Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body

Surgical Challenges in Infective Endocarditis: State of the Art

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

Early outcomes of the "Chimney" commando procedure in the small aortic and mitral annuli

BACKGROUND

Commando procedure, the surgical replacement of the mitral and aortic valves combined with reconstruction of the fibrosa fibrous body, is a technical challenge in patients with small aortic and mitral annuli. In this study, we evaluated the safety and early outcomes of the "Chimney" modality of the Commando procedure, in patients with small aortic and mitral annuli, after prior valve surgery, using a self-assembled valved conduit.

METHODS

From April 2021 to April 2022, 30 consecutive cases of the "Chimney" Commando procedure, with a self-assembled valved conduit and other combined cardiac procedures, were fully performed for re-operative patients with small aortic roots. Data were obtained through a medical record review, at the Asian Heart Hospital in Wuhan, China.

RESULTS

The patient's mean age was 52.7 ± 13.53 years, with 93.3% females. All patients had a previous heart valve surgery, 90% of which had double valve replacement (DVR). Hospital death occurred in 3.3% (n = 1) of the patients, due to malignant arrhythmias and multiorgan failure. Postoperative echocardiogram exams showed that the sizes of the aortic and mitral valve prostheses were 24.23 ± 1.60 mm and 28.33 ± 1.21 mm, respectively. All patients had intact intervalvular fibrosa (IVF) repair and no patient had any aberration in the left heart chamber communication. With the exception of one postoperative sick sinus syndrome and one re-sternotomy for bleeding, there were no significant postoperative complications, such as mortality, renal failure requiring ongoing dialysis, or mediastinitis. Echocardiography exams in the sixth postoperative month showed that the mean gradients of the aortic and mitral valves were 16.26 ± 6.44 mmHg and 11.24 ± 4.90 mmHg, respectively.

CONCLUSIONS

In comparison with the standard Commando operation, the early outcomes and safety of the "Chimney" Commando procedure proved to be a feasible therapeutic option for patients with small aortic and mitral annuli, after prior valve operations. This approach enables the enlargement of the aortic and mitral annuli and the implantation of the necessary valve prosthesis.

Mid-term outcomes following the Hemi-Commando procedure for complex infective endocarditis involving the aortomitral junction

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.

Aorto-mitral curtain reconstruction in invasive double-valve endocarditis: mid-term outcomes

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.

Surgical Outcomes After Reconstruction of the Aortomitral Curtain

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.

Early and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation

OBJECTIVES

To analyze the early and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI).

METHODS

Retrospective single-center analysis of early and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival.

RESULTS

During the study period a total of 5756 patients underwent TAVI. Amongst them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013-2016 and 2017-2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. Median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). Median elapsed time between TAVI and redo SAVR was 7 months (3.5 -14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (p = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% CI; 22.0% - 78.0%) vs 58.3% (95% CI; 30.0% - 100%) survival at 24 months (p = 0.3)].

CONCLUSION

SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

Modification of Reconstruction of Left Ventricular Outflow Tract, Aortic Root and the Intervalvular Fibrous Body for Extensive Infective Endocarditis: A Single Center Experience

BACKGROUND

Extensive infective endocarditis stays a serious life-threatening disease with high mortality and morbidity. The aim of this study is to analyze our experience with our modified surgical technique for extensive infective endocarditis during the last 4 years.

METHODS

Between March 2017 and February 2021, all patients with extensive infective endocarditis required our modified technique consisting of a radical surgical resection of all infected cardiac tissues, the replacement of infected valves, and a reconstruction of the intervalvular fibrous body, the aortic root and the left ventricular outflow tract with modified elephant trunk were included in this study.

RESULTS

Our modified technique was performed on 41 patients during the study period. The age median was 74 (IQR: 66.5 - 76.5) and 61.0% (n = 25) were female. 33 patients (80.5%) were in New York Heart Association Class III-IV and 7 patients (17.1%) in cardiogenic shock. The median logistic EuroSCORE II as predicted risk of mortality was 35% (IQR: 28% - 78%). Median cardiopulmonary bypass time and cross-clamping time were 126 (IQR: 86.5-191) min and 78 (IQR: 55.5-108) min, respectively. Intraoperative mortality and 30-day mortality were 4.8% (2 patients) and 19.5% (8 patients), respectively. Low cardiac output with necessity for mechanical support, stroke and new renal dialysis developed in 9.8% (4 patients), 17.1% (7 patients), and 22.0% (9 patients), respectively. New pacemaker implantation was noted in 39.0% (16 patients). Intensive care stay and hospital stay had medians of 6 (IQR: 5-12) and 14 (IQR: 12.5-20.5) days, respectively. One-year mortality and 4-years mortality were 34.1% (14 patients) and 39.0% (16 patients), respectively. Kaplan-Meier survival estimates were 60.3% (95% CI: 46.2 - 78.6%) at 3 years.

CONCLUSIONS

Our modified technique can be performed in patients with extensive infective endocarditis with acceptable early and mid-term morbidity and mortality. We believe that this technique is an available option for this ill-fated group of patients.

Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart

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.

Outcomes of surgery for extensive infective endocarditis

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.

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

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

Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis

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).