Outcome after mitral valve repair for acute and healed infective endocarditis

Twenty-Year Experience with Surgery for Native and Prosthetic Mitral Valve Endocarditis

Background and Objectives: To evaluate the early and long-term results of surgical treatment of isolated mitral native and prosthetic valve infective endocarditis. Materials and Methods: All patients undergoing mitral valve repair or replacement for infective endocarditis at our institution between January 2001 and December 2021 were included in the study. The preoperative and postoperative characteristics and mortality of patients were retrospectively reviewed. Results: A total of 130 patients, 85 males and 45 females, with a median age of 61 ± 14 years, underwent surgery for isolated mitral valve endocarditis during the study period. There were 111 (85%) native and 19 (15%) prosthetic valve endocarditis cases. Fifty-one (39%) patients died during the follow-up, and the overall mean patient survival time was 11.8 ± 0.9 years. The mean survival time was better in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (12.3 ± 0.9 years vs. 8 ± 1.4 years; p = 0.1), but the difference was not statistically significant. Patients who underwent mitral valve repair had a better survival rate compared to patients who had mitral valve replacement (14.8 ± 1.6 vs. 11.3 ± 1 years; p = 0.06); however, the difference was not statistically significant. Patients who underwent mitral valve replacement with a mechanical prosthesis had a significantly better survival rate compared to patients who received a biological prosthesis (15.6 ± 1.6 vs. 8.2 ± 0.8 years; p < 0.001). Patients aged ≤60 years had significantly better survival compared to patients aged >60 years (17.1 ± 1.1 vs. 8.2 ± 0.9; p < 0.001). Multivariate analysis showed that the patient's age >60 years at the time of surgery was an independent risk factor for mortality, while mitral valve repair was a protective factor. Eight (7%) patients required reintervention. Freedom from reintervention was significantly higher in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (19.3 ± 0.5 vs. 11.5 ± 1.7 years; p = 0.04). Conclusions: Surgery for mitral valve endocarditis is associated with considerable morbidity and mortality. The patient's age at the time of surgery represents an independent risk factor for mortality. Mitral valve repair should be the preferred choice whenever possible in suitable patients affected by infective endocarditis.

A successful double valve repair on an interesting background: Case report

Aortic regurgitation in a bicuspid aortic valve is a complex entity that involves not only the semilunar valve but also the structure of the aortic root which is functionally and pathologically in a very close relationship to it. Considering repairing a bicuspid valve mandates a mindful involvement of all related structures concurrently. Here, we report an interesting case of both bicuspid aortic valve and mitral valve regurgitation in a patient with a history of infective endocarditis, that was successfully managed by double valve repair.

Role of Mitral Valve Repair for Mitral Infective Endocarditis

The 2 primary objectives of surgery in mitral valve infective endocarditis (IE) are total removal of the infected tissue and reconstruction of cardiac morphology, including repair or replacement of the affected valve. Single-institution series have suggested the feasibility and effectiveness of mitral valve repair (MVrep) over replacement in mitral IE in terms of in-hospital mortality and long-term event-free survival. This article reviews the history, details of the relevant repair techniques, and clinical results of MVrep for mitral IE.

Patient and Surgeon Predictors of Mitral and Tricuspid Valve Repair for Infective Endocarditis

Mitral repair (MVr) is superior to replacement for degenerative disease; however, its benefit is less established for endocarditis. We report outcomes of repair or replacement for mitral/tricuspid endocarditis and identify predictors of MVr. Patients undergoing first-time surgery for mitral (n = 260) or tricuspid (n = 71) endocarditis between 1992 to 2018 were identified. Patients with aortic endocarditis were excluded. Primary outcome was all-cause mortality and secondary outcome was MVr. Patients were stratified into active and treated endocarditis separately for mitral and tricuspid groups. Predictors of MVr were assessed through multivariable logistic regression and adjusted likelihood of MVr through marginal effects estimates. A mitral specialist was defined by performing ≥25 annual degenerative MVr. Among 331 patients, 70% (181/260) of those with mitral valve endocarditis and 52% (37/71) of those with tricuspid endocarditis underwent repair. The MVr group compared with replacement had a higher proportion of elective acuity and less diabetes, hypertension, active endocarditis, cardiogenic shock, and dialysis. Estimated 5-year survival did not differ between repair versus replacement for active mitral (68 ± 14% vs 60 ± 14%, P = 0.34) or tricuspid endocarditis (60 ± 17% vs 61 ± 19%, P = 0.67), but was superior after repair for treated mitral endocarditis (86 ± 7% vs 51 ± 24%, P = 0.014). Independent predictors of mortality included dialysis for active and treated mitral endocarditis, and mitral replacement (vs MVr) for treated mitral endocarditis. The likelihood of MVr was 82 ± 5% for mitral specialists and 47 ± 9% for non-specialists (P < 0.001). MVr for endocarditis should be pursued, if feasible. Importantly, achieving MVr was driven not only by patient factors, but also surgeon experience.

Mitral valve repair in infective endocarditis is not inferior to valve replacement: results from a Spanish nationwide prospective registry

INTRODUCTION

Infective endocarditis (IE) still carries high morbidity and mortality and frequently requires surgery. The benefit of mitral valve repair (MVr) in the setting of IE is yet to be proven. The goal of this study was to assess the results of MVr in patients with IE after a minimum follow-up of 1 year.

METHODS

This study is based on a Spanish nationwide prospective registry that included patients operated on for native mitral valve IE. The collaborating Institutions pooled their pre-, peri-, and postoperative data into the database of the GAMES group [Grupo de Apoyo al Manejo de la EndocarditiS (Group for support and management of infective endocarditis)].

RESULTS

Data from 27 hospitals were recorded and 3524 cases of active IE identified between 2008 and 2016. There were 1513 cases of mitral IE, of which 898 involved native valves. Of these, 437 patients underwent surgical treatment, and 369 completed the 1-year follow-up. The valve was repaired in 68 cases (18.4%). Preoperative groups were comparable (EuroSCORE MVr 7.7 vs MVR 8.0; p = ns). Mortality in the repair group was inferior to that in the replacement group (16.2% vs 27.2%, p = 0.058). At 1 year, mortality remained higher in the replacement group: 3.7% vs 2.9%. Relapse of the infection was slightly more frequent in the repair group (7.1% vs 3.7%; p = ns), although this did not lead to higher rates of reintervention (MVr/MVR: 2.9% vs 4.9%).

CONCLUSION

MVr is an attractive option for specific patients with IE and does not seem to negatively impact on relapses.

[Treatment of infectious endocarditis]

Antibiotic treatment of infective endocarditis is part of a multidisciplinary patient management that should be conducted within an "Endocarditis team". Initial antibiotic treatment of infective endocarditis should be parenteral and comply with current international guidelines. A switch to an oral antibiotic regimen may be considered after 2weeks of successful parenteral antibiotic treatment. Aminoglycosides should no longer be used for the initial treatment of native valve Staphylococcus aureus endocarditis. Valve surgery is required in almost half of the patients.

[Conservative mitral valve surgery in the treatment of mitral regurgitation due to infective endocarditis. Report of 21 cases]

BACKGROUND

To evaluate the feasibility of mitral valve repair in patients with infective endocarditis (IE).

METHODS AND RESULTS

Forty-seven patients operated for mitral endocarditis between 1995 and 2005; 21 underwent mitral valve repair. The repair was performed for acute endocarditis in seven patients at a median of 14 days after the onset of treatment and 14 patients for healed endocarditis after a median of six months.

RESULTS

Mitral valve repair was feasible in 21 patients (45%). This repair involved mitral annuloplasty in 16 patients (76%), shortening or transposition of chordae in 10 patients (48%), a pericardial patch in five patients (24%), and suture of perforation in two patients (9%). Associated procedures were aortic valve replacement in seven patients and tricuspid annuloplasty in two. There were no operative deaths. The mean follow up was five years (one to 11). One patient was reoperated for severe mitral regurgitation and another had a stroke due to cerebrovascular embolism in the first postoperative years. No recurrence of infectious endocarditis occurred.

CONCLUSIONS

Mitral valve repair in IE gives satisfactory results in terms of survival and symptomatic improvement with a low operative risk. With antibiotic therapy, it provides a cure of mitral lesions even when carried out in the acute phase of endocarditis. Finally, it feasible in several cases with excellent results.

Surgery for infective endocarditis

Infective endocarditis (IE) is estimated to have an incidence of five to seven cases per 100,000 person-years. Although not a common clinical entity, IE is associated with substantial morbidity and risk of mortality. IE, especially infections due to Staphylococcus aureus, are increasingly healthcare-associated infections. Despite significant advances in diagnosis and management, mortality from IE has changed little since the availability of penicillin; however, this lack of improvement in mortality is likely due to an increasing number of infections from more virulent and drug-resistant pathogens coupled with infections that occur in patients with other comorbidities and those associated with prosthetic valves. Surgery is an important part of therapy for many patients, but surprisingly, little evidence is available to help clinicians determine which patients will benefit most from surgical therapy for the management of IE.