (p = .720). Survival of patients with EIE at 5 years was 60% and with non-EIE 71% (p = .029). The frequency of complications was higher in EIE (54%) than in non-EIE patients (25%) (p < .001), due to the higher need for permanent pacemaker implantations (34% vs. 4% p < .001). Freedom from re-operations at 5 years was 91% in the EIE group and 97% in the non-EIE group (p = .203). CONCLUSIONS Early mortality of surgery for EIE was comparable with non-EIE. Midterm survival was lower after surgery for EIE than after surgery for non-EIE but there was no difference in survival of patients with IE limited to the valve annulus amenable to patch repair and patients with endocarditis requiring IFB reconstruction.
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Affiliation(s)
- Antti Huuskonen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Markku Kaarne
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Antti Vento
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Tatu Juvonen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Peter Raivio
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Association between Volume and Outcomes of Infective Endocarditis Surgery: A Nationwide Cohort Study. Ann Thorac Surg 2021; 114:1695-1704. [PMID: 34562463 DOI: 10.1016/j.athoracsur.2021.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND To determine the relationship between hospital surgical volume and mortality risk and valve repair rate in infective endocarditis (IE) surgery. METHODS Using the Taiwan National Health Insurance Research Database (NHIRD), 3873 patients were identified who underwent surgery between 2000 and 2013. The cumulative hospital volume of valve surgery for IE was calculated, and patients were divided into 4 subgroups according to the quartile. Outcomes were mortality and valve repair rate and the cut point of referral excellence. RESULTS The distribution of IE surgery has been shifting to lower volume hospitals over the years. The global disease severity (Charlson's Comorbidity Index score [CCI score]) of patients was greater in the lowest volume hospital than in the highest volume hospital (2.4 vs. 2.0). The crude in-hospital mortality rate was 15.8% and 9.4% for the lowest and highest volume hospitals, respectively, with a significant difference (adjusted odds ratio: 1.86, 95% confidence interval: 1.22-2.85) after adjustment of baseline characteristics including the CCI score. The mitral valve (MV) repair rate increased with the increase in cumulative volume. During a mean follow-up period of 4.4 years, 324 (41.9%) and 254 (30.9%) patients died in the lowest and highest volume subgroups, respectively, and the difference was significant (adjusted hazard ratio: 1.59, 95% CI: 1.21-2.10). CONCLUSIONS A higher cumulative volume of IE surgery is associated with a lower risk of mortality and a higher likelihood of successful MV repair. Therefore, interfacility transfer to a high-volume hospital may improve outcomes of IE surgery.
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(Infective endocarditis of bicuspid aortic valve complicated by an abscess in in aortomitral continuity and intracardiac fistula). COR ET VASA 2021. [DOI: 10.33678/cor.2021.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J Clin Med 2021; 10:jcm10143163. [PMID: 34300329 PMCID: PMC8305575 DOI: 10.3390/jcm10143163] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Davierwala PM, Marin-Cuartas M, Misfeld M, Deo SV, Lehmann S, Garbade J, Holzhey DM, Borger MA, Bakhtiary F. Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body. Eur J Cardiothorac Surg 2021; 58:1080-1087. [PMID: 32380545 DOI: 10.1093/ejcts/ezaa146] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement. METHODS A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation. RESULTS Patients' mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) <35% (OR 12.06; P = 0.03), for 90-day mortality acute kidney injury requiring dialysis (OR 6.2; P = 0.02) and LVEF <35% (OR 9.66; P = 0.03) and for long-term mortality cardiogenic shock (hazard ratio 2.46; P = 0.01). CONCLUSIONS Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.
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Affiliation(s)
- Piroze M Davierwala
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Salil V Deo
- Department of Veterans Affairs, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Sven Lehmann
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Jens Garbade
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - David M Holzhey
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Farhad Bakhtiary
- Department of Cardiothoracic Surgery, Helios Klinikum Siegburg, Siegburg, Germany
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Witten JC, Tan CD, Rodriguez ER, Shrestha NK, Gordon SM, Hussain ST, Apte SS, Unai S, Blackstone EH, Pettersson GB. Invasive Aortic Valve Endocarditis: Clinical and Tissue Findings from a Prospective Investigation. Ann Thorac Surg 2021; 113:535-543. [PMID: 33839129 DOI: 10.1016/j.athoracsur.2021.03.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 02/27/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Advanced aortic valve infective endocarditis (IE) with progression and destruction beyond the valve cusps-invasive IE-is incompletely characterized. We aimed to further characterize invasive disease extent, location, and stage and correlate macroscopic operative findings with microscopic disease patterns and progression. METHODS Forty-three patients with invasive aortic valve IE were prospectively enrolled from 8/2017 to 7/2018. Twenty-three (53%) had prosthetic valve, 2 (5%) allograft, and 18 (42%) native aortic valve IE. Surgical findings and intraoperative photography were analyzed for invasion location, extent, and stage. Surgical samples were formalin-fixed and analyzed histologically. Time course of disease and management was evaluated. RESULTS Pathogens included Staphylococcus aureus in 17 (40%). Invasion predominantly affected the non-left commissure (76%) and was circumferential in 15 (35%; 14 were prosthetic valves). Extra-aortic cellulitis was present in 29 (67%), abscess in 13 (30%), abscess cavity in 29 (67%), and pseudoaneurysm in 8 (19%); 7 (16%) had fistulae. Histopathology revealed acute inflammation, abscess formation, and lysis of connective tissue, but not myocardium or elastic tissue. Median time from onset of symptoms to antibiotics was 5 days, invasion confirmation 15 days, and surgery 37 days. S. aureus cases had a 21-day shorter time course than non-S. aureus cases. Eight patients developed new/worsening heart block. CONCLUSIONS Advanced invasive aortic valve IE demonstrates consistent gross patterns and stages correlating with histopathologic findings. Invasion results from a confluence of factors, pathogen, time, host immune response and other and primarily affects the fibrous skeleton of the heart and expands to low-pressure regions.
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Affiliation(s)
- James C Witten
- Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Carmela D Tan
- Department of Anatomic Pathology, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - E René Rodriguez
- Department of Anatomic Pathology, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nabin K Shrestha
- Department of Infectious Disease, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Gordon
- Department of Infectious Disease, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Syed T Hussain
- Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suneel S Apte
- Department of Biomedical Engineering, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio.
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Elgharably H, Pettersson GB, Navia JL. Aortic allograft for endocarditis of the intervalvular fibrosa. Ann Thorac Surg 2021; 112:1383-1384. [PMID: 33621557 DOI: 10.1016/j.athoracsur.2020.11.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
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Nappi F, Acar C. Monobloc or Separate Aortic and Mitral Homografts for Endocarditis of the Intervalvular fibrosa? Ann Thorac Surg 2021; 112:1382-1383. [PMID: 33539785 DOI: 10.1016/j.athoracsur.2020.10.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 10/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Francesco Nappi
- Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, 36 Rue des Moulins Gémeaux, 93200 Saint-Denis, France
| | - Christophe Acar
- Department of Cardiovascular Surgery, Hôpital de la Salpétrière, Paris, France
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De Palo M, Scicchitano P, Malvindi PG, Paparella D. Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis. Antibiotics (Basel) 2021; 10:antibiotics10010050. [PMID: 33419074 PMCID: PMC7825452 DOI: 10.3390/antibiotics10010050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 12/25/2022] Open
Abstract
The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).
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Affiliation(s)
- Micaela De Palo
- Section of Cardiac Surgery, A.O.U. Consorziale Policlinico di Bari, 70124 Bari, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
| | - Pietro Scicchitano
- Section of Cardiology, F. Perinei Hospital, Altamura, 70022 Bari, Italy;
| | | | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy
- Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
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Chaud GJ, Perron J, Pagé S, Laflamme M, Côté JM, Jacques F. An autopsy view of the Hemi-commando procedure. J Card Surg 2020; 36:701-702. [PMID: 33259089 DOI: 10.1111/jocs.15221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 12/01/2022]
Abstract
Invasive endocarditis involving the fibrous skeleton of the heart requires complex high-risk surgical management. For combined aortic and mitral infection in whom the posterior mitral leaflet and at least the free edge of anterior mitral valve could be spared, a modification of the Commando procedure was suggested: the "Hemi-commando procedure." We report the autopsy images of a Hemi-commando procedure after in unfortunate death in a 24 years old man 17 days after surgery.
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Affiliation(s)
- German J Chaud
- Service of Cardiac Surgery, Multidisciplinary Departement of Cardiology, Institut de cardiologie et de pneumologie, Université Laval, Qubec, Canada
| | - Jean Perron
- Service of Cardiac Surgery, Multidisciplinary Departement of Cardiology, Institut de cardiologie et de pneumologie, Université Laval, Qubec, Canada
| | - Sylvain Pagé
- Service of Pathology, Institut de cardiologie et de pneumologie, Université Laval, Qubec, Canada
| | - Maxime Laflamme
- Service of Cardiac Surgery, Multidisciplinary Departement of Cardiology, Institut de cardiologie et de pneumologie, Université Laval, Qubec, Canada
| | - Jean-Marc Côté
- Service of Cardiology, Multidisciplinary Departement of Cardiology, Institut de cardiologie et de pneumologie, Qubec, Canada
| | - Frédéric Jacques
- Service of Cardiac Surgery, Multidisciplinary Departement of Cardiology, Institut de cardiologie et de pneumologie, Université Laval, Qubec, Canada
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Jamal SM, Kichloo A, Albosta M, Bailey B, Singh J, Wani F, Shah Zaib M, Ahmad M, Khan MD, Soni R, Aljadah M, Khan HW, Khan M, Khan MZ. In-hospital outcomes and prevalence of comorbidities in patients with infective endocarditis with and without heart blocks: Insight from the National Inpatient Sample. J Investig Med 2020; 69:358-363. [PMID: 33115957 DOI: 10.1136/jim-2020-001501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/03/2022]
Abstract
Infective endocarditis (IE) complicated by heart block can have adverse outcomes and usually requires immediate surgical and cardiac interventions. Data on outcomes and trends in patients with IE with concurrent heart block are lacking. Patients with a primary diagnosis of IE with or without heart block were identified by querying the Healthcare Cost and Utilization Project database, specifically the National Inpatient Sample for the years 2013 and 2014, based on International Classification of Diseases Clinical Modification Ninth Revision codes. During 2013 and 2014, a total of 18,733 patients were admitted with a primary diagnosis of IE, including 867 with concurrent heart blocks. Increased in-hospital mortality (13% vs 10.3%), length of stay (19 vs 14 days), and cost of care ($282,573 vs $223,559) were found for patients with IE complicated by heart block. Additionally, these patients were more likely to develop cardiogenic shock (8.9% vs 3.2%), acute kidney injury (40.1% vs 32.6%), and hematologic complications (19.3% vs 15.2%), and require placement of a pacemaker (30.6% vs 0.9%). IE and concurrent heart block resulted in increased requirement for aortic (25.7% vs 6.1%) and mitral (17.3% vs 4.2%) valvular replacements. Conclusion was made that IE with concurrent heart block worsens in-hospital mortality, length of stay, and cost for patients. Our analysis demonstrates an increase in cardiac procedures, specifically aortic and/or mitral valve replacements, and Implantable Cardiovascular Defibrillator/Cardiac Resynchronization Therapy/ Permanent Pacemaker (ICD/CRT/PPM) placement in IE with concurrent heart block. A close telemonitoring system and prompt interventions may represent a significant mitigation strategy to avoid the adverse outcomes observed in this study.
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Affiliation(s)
- Shakeel M Jamal
- Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Asim Kichloo
- Department of Internal Medicine, CMU Medical Education Partners, Saginaw, Michigan, USA
| | - Michael Albosta
- Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Beth Bailey
- Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Jagmeet Singh
- Department of Internal Medicine/Division of Nephrology, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Farah Wani
- Department of Family Medicine, Samaritan Medical Center, Watertown, NY, USA
| | | | - Muhammad Ahmad
- Internal Medicine, Central Michigan University, Saginaw, Michigan, USA
| | | | - Ronak Soni
- Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Michael Aljadah
- Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hafiz Waqas Khan
- Department of Internal Medicine, Michigan State University, Flint, Michigan, USA
| | - Mahin Khan
- Department of Internal Medicine, Michigan State University, Flint, Michigan, USA
| | - Muhammad Z Khan
- Department of Internal Medicine, West Virginia University, Morgantown, West Virginia, USA
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Miletic K, Tong MZ. Fibrous skeleton reconstruction for invasive aortic and mitral valve endocarditis. Asian Cardiovasc Thorac Ann 2020; 28:381-383. [PMID: 33023307 DOI: 10.1177/0218492320957121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Invasive endocarditis of the aortic and mitral valves with involvement of the intervalvular fibrosa is a particular surgical challenge. We describe a technique for aortic and mitral valve replacement with concomitant reconstruction of the intervalvular fibrosa, utilizing a folded bovine pericardial patch (Commando operation).
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Monsefi N, Öztürk M, Shavahatli T, El-Sayed AA, Bakhtiary F. Outcome of surgery for acute infective endocarditis: does preoperative stroke have an impact on mortality? Indian J Thorac Cardiovasc Surg 2020; 36:373-381. [PMID: 33061145 DOI: 10.1007/s12055-020-00943-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/21/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022] Open
Abstract
Purpose Surgical therapy of infective endocarditis (IE) is challenging and can be associated with high mortality. In this study, we present the early outcomes of patients who underwent cardiac surgery for IE. Methods From 2017 until 2019, 66 patients underwent surgical treatment for IE. Staphylococcus aureus infection was identified in 14 patients (21%). In the same period, about 813 valve replacement procedures were performed with 8% incidence of IE. Mean age was 66 ± 12 years and 32% were females. Mean ejection fraction was 55 ± 9%. Seven patients (11%) had stroke due to septic embolism preoperatively. In 20 patients (30%), prosthetic valve endocarditis was an indication for reoperation. Thirty-day postoperative mortality and impact of preoperative stroke were analyzed. Results Thirty-day mortality was 17% (n = 11). Mean EuroSCORE I was 28 ± 22%. Mean cross clamp time was 63 ± 37 min. Fourty patients (61%) underwent one-valve procedure, 25 patients (38%) had double-valve, and one (1%) triple-valve operation. All seven patients with preoperative neurologic dysfunction had unremarkable postoperative course without death or neurologic deterioration. Five of them had no worsening in neurological status, while 2 patients had slight improvement in speech. The comparison between the two groups (patients without preoperative neurological vs. patients with preoperative neurological dysfunction) revealed no significance in the postoperative mortality rate (18% vs. 0% with p = 0.26). Postoperative echocardiography revealed competent valve function in all cases. Conclusion Surgical treatment for IE still remains a challenge with high morbidity and mortality. Patients with preoperative neurologic dysfunction due to septic embolism have good early postoperative results without increased mortality.
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Affiliation(s)
- Nadejda Monsefi
- Department of Cardiothoracic Surgery, Helios Heart Center NRW, Siegburg-Wuppertal, University of Witten Herdecke, Witten, Germany
| | - Mahmut Öztürk
- Department of Cardiothoracic Surgery, Helios Heart Center NRW, Siegburg-Wuppertal, University of Witten Herdecke, Witten, Germany
| | - Tunjay Shavahatli
- Department of Cardiothoracic Surgery, Helios Heart Center NRW, Siegburg-Wuppertal, University of Witten Herdecke, Witten, Germany
| | - Ali Ahmad El-Sayed
- Department of Cardiothoracic Surgery, Helios Heart Center NRW, Siegburg-Wuppertal, University of Witten Herdecke, Witten, Germany
| | - Farhad Bakhtiary
- Department of Cardiothoracic Surgery, Helios Heart Center NRW, Siegburg-Wuppertal, University of Witten Herdecke, Witten, Germany
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Kovach C, Swirka M, McGuinn E, Honce JM, Groves DW, Tumolo AZ. Magnetic resonance imaging in a patient with temporary external pacemaker. HeartRhythm Case Rep 2020; 6:637-640. [PMID: 32983883 PMCID: PMC7498632 DOI: 10.1016/j.hrcr.2020.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Christopher Kovach
- Division of Cardiology, Department of Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Mallory Swirka
- Division of Cardiology, Department of Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Erin McGuinn
- Division of Cardiology, Department of Medicine, University of Colorado Hospital, Aurora, Colorado
| | - Justin M Honce
- Department of Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Daniel W Groves
- Division of Cardiology, Department of Medicine, University of Colorado Hospital, Aurora, Colorado.,Department of Radiology, University of Colorado Hospital, Aurora, Colorado
| | - Alexis Z Tumolo
- Division of Cardiology, Department of Medicine, University of Colorado Hospital, Aurora, Colorado
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Abdelsattar ZM, Elsisy MF, Schaff H, Stulak J, Greason K, Pochettino A, Arghami A, Rowse P, Bagameri G, Khullar V, Daly R, Cicek S, Dearani J, Crestanello J. Comparative Effectiveness of Mechanical Valves and Homografts in Complex Aortic Endocarditis. Ann Thorac Surg 2020; 111:793-799. [PMID: 32890491 DOI: 10.1016/j.athoracsur.2020.06.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/07/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The ideal surgical reconstruction of the aortic root in patients with complex endocarditis is controversial. We compared the short- and long-term outcomes between mechanical valves, bioprostheses, and homografts. METHODS We identified all patients undergoing an operation for active complex aortic endocarditis at our institution between 2003 and 2017. We grouped patients according to those who received a mechanical valve, bioprosthesis, or homograft. We used multiple logistic regression and proportional hazards models. To minimize confounding by indication, we used marginal risk adjustment to simulate that every patient would undergo (contrary to fact) all 3 operations. RESULTS Of 159 patients with complex active endocarditis, 48 (30.2%) had a valve plus patch reconstruction, and 85 (53.4%) had a root replacement. Of all, 50 (31.5%) had a mechanical valve, 56 (35.2%) had a bioprosthesis, and 53 (33.3%) had a homograft. The groups were similar in age, sex, body mass index, comorbid conditions, organism, abscess location, and mitral involvement (all P > .05). However, patients receiving mechanical reconstructions were more likely to have native valve endocarditis (46% vs 37.5% vs 17%; P = .005) and less likely to undergo root replacement (32% vs 28.6% vs 100%; P < .001). Marginal risk-adjusted operative mortality was lowest for mechanical valves (4.8%) and highest for homografts (16.9%; P = .041). Long-term survival after root replacement was worse with homografts than with mechanical valve conduits (adjusted hazard ratio, 2.9; P = .045). CONCLUSIONS In patients with complex endocarditis, mechanical valves are associated with similar, if not better, short- and long-term outcomes compared with homografts, even after adjusting for important baseline characteristics and limiting the analysis to root replacements only.
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Affiliation(s)
- Zaid M Abdelsattar
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota; Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Chicago, Illinois
| | - Mohamed F Elsisy
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell Schaff
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Stulak
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin Greason
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Arman Arghami
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip Rowse
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Vishal Khullar
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard Daly
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sertac Cicek
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph Dearani
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Juan Crestanello
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota.
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Liakopoulos OJ. Commentary: AVNeo (Ozaki) and transaortic mitral valve repair using autologous pericardium only for aortomitral endocarditis: The perfect solution in double-valve invasive aortomitral endocarditis? JTCVS Tech 2020; 3:108-109. [PMID: 34317836 PMCID: PMC8302950 DOI: 10.1016/j.xjtc.2020.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiac Surgery, Kerckhoff-Clinic Bad Nauheim, Campus Kerckhoff, University of Giessen, Giessen, Germany
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Benedetto U, Gergely S, Dimagli A, Sinha S. AVNeo (Ozaki) and transaortic mitral valve repair using autologous pericardium only for aortomitral endocarditis. JTCVS Tech 2020; 3:101-103. [PMID: 34317833 PMCID: PMC8302910 DOI: 10.1016/j.xjtc.2020.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/16/2020] [Accepted: 05/08/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Szabolcs Gergely
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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Jiang X, Liu J, Khan F, Tang R, Zhang Y, Gu T. Aortic and mitral valve surgery for infective endocarditis with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes. J Thorac Dis 2020; 12:1427-1436. [PMID: 32395280 PMCID: PMC7212136 DOI: 10.21037/jtd.2020.03.04] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Reconstruction of the aorto-mitral curtain (AMC) for invasive double-valve infective endocarditis (IE) is a rare and challenging procedure. This study presents the short- and mid-term results of reconstruction of AMC in a single center. Methods From 2016 to 2019, 14 patients with invasive double-valve underwent surgical reconstruction of the AMC, along with either double valve replacement or aortic valve replacement with mitral valve repair. Two patients were diagnosed as Behcet’s disease. Bicuspid aortic valve was detected in six patients. Mean follow up was 18.9±12.2 months. Results Positive blood culture was found in 10 (71.4%) patients: 3 of Abiotrophia defective (21.4%). The mean cardiopulmonary bypass (CPB) time was 154.5±25.9 minutes and the mean cross-clamp time was 116.8±18.2 minutes. One patient died of multiple organ failure (7.1%) 60 days after surgery. There was 1 (7.1%) case of stroke, 1 (7.1%) of atrioventricular block with pacemaker implantation, 1 (7.1%) of reoperation for bleeding. There was no late death during follow-up. The survival at 3 years was 92.9%. Freedom from reoperation at 1, 2, and 3 years was 100%, 100%, and 100% during follow-up, respectively. Conclusions The double-valve replacement and AMC reconstruction (the Commando procedure) is an effective technique in complex heart valve disease. The short- and mid-term results with this technique are optimal, with a very low in-hospital mortality and nearly 100% of long-term survival during follow-up.
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Affiliation(s)
- Xuan Jiang
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Jinduo Liu
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Fareed Khan
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Rui Tang
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Yuhai Zhang
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
| | - Tianxiang Gu
- Department of Cardiac Surgery, First Affiliated Hospital, China Medical University, Shenyang 110001, China
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Stelzer PE. Invited Commentary. Ann Thorac Surg 2019; 108:1324. [PMID: 31276642 DOI: 10.1016/j.athoracsur.2019.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Paul E Stelzer
- Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, New York, NY 10029.
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