Surgical Management of Mitral Valve Infective Endocarditis

Infective Endocarditis in Patients Receiving Hemodialysis: A Current Review

Background

Cardiovascular and infective complications are commonly observed in patients receiving hemodialysis (HD) with cardiovascular events and infection-related complications being the first and second leading causes of death. Infective endocarditis (IE) is characterized by inflammation of the endocardium caused by infection, typically affecting the cardiac valves and can be in acute, subacute, or chronic forms. It is a serious complication within the HD population due to their predisposition for both infection and valvular damage. Considering the frailty and burden of comorbidities in those receiving HD, management of IE in the HD population is very challenging. There has been continuous discussion and debate on optimizing the diagnostic and treatment approach of IE in this patient group to improve their clinical outcomes. Currently, reported outcomes are relatively poor and there are updates from numerous guidelines relating to advances in IE management.

Summary

In this review, we will evaluate the evidence in relation to the epidemiology of HD-associated IE and discuss the important risk factors of IE in patients requiring dialysis. We will also evaluate the current recommendations regarding diagnosis and treatment for suspected or confirmed IE cases amongst HD patients and present the updated data regarding clinical outcomes relating to HD-associated IE.

Key Messages

The incidence of IE in HD patients is expected to increase going forward as HD becomes more easily accessible alongside an emerging uptake of home HD. A more thorough insight into this topic is required to improve clinical practice relating to IE prevention and management in the HD population, given relatively poor clinical outcomes.

Mitral valve repair and replacement in infectious endocarditis: a systematic review and meta-analysis of clinical outcome

BACKGROUND

Infective endocarditis (IE) poses significant clinical challenges, often necessitating surgical intervention for improved patient outcomes. The choice between mitral valve repair (MVP) and mitral valve replacement (MVR) is crucial in managing IE. This systematic review and meta-analysis aims to compare the effectiveness of MVP and MVR in treating IE, focusing on outcomes such as postoperative bleeding, mortality, recurrent endocarditis, and stroke.

MAIN TEXT

A comprehensive literature search was conducted following PRISMA guidelines. Studies directly comparing MVP and MVR in IE patients were included. Data extraction and quality assessment were performed, and meta-analysis was conducted using RevMan software. Thirty-two studies involving 82,123 patients were included. MVP was associated with significantly lower rates of postoperative bleeding (OR: 0.58, 95% CI: 0.40-0.84) and reduced long-term mortality (OR: 0.40, 95% CI: 0.32-0.51) compared to MVR. However, MVR showed lower rates of recurrent endocarditis. MVP was also associated with a decreased likelihood of postoperative stroke (OR: 0.52, 95% CI: 0.40-0.68).2, 4 CONCLUSIONS: MVP demonstrates advantages over MVR in reducing postoperative bleeding, long-term mortality, and stroke risk in IE patients. However, individual patient factors and surgical expertise must be considered in treatment decisions. Further research, including randomized controlled trials, is needed to validate these findings and refine treatment algorithms for IE management.

Limited Versus Radical Resection in Mitral Valve Infective Endocarditis Surgery

Background: Mitral valve repair is preferred in patients undergoing surgical treatment for infective endocarditis (IE) of the native mitral valve, however, radical resection of infected tissue and patch-plasty might potentially lead to low or non-durable repair. We aimed to compare a limited-resection and non-patch technique with the classic radical-resection technique. Methods: Eligible candidates were patients with definitive IE of the native mitral valve undergoing surgery between January 2013 and December 2018. Patients were classified according to the surgical strategy into two groups: limited- versus radical-resection strategy. Propensity score matching was used. Endpoints were repair rate, all-cause mortality (30-day and 2-year), re-endocarditis and reoperation at q-year follow-up. Results: After propensity score matching, 90 patients were included. Follow-up was 100% complete. Mitral valve repair rate was 84% in the limited-resection versus 18% in the radical-resection strategy, p < 0.001. The 30-day and 2-year mortality were 20% versus 13% (p = 0.396) and 33% versus 27% (p = 0.490) in the limited-resection versus radical-resection strategy, respectively. The incidence of re-endocarditis during the 2-year follow-up was 4% in the limited-resection strategy versus 9% in the radical-resection strategy, p = 0.677. Three patients in the limited-resection strategy underwent reoperation of the mitral valve, while there were none in the radical-resection strategy (p = 0.242). Conclusions: Although mortality in patients with IE of the native mitral valve remains high, the limited-resection and non-patch surgical strategy is associated with a significantly higher repair rates with comparable 30-day and mid-term mortality, risk of re-endocarditis and re-operation compared to the radical-resection strategy.

Cardiac pseudoaneurysm as a complication of native mitral valve infective endocarditis

Background

The delayed development of a mitral valve annulus pseudoaneurysm is a rare and late complication of a native mitral abscess cavity.

Case summary

Currently, there are no documented cases of a pseudoaneurysm developing from an abscess cavity of the posterior annulus of the native mitral valve. We report a case of a patient who presented with worsening progressive shortness of breath that was found to be secondary to a pseudoaneurysm. This was detected by 2D echocardiogram and cardiac computed tomography angiography.

Discussion

In our case, the patient developed a late complication of a ventricular pseudoaneurysm originating from the mitral annular area of the abscess cavity. Per the surgical literature, one method to avoid the aforementioned complication is via cavity repair with a bovine patch.

Spontaneous healing of a ruptured mycotic aneurysm of the posterior mitral leaflet: Unexpected resolution of a severe mitral regurgitation

Mycotic mitral valve aneurysm is an uncommon complication that rarely appears in isolated mitral valve endocarditis. The weakened aneurysmal wall may rupture, causing severe mitral regurgitation. In this situation surgery is essential. We present a case of a rare complicated mycotic posterior mitral aneurysm. After completing the antibiotic course for Streptococcus agalactiae infective endocarditis, an unexpected healing process within the aneurysm led to the virtual disappearance of the mitral regurgitation and remarkably changed the patient's clinical outcome. We emphasize the key role of three-dimensional transesophageal echocardiography, as it is becoming the reference imaging technique for infective endocarditis.

Feasibility and outcome of mitral valve repair in patients with infective endocarditis

Background

Valve repair is the treatment of choice for native mitral valve regurgitation. The feasibility of repair when the defect is caused by acute infective endocarditis (IE) is debated. This study aims to compare the outcome of repair and replacement procedures, to report the rate of repair in a single surgical center, and to review the literature on this topic.

Results

We retrospectively analyzed 108 patients with native mitral IE, potentially eligible for surgical repair. Of these 108, 90 (83%) underwent surgery, and 18 were treated conservatively. Among the 90 surgical patients, 57 (63%) underwent valve replacement and 33 valve repair (37%). The mean follow-up duration was 3 years. The two primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the post-operative incidence of major adverse events (hospitalization for any cause, pacemaker implantation, new onset of atrial fibrillation, sternal dehiscence), left ventricular systolic function (LVSF), and valvular function at 1-year echocardiographic follow-up. All-cause mortality was lower for valve repair, although not significantly (p = 0.86), as well as nonfatal adverse events (p = 0.92) and relapse rate (p = 0.20) at 3 years. We did not find differences between the two groups at echocardiographic follow-up, neither for left ventricular systolic function (p = 0.22), nor for valvular continence (p = 0.28).

Conclusions

In our experience, the mid-term outcome of repair in IE is comparable to valve replacement and should be considered whenever possible, as in degenerative valve disease. The review of the literature supports this strategy.

Outcomes of mitral valve repair in acute native mitral valve infective endocarditis

OBJECTIVES

Mitral valve repair (MVR) is considered the treatment of choice for mitral valve (MV) regurgitation. However, MVR in acute native MV infective endocarditis is technically challenging and not commonly performed. Our goal was to report our outcomes of MVR in acute native MV infective endocarditis.

METHODS

Between January 2016 and December 2017, 35 patients presenting with acute native MV infective endocarditis underwent MVR. Primary end points were successful MVR and freedom from recurrent endocarditis. Secondary end point was the postoperative incidence of major adverse events.

RESULTS

The mean age was 58 ± 13 years (74% men) and the median logistic EuroSCORE was 17.1%. Twenty patients underwent isolated MVR; the other 15 patients underwent concomitant procedures. MVR was performed with removal of the vegetation (vegectomy), limited resection of the infected tissue, direct closure of the defect, besides annuloplasty in all patients. Mean intensive care and hospital stays were 5 and 17 days, respectively. All-cause mortality was 11% (4/35) at 30 days and a total of 23% (8/35) within a follow-up period of 10 ± 7.7 months. Endocarditis recurred in 2 patients 15 and 8 months after surgery, respectively. Both underwent successful MV re-repair. Follow-up echocardiography indicated none-to-trace, mild or moderate regurgitation in 15, 10 and 2 patients, respectively.

CONCLUSIONS

Although MVR in acute native MV infective endocarditis is a complex procedure, it offers a treatment option for such patients with acceptable short-term results. Limited resection in addition to annuloplasty is our preferred method of repair. Nevertheless, long-term results in a larger cohort are still mandatory.

Early Operation in Patients With Mitral Valve Infective Endocarditis and Acute Stroke Is Safe

BACKGROUND

To determine if preoperative embolic stroke is associated with an increased risk of postoperative stroke among patients undergoing early operation for mitral valve (MV) infective endocarditis (IE), we compared outcomes among patients presenting with and without acute stroke.

METHODS

From 2003 to 2015, 243 consecutive patients underwent surgery for active MV IE. Patients were categorized into 2 groups: 72% (174 of 243 patients) with no preoperative acute stroke (clinical, radiographic or both) and 28% (69 of 243 patients) with stroke. Both preoperative and postoperative strokes were confirmed in all patients with brain computed tomography or magnetic resonance imaging and comprehensive examination by a neurologist.

RESULTS

Among patients presenting with stroke, 33% (23 of 69 patients) were asymptomatic and had only positive imaging findings. The median time from admission to operation was 5 days. The overall rate of new postoperative stroke was 4% (10 of 243 patients). The rate of postoperative stroke was not different between the 2 groups: 4% (7 of 174 patients) among patients with no preoperative stroke and 4% (3 of 69 patients) with stroke (p = 0.9). One patient developed a hemorrhagic conversion of an acute infarct. Operative mortality was 7% (13 of 174 patients) among patients with no preoperative stroke and 7% (5 of 69 patients) among patients with stroke (p = 0.9).

CONCLUSIONS

MV surgery for IE and acute stroke can be performed early with a low risk of postoperative neurologic complications. When indicated, surgical intervention for MV IE complicated by acute stroke should not be delayed.

Minimally invasive valve surgery in high-risk patients

The use of minimally, or less invasive, approaches to cardiac valve surgery has increased over the past decade. Because of its less traumatic nature, early studies in lower risk patients demonstrated the approach to be associated with an enhanced recovery, increased patient satisfaction, and good operative outcomes. With time, despite a steep learning curve, surgeons expanded this approach to perform more complex procedures, and include patients with more co-morbidity. The aim of this publication is to review the current literature involving the use of minimally invasive valve surgery (MIVS) in higher-risk patients.

Nephrologists Hate the Dialysis Catheters: A Systemic Review of Dialysis Catheter Associated Infective Endocarditis

A 53-year-old Egyptian female with end stage renal disease, one month after start of hemodialysis via an internal jugular catheter, presented with fever and shortness of breath. She developed desquamating vesiculobullous lesions, widespread on her body. She was in profound septic shock and broad spectrum antibiotics were started with appropriate fluid replenishment. An echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet. CT scan of the chest, abdomen, and pelvis showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts. There was splenomegaly with triangular hypodensities consistent with splenic infarcts. Blood cultures repeatedly grew Candida albicans. Despite parenteral antifungal therapy, the patient deteriorated over the course of 5 days. She died due to a subsequent cardiac arrest. Systemic review of literature revealed that the rate of infection varies amongst the various types of accesses, and it is well documented that AV fistulas have a much less rate of infection in comparison to temporary catheters. All dialysis units should strive to make a multidisciplinary effort to have a referral process early on, for access creation, and to avoid catheters associated morbidity.

Paravalvular abscess of the mitral valve with fistula to the left ventricle and detachment of the coronary sinus in a young woman

Infective endocarditis (IE) of the mitral valve (MV) manifesting paravalvular abscess (PA) is challenging. A 30-year-old woman presented with PA fistulating to the left ventricle, detachment of the coronary sinus and systemic embolization. During a course of fever of unknown origin, the patient received laparoscopic surgery under the diagnosis of strangulating intestinal obstruction due to colitis. Following abdominal surgery, abscess having blood flow within it from the left ventricle was pointed out at the left ventriculo-atrial junction by transthoracic echocardiography. Emergency surgery was performed under the diagnosis of PA of MV. Abscess debridement followed by reconstruction of the mitral annulus and coronary sinus with fresh autologous pericardium and mitral valve replacement (MVR) using a mechanical prosthetic valve were successfully performed. Timely and accurate diagnosis followed by the early surgical intervention with aggressive debridement of abscess and reconstruction with autologous pericardium should improve the outcome of this high-risk disease.