Heart valve operations in patients with active infective endocarditis

Sixty-two consecutive patients underwent heart valve operation for active infective endocarditis. There were 42 men and 20 women whose mean age was 49 years (range, 21 to 79 years). The infection was in the aortic valve in 37 patients, the mitral valve in 18, the aortic and mitral valves in 5, and the tricuspid valve in 2. Twenty-four patients had prosthetic valve endocarditis. Staphylococcus and Streptococcus were responsible for 86% of the infections. Annular abscess was encountered in 33 patients. Complex valve procedures involving reconstruction of the left ventricular inflow or outflow tract or both were performed in 31 patients. There were three operative deaths (4.8%). Predictors of operative mortality were prosthetic valve endocarditis, preoperative shock, and annular abscess. Patients were followed for 1 month to 130 months (mean follow-up, 43 months). Only 1 patient required reoperation for persistent infection. There were ten late deaths. Most survivors (96%) are currently in New York Heart Association class I or II. The 5-year actuarial survival was 79% +/- 7%. These data demonstrate excellent results in patients with native valve endocarditis, and support the premise that patients with prosthetic valve endocarditis should have early surgical intervention.     

Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement.

Patients (n = 195) undergoing aortic valve replacement (n = 209) for native or prosthetic valve endocarditis were studied to determine risk factors for death and recurrent endocarditis and also to determine the valve type least likely to be associated with recurrent endocarditis. Ten-year survival was 60%, the highest risk of dying occurring within the first 3 postoperative months. Risk factors for death in this early phase included increased urea concentration, higher New York Heart Association functional class, prosthetic valve endocarditis, infection status (lower in patients with healed endocarditis), longer duration of cardiopulmonary bypass, and nonuse of an allograft valve. In the late phase (beyond 3 months), risk factors included age at operation and Staphylococcus aureus infection (only in New York Heart Association functional class V). Ten years after aortic valve replacement, 79% of valves were free of recurrent endocarditis. The highest risk of recurrence was in the first 4 months. Longer duration of cardiopulmonary bypass was a weak risk factor for recurrent endocarditis in the early phase, and in the late phase risk factors were S. aureus infection (only in New York Heart Association functional classes III, IV, and V) and the use of now discontinued biologic valves. Allograft aortic valve replacement was shown to be associated with a low and constant risk of recurrent endocarditis, whereas other valve types were associated with a high early risk. The allograft valve should be the preferred replacement device for aortic root infection.     

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.     

Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.     

Early surgery for active infective endocarditis.

OBJECTIVE: The timing of surgery for active infective endocarditis remains controversial. In this report, we have reviewed 26 patients who underwent surgery for active infective native-valve endocarditis between April 1992 and December 1998. PATIENTS AND METHOD: There were 19 male and 7 female patients (mean age 45 years). The aortic valve was involved in 8 patients, the mitral valve in 6 patients, tricuspid valve in 2 patients, both aortic and mitral valves in 7 patients, both aortic and tricuspid valve in 2 patients, and both mitral and tricuspid valve in one patient. The most common microorganisms were streptococcal species. Preoperative high New York Heart Association functional class (III and IV) was presented in 20 patients (77%). Progressive heart failure and the echocardiographic findings of vegetation (larger than 1 cm) were the main operative indications. Emergency or urgent surgery was required in 18 patients (70%). All patients underwent valve replacement, involving 25 mechanical prosthesis and 8 bioprosthesis. RESULTS: The operative mortality was 7.8% (n = 2). In the two patients who died, the infection had extended to the deep cardiac tissue and to the cerebral artery. The mean follow-up of the 24 survivors was 33 months (range from 6 to 82 months). There was no late death and no recurrence of infective endocarditis. CONCLUSION: In case of active infective endocarditis, early surgical intervention is recommended in patients with rapidly progressive cardiac deterioration or vegetation seen on echocardiography.     

原发性感染性心内膜炎瓣膜损害的外科治疗

目的总结２２例原发性感染性心内膜炎（ＰＩＥ）致瓣膜损害的外科治疗经验。方法心脏瓣膜置换术２０例，主动脉瓣和肺动脉瓣病灶清除及瓣膜成形术１例，三尖瓣病灶清除及瓣膜成形术１例。结果手术死亡率１３．６％，早期人工瓣膜心内膜炎１例（４．５％）。随访１５例，随访率６８．２％，随访时间２～８９个月，平均３５．６个月；发生晚期人工瓣膜心内膜炎１例（６．６％），再次手术出院后半月猝死，死因不明。其余１４例情况良好。结论ＰＩＥ致瓣膜损害时应积极手术治疗。只要手术方法正确，抗菌素应用合理，则手术疗效满意     

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices

BACKGROUND: Operation for active infective endocarditis carries high mortality and morbidity rates, especially when the annulus is involved. Overall the literature favors the use of autograft and homograft valves because of better resistance to infection. In our clinic during the last 5 years we used an aggressive surgical approach to infective endocarditis in combination with implantation of mechanical or stented bioprosthetic devices. METHODS: From 1994 to 1999, 50 adults with aortic and/or mitral valve endocarditis underwent valve replacement. The median age of the 36 men and 14 women was 58 years (range, 17 to 78 years). All patients had active endocarditis at the time of operation. Native valve endocarditis was present in 48 patients and prosthetic valve endocarditis was present in 2 patients. The aortic valve was affected in 24 patients, the mitral valve in 21 patients, and both the aortic and mitral valves in 5 patients. Two of the patients with mitral endocarditis also had infection of the tricuspid valve. Annular destruction was present in 24 patients (48%). The patients were treated with radical excision of all infected tissue. The annular defects were closed, if possible, with direct sutures. Otherwise, a reconstruction was performed. Follow-up was 100% complete with a median follow-up period of 45 months (range, 6 to 66 months). RESULTS: The procedures were performed without lethal bleeding complications. Early mortality was 12% and the actuarial survival at follow-up was 80%. In none of the patients who died was death related to the prosthetic valve or recurrence of the endocarditis. Only 1 patient (2%) developed recurrence of the infective endocarditis and was reoperated with a Ross procedure. Three and a half years later the patient developed severe valve insufficiency of the autograft and was operated again with implantation of a mechanical device. CONCLUSIONS: Native and prosthetic valve endocarditis can be treated successfully with aggressive surgical debridement and implantation of mechanical or stented bioprosthetic devices with a low risk of recurrent 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.     

Staged laparoscopic splenectomy and valve replacement in splenic abscess and infective endocarditis

Splenic abscess is a rare clinical entity that is most commonly associated with infective endocarditis. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death. We describe 2 patients with infective endocarditis and splenic abscess treated by laparoscopic splenectomy followed by valve replacement.     

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 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.     

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.     

Bioprosthetic Versus Mechanical Valve Replacement in Patients with Infective Endocarditis

During the 5-year period, 1979-1984, at the Texas Heart Institute, 4,598 patients underwent cardiac valve replacement procedures of which 185 were for acute infective endocarditis. Staphylococcus and streptococcus accounted for 80% of the cases and congestive heart failure was a leading indication in 63%. The purpose of this article is to evaluate the recurrence of endocarditis dependent upon whether the patient had an Ionescu-Shiley bioprosthetic pericardial valve or a mechanical valve (St. Jude Medical). Actuarial freedom from both early and late reoperation was higher for prosthetic valves than bioprosthetic valve patients. We conclude that mechanical valves are the valves of choice in acute infective endocarditis which apparently is the results of less biologic tissue available for exposure to infection by the offending organisms.     

Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses.

A total of 108 patients hospitalized with active (acute) endocarditis on either a native aortic valve (n = 66) or a previously inserted replacement device (n = 42) underwent aortic valve replacement because they were too ill for hospital discharge. A nonstented aortic allograft valve was used in 78 patients and prosthetic (mechanical or bioprosthetic) valves in 30 patients. The survival rate was 82% at 1 months, 73% at 1 year, 64% at 5 years, and 36% at 15 years. It was better in patients with native valve endocarditis than prosthetic valve endocarditis. The incremental risk factors for death in the early phase postoperatively were older age at operation, higher New York Heart Association functional class, and a larger number of previous aortic valve procedures. There were 13 episodes of recurrent endocarditis, giving an actuarial freedom of 80% at 10 years. The hazard function for recurrent endocarditis had only a low constant phase when allograft valves were used, which contrasted with the existence of a high peaking early phase (in addition to the constant phase) when prosthetic devices were used. No risk factors for recurrent endocarditis were found in patients receiving a prosthesis, and "localized" versus "extensive" endocarditis was the only risk factor when an allograft was used. Reoperation was performed in 24 patients for a variety of reasons, and freedom from reoperation was 61% at 10 years. It is concluded that the allograft valve is the valve of choice when aortic valve replacement is required for active endocarditis.     

原发性感染性心内膜炎的外科治疗（附102例报告）

回顾性分析原发性感染性心内膜炎１０２例，其中主动脉瓣病变７１例，二尖瓣病变１６例，主动脉瓣与二尖瓣联合病变６例，三尖瓣病变５例，肺动脉瓣病变４例。按照病人术前心功能状态，分为：（１）急性心功能不全组（２５例）；（２）慢性心功能不全组（７７例）。施行主动脉瓣替换术７１例，二尖瓣替换术１６例，双瓣替换术６例，三尖瓣修复成形术５例，肺动脉瓣成形术４例。术后早期死亡９例（８．８％）。９３例生存者随访时间３个月～１６年，平均随访时间４．３年。晚期死亡６例，其中２例为人工瓣膜心内膜炎，复发率为２％。作者对手术时机与手术方式的选择作了讨论，并介绍了围术期处理的经验。     

Reconstruction of the left ventricle with autologous pericardium

Autologous pericardium was used to reconstruct different parts of the left ventricle in 25 desperately ill patients. Fourteen patients had intractable sepsis resulting from infective endocarditis and myocardial abscess and 10 patients had noninfectious disorders. Of the patients with infections, 12 had valvular endocarditis with periannular abscess and three had interventricular septal abscess. The noninfected patients had acute rupture of the ventricular wall after mitral valve replacement (one patient) heavily calcified or surgically absent mitral anulus (three patients), or rupture of the interventricular septum after acute myocardial infarction (six patients). The interventricular septum, the posterior wall of the left ventricle, and the periannular areas were reconstructed by suturing appropriately tailored pericardial patches directly to the endocardium. In patients who also required valve replacement, the prosthetic valve was partially or completely secured to the pericardial patch. There were three operative deaths. All three patients were in either septic or cardiogenic shock before operation and in none of them was the death related to the pericardial patch. All 22 survivors have been observed from 3 to 34 months, an average of 14 months. There has been no case of patch dehiscence, patch aneurysm, prosthetic valve dehiscence, or recurrent endocarditis. Autologous pericardium appears to be safe for reconstruction of the left ventricle. It is easy to handle and problems with suture line bleeding are practically nonexistent.     

Emergency Aortic Valve Replacement in Active Endocarditis with the Björk-Shiley Tilting Disc Valve Prosthesis

Because of severe and intractable heart failure in three patients with infective endocarditis, an emergency replacement of the aortic valve with a Björk-Shiley prosthesis was carried out. Heart failure, which is the most common cause of death in infective endocarditis, was in these cases due to acute aortic regurgitation caused by perforation and other damage of the aortic valve. One patient died in the early postoperative period because of myocardial damage and respiratory insufficiency. The other two survived and are in relatively good condition after follow-up periods of 2 years and 6 months, respectively. The emergency replacement of incompetent valves may be a lifesaving procedure during the course of active endocarditis.     

Emergency aortic valve replacement in active endocarditis with the Bj?rk-Shiley tilting disc valve prosthesis.

Because of severe and intractable heart failure in three patients with infective endocarditis, an emergency replacement of the aortic valve with a Bj?rk-Shiley prosthesis was carried out. Heart failure, which is the most common cause of death in infective endocarditis, was in these cases due to acute aortic regurgitation caused by perforation and other damage of the aortic valve. One patient died in the early postoperative period because of myocardial damage and respiratory insufficiency. The other two survived and are in relatively good condition after follow-up periods of 2 years and 6 months, respectively. The emergency replacement of incompetent valves may be a lifesaving procedure during the course of active endocarditis.     

Surgical treatment of acute infective valvular endocarditis (18 years experience)

BACKGROUND: Infective endocarditis morbidity remains high: 3 to 8 cases per 100,000 of population. Antibiotic therapy is ineffective. Its surgical treatment experience is relatively limited. Aim: To share the surgical treatment experience of 855 patients with acute infective valvular endocarditis (AIVE) treated during 1982 to 2000 in the Institute of Cardiovascular Surgery AMS, Ukraine. MATERIALS AND METHODS: 855 (75.4%) of 1128 hospitalized patients with AIVE were operated upon. Surgical interventions included removal of diseased tissues, heart chambers treatment with antiseptic solutions, wash out with normal saline solution, replacement or plastic procedure of valves. RESULTS: Heart abscesses were found in 132 (15.5%) patients. Hospital mortality was after aortic valve replacement 12.6%; mitral valve replacement 9.7%; plastic procedure on mitral valve 0%; aortic and mitral valve replacement 30%; tricuspid valve replacement 15.4%; and plastic procedure on tricuspid valve 6.1%. Recurrences of infective process occurred in 51 (6.0%) patients. Infections were observed more frequently in patients with heart abscesses: 10.6% versus 5.7% (p < 0.02). RESULTS: 716 (96.7%) patients were studied 2 to 194 (87.4+/-39.4) months postoperatively. Tenth year postoperative survival was 62.1+/-27.7% including hospital mortality. CONCLUSIONS: (1) AIVE has become one of the most frequent causes of acquired heart lesions in the postChernobyl nuclear power station catastrophe era. (2) Heart failure development in postoperative period is stipulated by the disease duration. (3) Presence of heart abscesses favors recurrence of development of infective endocarditis. (4) Postoperative antibiotic therapy for more than 3 weeks does not help in prevention of recurrences.     

Viable cryopreserved aortic homograft for aortic valve endocarditis and annular abscesses

Six consecutive patients with active aortic valve endocarditis, including 2 with extensive subannular aortic root abscess, were successfully treated with viable cryopreserved homograft aortic valve replacement. Two patients required extensive aortic root reconstruction with an appropriately trimmed aortic homograft to cover large abscess cavities. All patients showed resolution of infection with no perioperative mortality or clinically significant morbidity. Three patients had a minor degree of aortic insufficiency on postoperative echo-Doppler study. On follow-up at 6 to 48 months, all patients were in New York Heart Association functional class I. The resistance of the unstented homograft to infection makes it an attractive choice for patients requiring aortic valve replacement for active endocarditis. The results of surgical intervention in patients with extensive aortic root involvement may be further improved by the flexibility afforded by the homograft to be "custom-fit" to the abnormal aortic root and the ability to achieve secure abnormal aortic root and the ability to achieve secure valve fixation without use of prosthetic material.