Surgery for infective endocarditis: determinate factors in the outcome

AIM: The appropriate operative procedures for treatment of infective endocarditis (IE) are still controversial. The authors reviewed their own operative results focusing on preoperative risk factors, intraoperative findings and operative procedures. METHODS: The authors reviewed the cases of 40 adult patients who had undergone surgery since 1999. The mean age of patients was 58 years ranging from 31 to 78 including 30 males and 10 females. Thirty-three patients had native valve endocarditis (NVE) and the remaining seven patients had prosthetic valve endocarditis (PVE). Diseased lesions were located in the mitral valve (MV) in 21 patients, aortic valve in 15 and mitral plus aortic valves in four. Twenty-eight patients (70%) were operated on during the active phase of IE. Streptococcus, Staphyrococcus and Enterococcus species were predominant in the bacterial examination. RESULTS: Active vegetation was observed in 26 (65%) patients. Perforation of valve leaflets was observed in 11 (28%) cases. Changes of native MV leaflet were mild in 8 (40%) out of 20, which seemed to be reparable, while, changes of the native aortic valve leaflet were moderate to severe in 13 (87%) out of 15 patients. Valvular annuls were involved in the infection in 17 (43%) patients. Of the 33 NVE patients, prosthetic valve replacement was performed in 29 patients incduding 19 mitral and 15 aortic valves. MV plasty was performed in 4 patients. In seven PVE patients, prosthetic MV replacement was performed twice. In the aortic group, three patients underwent aortic root translocation, The Ross procedure and standard root replacement were performed respectively. Four patients died after surgery including one NVE case and three PVE cases. Three PVE patients who underwent aortic root translocation or the Ross procedure survived. The hospital mortality of NVE and PVE surgery was 3% and 43% (P<0.01), respectively. By univariant anlysis, there were no significant correlations between operative results and preoperative factors such as bacteria, infective phase, cardiac failure, renal failure, sepsis or brain morbidity. The only significant factor on hospital mortality was PVE. Three patients died of non-cardiac diseases during the follow-up period. CONCLUSION: Operative results of NVE were good after complete resection of infective sites including valve annulus. Both valve replacement and plasty were available for NVE patients. In PVE, new strategies are indispensable and aortic root translocation or the Ross procedure should be a treatment of choice.     

Clinical evaluations of surgical treatment of infective endocarditis

This paper shows the clinical evaluations of surgical and medical treatment of infective endocarditis (IE). IE occurred in 33 cases (10.1%) among 372 cases of valve replacement. Of all the 33 patients, IE was consisted of native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). IE was evaluated as for the microorganism, complication, operative indication and operative mortality. At first, all of NVE underwent surgical treatment, active phase endocarditis 4 and healed endocarditis 14. Microorganism was streptococcus aureus in an overwhelming majority. Operative indications was congestive heart failure in almost all cases, next to vegetation and infection resistant to medical treatment. Operative mortality was 5.6% (1 out of 18 cases), which case was in the septic shock and cerebral bleeding prior to the surgical treatment. The others was satisfactory condition postoperatively. Next of PVE, PVE happened in 15 cases, in which there were 5 cases of bioprosthetic PVE and 10 cases of mechanical valve PVE. Microorganism for PVE was staphylococcus epidermidis in the major part (60%). Mortality in PVE was 53.3% (8 out of 15), but mechanical valve PVE was worse in prognosis than bioprosthetic PVE. Cerebral complications occurred in 3 cases of mechanical valve PVE, on the other hand there was no cerebral complication in bioprosthetic PVE. As for the hemodynamic change in PVE, mechanical valve PVE had the tendency to take the prompt or sudden deterioration of hemodynamics caused by endocarditis surrounding the suture ring, especially in mitral position, on the contrary hemodynamic deterioration was gradually proceeded in bioprosthetic PVE. UCG made much of the diagnosis of PVE, especially in mechanical valve PVE, in which cases endocarditis was recognized only surrounding the suture ring. PVE takes the miserable outcome in many cases, so carefully observation is necessary in order not to lose the timing of the surgical treatment.     

Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis

BACKGROUND: The objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis. METHODS: A retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute. RESULTS: Seventy-seven patients (57 men and 20 women, mean age 48 +/- 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 70% +/- 9%, 59% +/- 10%, and 55% +/- 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 45% +/- 10%, 40% +/- 10%, and 36% +/- 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% +/- 9% following aortic valve replacement and 79% +/- 9% following mitral valve replacement. Five-year survival for PVE averaged 66% +/- 12% following aortic valve replacement and 43% +/- 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2. CONCLUSIONS: Prosthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.     

Surgical aspect of active infective endocarditis

Twenty patients with active infective endocarditis, 11 with native valve endocarditis (NVE) and 9 with prosthetic valve endocarditis (PVE), were treated surgically from 1975 through April 1987 at Kyushu University Hospital. The operative indications were congestive heart failure mainly due to massive aortic regurgitation in 18, periannular abscess in 6, major embolism in 5 and severe hemolysis in 3 patients. In the group of NVE, single aortic valve replacement was performed in 4 patients and multiple valve replacement in the remainder. One patient died early postoperatively from LOS. Two patients with recurrent infective endocarditis, which occurred within 60 days after previous prosthetic valve replacement, were operated subsequently as early PVE. All other patients became NYHA class I postoperatively except for one patient who died from thrombosed valve. In the group PVE, re-AVR was done in 3, re-MVR in five, double valve replacement in two and re-fixation of the prosthesis to the aortic annulus in one patient. Two patients with early PVE died from recurrent endocarditis late postoperatively. One of 7 patients with late PVE, who had suffered from myocardial and cerebral infarction before reoperation, died from multiple organ failure. There were 3 patients with perivalvular leakage due to late active PVE, whose preoperative signs of inflammation were negative or minimum. As recurrent perivalvular leakage due to persistent infective endocarditis might frequently occur in such cases, complete resection and debridement of infected foci should be emphasized.     

Surgical management of infective endocarditis

We reviewed fourty-six patients who had undergone surgery for infective endocarditis in the past fifteen years and identified risk factors affecting the outcome. Twenty-nine patients had infection of the native valve only, 11 had infective endocarditis associated with congenital heart disease, and 6 had prosthetic valve endocarditis. Overall hospital mortality was 6.5%. Prosthetic valve endocarditis carried a higher mortality (33%) than native valve endocarditis (3.4% or congenital heart disease with infective endocarditis (0%). For the patients with active endocarditis, the early mortality rate was higher (13%) than with inactive endocarditis (3.2%). Staphylococcal infections were more likely to cause severe valve destruction and residual infection than streptococcal infection. Our results indicated that surgical management of infective endocarditis should be done after the completion of adequate antibiotic therapy. Early diagnosis should reduce the mortality, prevent fatal complications, and lead to qualitative improvement of infective endocarditis.     

Surgical management for active infective endocarditis: A single hospital 10 years experience

Objective  Surgical treatment of active infective endocarditis (IE) requires not only homodynamic repair, but also, special emphasis on the eradiation of the infection to prevent recurrence. This study was undertaken to examine the outcome of surgery for active infective endocarditis. Methods  One hundred sixty-four consecutive patients (pts) underwent valve surgery for active IE in Madani Heart Centre (Tabriz, Iran) from 1996 to 2006. Patients presenting with IE diagnosis (according to Duke Criteriaset) were eligible for study. Results  The mean age of patients was 36.3±16 years overall: 34.6±17.5 years for native valve endocarditis and 38.6±15.2 years for prosthetic valve endocarditis (p=0.169). Ninety one (55.5%) of patients were men. The infected valve was native in 112 (68.3%) of patients and prosthetic in 52 (31.7%). In 61 (37%) patients, no predisposing heart disease was found. The aortic valve was infected in 78 (47.6%), the mitral valve in 69 (42.1%), and multiple valves in 17 (10.3%) of patients. Active culture-positive endocarditis was present in 81 (49.4%) whereas 83 (50.6%) patients had culture-negative endocarditis. Staphylococcus aureus was the most common isolated microorganism. Ninety patients (54.8%) were in NYHA classe III and IV. Mechanical valves were implanted in 69 patients (42.1%) and bioprostheses in 95 (57.9%), including homograft in 19 (11.5%). There were 16 (9%) operative deaths, but there was only 1 death in patients that underwent aortic homograft replacement. Reoperation was required in 18 (10.9%) of cases. On multivariate logistic regression analysis, Staphylococcus aureus infection (p=0.008), prosthetic valve endocarditis (p=0.01), paravalvular abscess (p=0.001) and left ventricular ejection fraction less than 40% (p=0.04) were independent predictors of inhospital mortality. Conclusions  Surgery for infective endocarditis continues to be challenging and associated with high operative mortality and morbidity. Prosthetic valve endocarditis, impaired ventricular function, paravalvular abscess and Staphylococcus aureus infection adversely affect in-hospital mortality. Also we found that aortic valve replacement with an aortic homograft can be performed with acceptable in hospital mortality and provides satisfactory results.     

Active infective endocarditis: low mortality associated with early surgical treatment

BACKGROUND: Early surgical treatment is important for successful outcome in selected cases of active, either native (NVE) or prosthetic valve endocarditis (PVE). The aim of this study was to evaluate the early results of the surgical treatment of active NVE and PVE. METHODS: During a 3-yr period (January 1 1996-December 31 1998), 57 out of 60 patients (pts) with active, either NVE (46 pts) or PVE (11 pts) underwent surgical treatment. There were 11 women (23.9%), average age of the group being 43.3+/-9.1yr (18-73). They were operated on 12-35days, mean 17.7+/-7.5days (for NVE) and 5-33days, mean 13.2+/-10.1days (for PVE) after the diagnosis of endocarditis was first suspected. All pts had at least one absolute indication for early surgical treatment, the most frequent being (in NVE) worsening heart failure (19 cases) and inability to control the infection (10 cases), while in PVE it was valve dehiscence (8 cases). In 8 cases of NVE and 2 cases of PVE fresh, antibiotic sterilized aortic homograft was used to replace the aortic valve. RESULTS: Operative mortality was 1.8% (1/57) and hospital mortality 5.2% (3/57). Three pts with PVE died before they were operated on, giving an overall mortality of 10% (6/60). Postoperative morbidity included valve dehiscence in two pts (probable late onset recurrent endocarditis - 3.5%), three episodes of acute renal failure (5.3%), four cases of respiratory insufficiency (7.0%) and one chronic pleural effusion (1.8%). All pts that were discharged from the hospital (54/60), are still alive and well 1-35months postoperatively (mean 20.3+/-9.6months), including pts with recurrent endocarditis and valve dehiscence, after they were successfully reoperated. CONCLUSIONS: Along with early diagnosis and appropriate antibiotic treatment, aggressive surgical attitude is of importance for the successful outcome in this group of seriously ill patients. Our data indicate that early surgical treatment in cases of active endocarditis may be associated with low mortality and morbidity.     

Evaluation of the practice of routine culturing of native valves during valve replacement surgery

BACKGROUND: We routinely cultured native heart valves removed during valve replacement surgery even when infected carditis (IE) was not suspected. Several probable contaminated cultures prompted us to evaluate this practice. METHODS: The medical records of all patients who had positive valve cultures from 1995 to 1997 were reviewed for admission diagnoses, operative surgery, pathology and microbiology report, postoperative infections, and antibiotic use. Cases were excluded only for incomplete medical records or preoperative suspicion of IE. Long-term outcome for the cases was obtained from review of outpatient records and phone contact with the patient or physician. RESULTS: Thirty-two of 222 (14.4%) evaluable patients had positive valve cultures. Coagulase-negative Staphylococcus was the most common isolate. IE was not suggested in any of these cases based upon the surgical or the pathology report. Only 1 of 32 (3%) developed postoperative prosthetic valve endocarditis (PVE). Three patients died of unrelated causes, and the 28 surviving patients showed no sign of PVE, with a mean follow-up of 23 months. CONCLUSIONS: The incidence of false-positive native valve cultures is high. Positive cultures did not predict the occurrence of PVE sufficiently to justify obtaining them. Treating patients who had positive native valve cultures would have been unwarranted and poses an unnecessary risk.     

Antibiothérapie curative et prophylactique des endocardites infectieuses

Durack's criteria, including echocardiographic manifestations, are the current standard for the diagnosis of infective endocarditis (IE). The most common microorganisms known to cause IE are streptococci and staphylococci, and therapeutic principles are based on an association of parenteral antibiotics, as far as possible bactericidal and prolonged. Treatment also includes the search for the source of infection and its eradication. IE with negative blood cultures requires special techniques to obtain the causal microorganisms. In about half of the cases, a nosocomial bacteriaemia results in IE in patients with a prosthetic valve. Surgery is mandatory in IE with complications and/or caused by particular microorganisms; surgery is essential in most patients with a prosthetic valve. Although the presence of specific links between some procedures and the occurrence of IE has not been clearly proven, a prevention policy is nevertheless justified, considering the morbidity and mortality. Prophylaxis is indicated in patients with the cardiac conditions at risk for IE. IE prophylaxis prevails over prophylactic antibiotics usually administered for surgery. © 1998 Elsevier, Paris     

Surgical treatment of active infective endocarditis and prosthetic valve endocarditis]

Fifteen patients with active native valve endocarditis (NVE) and 5 with prosthetic valve endocarditis (PVE) were subjected to this study. Among the patients with NVE, one of 10 with simple destruction of leaflets and 2 of 5 with annular infection died postoperatively of cerebral bleeding and persistent infection. Five patients with annular infection, whose microorganisms were Streptococcus faecalis, Staphylococcus epidermidis and gram-negative coccus, had a shorter duration from onset to operation (mean 38 days) compared with the others (mean 85 days). A patient with NVE requires an urgent operation, especially when these microorganisms are identified. Among those with PVE, 3 underwent operation at the active phase and one at the chronic phase. Two patients with mechanical valve endocarditis by Staphylococcus and Candida died, but the other 2 with bioprosthetic valve endocarditis by alpha-Streptococcus survived, because infection was localized in the leaflets. Another patient with mechanical valve endocarditis by alpha-Streptococcus survived with conservative management. While a patient with bioprosthetic valve endocarditis requires an early operation as well as NVE, a patient with mechanical valve endocarditis requires selected management considering the microorganism and general condition.     

Surgical treatment of paravalvular abscess: long-term results.

OBJECTIVE: To examine the outcomes of surgery for active infective endocarditis with paravalvular abscess. METHODS: Paravalvular abscess was defined as infective necrosis of the valve annulus that required patch reconstruction before implanting a new valve. Of 383 patients with active infective endocarditis who underwent surgical treatment, 135 (35%) had paravalvular abscess. Patients' mean age was 51+/-16 years and 68% were men. The infected valve was native in 69 patients and prosthetic in 66. The abscess involved the aortic annulus in 73 patients, the mitral annulus in 27, the aortic and mitral annuluses in 33, and the aortic and tricuspid and/or pulmonary annuluses in 2. Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches and valve replacement. Mean follow-up was 6.2+/-5.2 years and complete. RESULTS: There were 21 (15.5%) operative deaths. Preoperative shock and abscess in the aortic and mitral annuluses were independent predictors of operative death. There were 34 (25%) late deaths. Survival at 15 years was 43+/-6% for all patients, 50+/-8% for native valve endocarditis and 35+/-9% for prosthetic (p=0.41). Age by increments of 5 years and recurrent endocarditis were independent predictors of late death. There were 16 episodes of recurrent endocarditis in 15 patients, and the freedom from recurrent endocarditis was 82+/-4% at 15 years. Fifteen reoperations were performed in 14 patients. Freedom from reoperation was 72+/-9% at 15 years. CONCLUSIONS: Surgery for active endocarditis with paravalvular abscess was associated with high operative mortality, particularly in patients in shock and abscess of both mitral and aortic annuluses. Long-term survival was adversely affected by age and recurrent bouts of endocarditis.     

Stentless Porcine Bioprostheses in the Treatment of Aortic Valve Infective Endocarditis

Between January 1992 and June 1994, 23 patients underwent surgery for aortic valve endocarditis at the Department of Cardiovascular Surgery of the University of Verona; a subgroup of 10 patients underwent aortic valve replacement with a porcine stentless valve (Biocor LTDA n = 8; Toronto SPV n = 2). There were 7 males and 3 females with a mean age of 56.3 years (range, 36 to 73 years). Eight patients had active endocarditis and two had healed endocarditis. Nine patients had native valve in endocarditis, the presence of a bicuspid aortic valve in 2, and 1 patient had recurrent prosthetic valve endocarditis (PVE), 7 of whom were in New York Heart Association (NYHA) Functional Class IV. The main indications for operation were congestive cardiac failure, active sepsis, and presence of large and mobile vegetations by echo and arrhythmias. There were no operative or late mortalities in this subgroup of patients. Short-term survival is 100% at a mean follow-up time of 11.2 months (range, 4 to 18 months), with no recurrent endocarditis or valve-related complications.     

Early valve replacement in active infective endocarditis

Infective endocarditis is associated with a high mortality, but previous studies have suggested that the major complications of the condition might be prevented by early surgery. Of 50 patients treated for infective endocarditis at the Montreal Heart Institute from 1977 to 1982, 30 were treated nonsurgically and the remaining 20 underwent early valve replacement before preoperative antibiotic therapy was completed. Of these 20, 14 had native valve endocarditis and 6 prosthetic valve endocarditis. The organisms involved were Streptococcus sp in 11, Staphylococcus aureus in 2, gram-negative organisms in 3 and Candida parapsilosis in 1. Blood cultures remained negative in three patients. There were three early deaths (15%) following operation and one late death (5%). Infection on implanted prostheses did not recur, but reoperation was required in one patient because of prosthetic dehiscence 7 months after initial implantation. All resected valves displayed evidence of infection. Follow-up was obtained in all survivors. After an average follow-up of 26 months, 12 patients remained in functional class I and 4 in class II (New York Heart Association classification). Early valve replacement has resulted in improved survival of patients with infective endocarditis and is now associated with a low operative mortality and morbidity.     

Early and late outcomes after reoperation for prosthetic valve endocarditis

OBJECTIVE: Prosthetic valve endocarditis remains a challenging complication after heart valve replacement. To identify predictive risk factors, we have reviewed 30 patients who underwent surgery for prosthetic valve endocarditis between March 1986 and May 1999. METHODS: There were 15 men and 15 women (mean age 51 years). Prosthetic valve endocarditis was classified as early (< or = 1 year after operation) in 10 cases, and as late in the other 20 cases. The most common indication for surgery was moderate to severe congestive heart failure due to prosthetic valve dysfunction in 21 (70%) patients. The average follow-up period was 6.5 years, with a range of 0.3 to 14.1 years. RESULTS: The most common microorganism was Staphylococcus epidermidis in both patients with early (50%) and late prosthetic valve endocarditis (25%). The in-hospital mortality was 13.3% (4/30). There were six late deaths. The actuarial survival at 5 years was 78% and 66% at 10 years. An early onset of prosthetic valve endocarditis was the only significant determinant of both in-hospital mortality (p = 0.005) and overall mortality (p = 0.021). Emergency surgery had a statistically significant relationship with in-hospital mortality (p = 0.045). No significant influence on mortality after reoperation for prosthetic valve endocarditis was found in age, sex, valve position, antecedent native valve endocarditis, or in the type of pathological findings (ring abscess, valve dehiscence, and vegetation). CONCLUSION: Early onset of prosthetic valve endocarditis and emergency surgery were important risk factors for mortality due to prosthetic valve endocarditis.     

Surgical management of acute aortic root endocarditis with viable homograft: 13-year experience.

OBJECTIVE: Cryopreserved homograft valves have been used for acute infective aortic root endocarditis with great success but it is compounded by its availability in all sizes. The long-term clinical results of geometric mismatched homografts are not well defined and addressed. METHODS: Over a 15-year period (April 1986-June 2001), 816 patients presented with active infective endocarditis. One hundred and eighty-two of the patients aged between 9 and 78 years (mean: 51.0 +/- 1.13 years) consisting of 142 males and 40 females received homograft aortic valves. One hundred and ten patients were in NYHA functional class III and 72 in class IV and in cardiogenic shock. Of the patients, 2.7% suffered from septic embolism. One hundred and twenty-four (68.1%) patients presented with periannular abscesses and 58 (31.9%) with no abscess while 107 native valve (NVE) and 75 prosthetic valve (PVE) endocarditis were diagnosed preoperatively by transesophageal echocardiography (TEE) and confirmed intraoperatively. Freehand subcoronary implantation (FSCI) was used in 106 patients and root replacement in 76 patients. RESULTS: The operative death was 8.5% and for patients in NYHA functional class IV and in cardiogenic shock was 14.5%. Late mortality rate was 7.9%. Patient survival after discharge from hospital at 1 year was 97% and at 10 years was 91%, respectively. Thirty-one (22.1%) patients underwent reoperation after 1.7 years (mean) with two deaths (6.4%). Early (< or = 60 days) and late reinfection rate was 2.7 and 3.6%, respectively. Freedom from reoperation for matched and undersized homografts at 10-13 years was 85 and 55%, respectively. The univariate model identified undersized homograft (P=0.002), FSCI (P=0.09) and reinfection (P=0.0001) as independent risk factors for developing early and late valve dysfunction resulting in reoperation and homograft explant. CONCLUSION: Early aggressive valve replacement with homograft for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery. Homografts exhibit excellent clinical performance and durability with a low rate of reinfection, if properly inserted. Undersized homograft is an incremental risk factor for early and late reoperation.     

Optimizing outcomes in infective endocarditis: A comprehensive literature review

Background: Despite being rare, infective endocarditis (IE) is a life-threatening disease with poor prognosis. New diagnostic and therapeutic strategies are emerging; however, predisposing factors and microbiology of the disease are also changing with time. Because of this, there has been a lack of reduction in the disease's incidence and new challenges for clinicians have arisen such as an increasingly aging population and growing antimicrobial resistance. Aims: In this paper, we aim to provide an overview of the changing trends in IE, current diagnosis, and management strategies, as well as the emerging role of the infective endocarditis teams in the care of patients with this disease. Materials & Methods: A comprehensive electronic search was done utilizing PubMed, Ovid, SCOPUS, Embase and google scholar. The search terms included ‘Endocarditis’, ‘IE’, ‘Infection’, ‘Vegetation’, ‘Duke criteria’, ‘native valve infection’, ‘prosthetic valve’, ‘valve infection’, ‘endocarditis outcome’ and ‘endocarditis bacteriology’. The references of the identified articles were then searched for any potential articles that can be included. The inclusion criteria were any article that discussed the evidence behind incidence and management of IE including the role of endocarditis team. The exclusion criteria were case reports, expert opinion, and editorials. Results: All the relevant findings are summarized in specified tables and within appropriate sections. Discussion: It is vital to determine the current trends in the epidemiology and microbiology of the condition so that the diagnostic threshold can be adapted, to identify new at-risk groups and achieve an accelerated evaluation strategy that allows for earlier diagnosis and treatment. Conclusion: Management of IE can benefit from the input of different specialties, such as cardiology, cardiothoracic surgery, infectious disease, and microbiology. Therefore, adopting a multidisciplinary approach towards treatment is crucial to reduce morbidity and mortality from preventable complications of this pathology.     

A case report of early valve replacement surgery in infective endocarditis with mycotic cerebral aneurysm

Mycotic cerebral aneurysm is a relatively infrequent complication of infective endocarditis. However, rupture and intra-cranial hemorrhage involves so high a mortality that few patients can be saved from this condition. We reported a 22-year-old woman with mitral regurgitation and ruptured mycotic cerebral aneurysm caused by infective endocarditis. Vegetation floating between the left atrium and the ventricle was observed by UCG. It was difficult to decide which operation should be done first, valve replacement or excision of cerebral aneurysm. To avoid further intracerebral bleeding caused by anticoagulant therapy connected with cardiotomy, the cerebral aneurysm was excised prior to the valve replacement. Mitral valve was replaced with a Bj?rk-Shiley prosthetic valve 48 hours after the craniotomy. The postoperative course was uneventful and no neurological deficit was found. This report indicates that valve replacement surgery can be successfully performed only 48 hours after craniotomy without any bleeding complications.     

Long-term results of multivalve surgery for infective multivalve endocarditis.

OBJECTIVE: The natural history of medically treated multivalvular endocarditis is associated with dismal short and long term survival. However, the impact of surgical intervention on these results is relatively unknown. The objective of this retrospective study was to report our long-term results in patients requiring multivalve surgery for multivalvular endocarditis. METHODS AND RESULTS: Over a 24 year period beginning in 1972, multivalve surgical procedures were performed on 63 patients for infective endocarditis. Prosthetic valve endocarditis was present in 25 (40%), and acute or active endocarditis in 38 (60%). The early mortality was 16%. Out of 53 patients discharged from the hospital 87+/-4% were alive at 5 years and 64+/-9% at 10 years. There was no difference in early or late mortality between patients with prosthetic and native endocarditis (P=0.15 and P=0.77 for early and late mortality, respectively). The presence of active endocarditis did not affect operative outcome or late mortality. Twenty-one patients (88%) were in NYHA FC I, and none were in NYHA FC IV. The only prognostic factor of early and late mortality was the presence of an abscess at the time of the surgery. CONCLUSIONS: These results indicate that multivalve infective endocarditis treated surgically is associated with acceptable early and late mortality and excellent postoperative functional status. The early surgical intervention prior to an abscess formation offers the best chance for survival of patients with multivalve endocarditis.     

Rarity of invasiveness in right-sided infective endocarditis

Objective

The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right- versus left-sided IE in surgically treated patients.

Early surgery for hospital-acquired and community-acquired active infective endocarditis

Active infective endocarditis (IE) is classified into two groups; hospital acquired IE (HIE) and IE other than HIE, which was defined as community-acquired IE (CIE). Eighty-two patients underwent surgical treatment for active IE. Seventy-one cases were CIE group and eleven were HIE. There were six patients with native valve endocarditis and five cases of prosthetic valve endocarditis in the HIE group. We compared the surgical outcome of both types of active IE retrospectively. The preoperative status of the patients in the HIE group was more critical than that in the CIE group. Streptococcus spp. were the major micro-organisms in the CIE group (39%), while 82% of the HIE cases were caused by Staphylococcus spp. All Staphylococcus organisms in the HIE group were methicillin resistant. There were 10 hospital deaths, three in the CIE group and seven in the HIE group. Operative mortality in the HIE group was significantly higher than in the CIE group (63.6% vs. 4.2%, P<0.001). The outcome of early operation was satisfactory for active CIE, but poor for HIE. These types of active IE should be considered separately.