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.     

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.     

Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?

BACKGROUND: The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval. METHODS: Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1). RESULTS: Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months. CONCLUSIONS: These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.     

Surgery for infective endocarditis—analysis of factors affecting outcome

PurposeDespite advances in medical care, infective endocarditis (IE) has high mortality. Surgery for IE though recommended for complications of the disease is still not commonly offered due to conflicting reports in the literature. We reviewed our results of surgery for IE from the last 5 years to assess their outcome.MethodsA retrospective review from a single center of consecutive patients who underwent surgery for infective endocarditis from September 2014 to December 2019 was done. Data was collected from hospital records and follow-up done up to May 2020. Outcomes evaluated were mortality, follow-up survival, and postoperative complications. Factors affecting mortality and survival were analyzed.ResultsNinety-seven patients underwent surgery for IE during this period. Seventy-nine had native valve endocarditis (NVE) and 18 had prosthetic valve endocarditis (PVE). The overall postoperative mortality was 13%, with mortality for native valve endocarditis being 11% and that for prosthetic valve endocarditis being 22%, which was not statistically significant. Three-year survival for the overall group was 88.7% with 88.1% for NVE and 91.7% for PVE. Multivariate predictors of operative mortality were a high EuroSCORE II, diabetes mellitus, and the presence of Staphylococcus organism.ConclusionSurgery for infective endocarditis has a very acceptable early outcome and intermediate-term survival.     

Homograft reconstruction of the aortic root for endocarditis with periannular abscess: a 17-year study.

OBJECTIVE: The study was conducted to evaluate the long-term results of homograft reconstruction of the left ventricular outflow tract with a cryopreserved aortic homograft in the presence of aortic root abscess associated with a biofilm bacterial infection. METHODS: Between January 1987 and December 2003, 161 patients with aortic root abscess underwent freehand aortic valve (FAVR, N = 78) and aortic root replacement (ARR, N = 83) with an antibiotic treated cryopreserved aortic homograft. Their mean age was 53.1+/-15.6 years. Endocarditis of the native valve was found in 80 patients and of the prosthetic valve in 81; of the prosthetic valves 49 (60.5%) were mechanical and 32 (39%) bioprosthetic. Aortic ventricular discontinuity was found in 83 patients. The common responsible microorganisms were the biofilm bacteria: Staphylococcus (S. epidermidis: 34, S. aureus: 13) in 47 patients followed by Enterococcus in 23 and Streptococcus in 39. Surgery was urgent in 80 patients and emergent in 81, of whom 44 were in cardiogenic shock. Follow-up totaled 810.8 patient-years (mean: 5.0+/-4.3 years) and was 100% complete. RESULTS: Operative mortality was 9.3% for elective/urgent and 14.3% for emergency surgery. A total of 7.3% patients died after hospital discharge during the 17-year follow-up period. The actuarial patient survival at 17 years was 70.4+/-3.6%. Early and late residual/recurrent infections and paravalvular leaks occurred in 4.3 and 2.5%, respectively. Reoperations were carried out in 30 patients, 11 for residual/recurrent infection and paravalvular leaks. Twenty-one patients with FAVR and 9 with ARR techniques underwent reoperation. Early reoperation rate was 4.3%. The actuarial freedom from residual/recurrent infection and paravalvular leaks was 91.6+/-2.4%. Actuarial freedom from reoperation at 17 years was 75+/-3.7%. It was 82.9+/-5.5% for ARR and 63.5+/-6.7% for AAVR technique. The actuarial freedom from structural valve deterioration (SVD) at 17 years was 98.6+/-0.4.% at a rate of %/patient-year. CONCLUSIONS: Radical debridement of the infected aortic root and homograft ARR offer a low recurrent infection rate and an overall low valve-related morbidity and mortality for up to 17 years. The antibiotic permeable cryopreserved homograft has proven to be resistant to biofilm bacterial infection.     

Reoperations in valvular heart disease

Background Reoperations for valvular heart disease are associated with a higher overall mortality than the primary operations. In this retrospective analysis, we present our experience of reoperative valvular heart surgery over a period of 25 years. Methods From January 1975 to July 2000, 13039 operations were performed for valvular heart disease. Of these 665 were reoperations. The mean age of the patients at the primary operation was 24.0±10.2 years (range: 8 to 65 years) and at re-operation was 35.6±11.6 years (range: 9 to 65 years) with an interval of 9.4±2.2 years (range: 0.2 to 25 years) between the 2 procedures. Four hundred and forty reoperations were performed following a previous closed mitral valvotomy and procedures included, redo closed mitral valvotomy (n=28), mitral valve replacement (n=30), open mitral commissurotomy (n=51), mitral valve repair (n=9), homograft mitral valve replacement (n=2), double valve replacement (n=47), aortic valve replacement (n=2) and homograft aortic valve replacement plus open mitral commissurotomy (n=l). Eighty six patients underwent reoperations following mitral valve replacement. Valve thrombosis (n=50) and endocarditis (n=10) were principle causes of reoperation. Forty three patients required reoperation following failed mitral valve repair, 19 following open mitral commissurotomy and 8 following homograft mitral valve replacement. Sixty five patients underwent reoperation following aortic valve operations: prosthetic aortic valve replacement in 43, homograft aortic valve replacement in 5, aortic valve repair in 10, and Ross procedure in 7. Results Majority of patients were operated through midsternotomy. Aortic cannulation was possible in all but 4 patients in whom femoral artery cannulation was required. Operative mortality following reoperations was 7.5% (n=50). Peri-operative bleeding, low cardiac output and infective endocarditis were major causes of operative deaths. Other post-operative complications included cerebrovascular accident (n=3), acute renal failure (n=10) and jaundice (n=25). Fifteen patients developed significant wound infection. Conclusions Patients undergoing operation for valvular heart disease frequently require reoperation. Reoperative valvular heart surgery is safe and can be undertaken with acceptable mortality and morbidity.     

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.     

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 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.     

Infective endocarditis in hemodialysis patients: clinical features, echocardiographic data and outcome

Background  Infective endocarditis (IE) is a dreaded complication in hemodialysis (HD) patients and is strongly associated with morbidity and mortality. Objectives  Our aim was to investigate clinical and echocardiographic characteristics, microbiological profile, management and outcome of patients on HD in a Tunisian (Tunisia, North Africa) high-volume tertiary-care centre. Methods  Among 182 patients who fulfilled the modified Duke criteria for infective endocarditis between January 1997 and December 2006, 16 were on chronic HD and were included in the study. Results  Mean age was 52.5 ± 22.3 years, ten were male and arteriovenous fistulas were the most commonly used access sites (12 out of 16 cases). Average duration of dialysis was 27.3 ± 30 months. Major causative organisms were Staphylococcus species (including methicillin-resistant Staphylococcus aureus) in 11 (68.7%) of the 16 cases. The mitral valve was the most commonly affected [9 patients out of 16 (56.2%)], followed by aortic valve in 4 cases (25.0%) and tricuspid valve in 1 case (6.2%). Complications were frequent, including congestive heart failure (56.2%), secondary septic localisations (31.2%), arterial emboli (18.7%), and cerebral haemorrhage (6.2%). Five patients underwent surgery and seven died during hospitalization (43.7% mortality rate). No recurrences of IE were recorded in the nine survivors after average 21.7 ± 17.3 months follow-up. Conclusion  In this largest reported confirmed IE series in dialysis patients in a developing country, mortality was very high; mitral valve was the most commonly affected valve. Staphylococcus species were the major causative organisms.     

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.     

Mortality risk factors in chronic haemodialysis patients with infective endocarditis.

BACKGROUND: It is well documented that infective endocarditis (IE) is strongly associated with morbidity and mortality in haemodialysis (HD) patients. Less clear are the mortality risk factors for IE, particularly in an urban African-American dialysis population. METHODS: IE patients were identified from the medical records for the period from January 1999 to February 2004 and confirmed by Duke criteria. The patients were classified as 'survivors' and 'non-survivors' depending on in-hospital mortality, and risk factors for IE mortality were determined by comparing the two cohorts. Survivors were followed as out-patients with death as the endpoint. RESULTS: A total of 52 patients with 54 episodes of IE were identified. A catheter was the HD access in 40 patients (74%). Mitral valve (50%) was the commonest valve involved, and Gram-positive infections accounted for 87% of IE. In-hospital mortality was high (37%) and valve replacement was required for 13 IE episodes (24%). On logistic regression analyses, mitral valve disease [P = 0.002; odds ratio (OR) = 15.04; 95% confidence interval (CI) = 2.70-83.61] and septic embolism (P = 0.0099; OR = 9.56; 95% CI = 1.72-53.21) were significantly associated with in-hospital mortality. Using the Cox proportional hazards model, mitral valve involvement (P = 0.0008; hazard ratio 4.05; 95% CI = 1.78-9.21) and IE related to drug-resistant organisms such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus sp. (P = 0.016; hazard ratio 2.43; 95% CI = 1.18-5.00) were associated with poor outcome after hospital discharge. CONCLUSIONS: IE was associated with high mortality in our predominantly African-American dialysis population, when the mitral valve was involved, or septic emboli occurred and if MRSA or VRE were the causal organisms.     

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.     

Prosthetic valve endocarditis. Analysis of factors affecting outcome of therapy

We analyzed the outcome of 116 patients with prosthetic valve endocarditis treated between 1975 and 1983 and used multivariate analysis to identify risk factors for in-hospital mortality and bad outcome during follow-up. Complicated prosthetic valve endocarditis was defined as the presence of a new or changing heart murmur, new or worsening heart failure, new or progressive cardiac conduction abnormalities, or prolonged fever during therapy. Complicated prosthetic valve endocarditis was present in 64% of patients; factors associated with complicated prosthetic valve endocarditis included aortic valve infection (odds ratio 4.3, p = 0.002) and onset of endocarditis within 12 months of the cardiac operation (odds ratio 5.5, p = 0.0001). The in-hospital mortality rate for prosthetic valve endocarditis was 23%; patients with complicated prosthetic valve endocarditis had a higher mortality than patients with uncomplicated infection (odds ratio 6.4, p = 0.0009). Combined medical-surgical therapy was used in 39% of patients; surgical therapy was more common in patients with complicated prosthetic valve endocarditis (odds ratio 16, p less than 0.0001) and in patients infected with coagulase-negative staphylococci (odds ratio 3.9, p = 0.003). Survival after initially successful therapy for prosthetic valve endocarditis was adversely affected by the presence of moderate or severe congestive heart failure at hospital discharge (p = 0.03). Bad outcome during follow-up (death, relapse of prosthetic valve endocarditis, or subsequent cardiac operation related to sequelae of the original infection) was more common in the medical than the medical-surgical therapy group (p = 0.02). The difference in long-term outcome between patients treated initially with medical or with medical-surgical therapy was particularly evident in those with complicated prosthetic valve endocarditis (p = 0.008). The presence of complicated prosthetic valve endocarditis is a central variable in assessing prognosis and planning therapy; the majority of patients with complicated prosthetic valve endocarditis are best treated with medical-surgical therapy. Those who are not treated surgically during their initial hospitalization are at high risk for progressive prosthesis dysfunction and require careful follow-up.     

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.     

Prosthetic valve endocarditis associated with paravalvular aortic and mitral abscesses

A 63-year-old female, who had undergone aortic and mitral valve replacement 16 years ago, was admitted because of urinary tract infection. The patient developed cerebral hemorrhage. Methicillinresistant Staphylococcus aureus was isolated from her blood culture. Transesophageal echocardiography revealed paravalvular aortic and mitral abscesses, and the diagnosis of prosthetic valve endocarditis was established. A redo double valve replacement was performed. Both paravalvular abscess cavities were debrided and closed with fresh autologous pericardial patches, and mechanical valves were implanted. The patient's postoperative course was uneventful, and she had no sign of recurrent infection 3 years postoperatively.     

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis

Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Methods. From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 ± 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 ± 3.4 years.

Results. Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% ± 9% in Ross-AVR, 69% ± 11% in homo-AVR, and 29% ± 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR.

Conclusions. Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.     

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.     

Infective endocarditis in dialysis patients: new challenges and old

BACKGROUND: Since the 1960s chronic hemodialysis (HD) has been recognized as a risk factor for the development of infective endocarditis (IE). Historically, it has been particularly associated with vascular access via dual lumen catheters. We wished to examine the risk factors for, and consequences of, IE in the modern dialysis era. METHODS: Cases of IE (using the Duke criteria) at St. Thomas' Hospital (1980 to 1995), Guy's (1995 to 2002), and King's College Hospitals (1996 to 2002) were reviewed. RESULTS: Twenty-eight patients were identified as having developed IE (30 episodes of IE). Twenty-seven patients were on long-term HD and one patient was on peritoneal dialysis (PD). Mean age was 54.1 years, and mean duration of HD prior to IE was 46.3 months. Eight patients were diabetic. Primary HD hemoaccess was an arteriovenous fistula (AVF) in 41.3%, a dual-lumen tunneled catheter (DLTC) in 37.9%, a polytetrafluoroethylene (PTFE) graft in 10.3%, and a dual- lumen non-tunneled catheter (DLNTC) in 4%. The presumed source of sepsis was directly related to hemoaccess in 25 HD patients: DLTC in 48%; AVF in 32%; PTFE in 12%; and DLNTC in 4%. Staphylococcus aureus[including methicillin resistant Staphylococcus aureus (MRSA)] was present in 63.3%. The mitral valve was affected in 41.4% of patients, aortic valve in 37.9% of patients, and both valves were affected in 17.2% of patients. Of note, 51.7% of patients had an abnormal valve before the episode of IE. In 15 cases surgery was undertaken. Fourteen patients survived to discharge, and 12 survived for 30 days. In 15 cases antibiotic treatment alone was employed; in this case, eight patients died and seven survived to discharge. CONCLUSION: This is the largest reported confirmed IE series in dialysis patients. Infective endocarditis in HD patients remains a challenging problem-although hemoaccess via dual-lumen catheters remains a significant risk, many cases developed in patients with AVFs and this group suffered the greatest mortality. An abnormal valve (frequently calcified) was another risk factor; because valve calcification is now common after 5 years on dialysis, more effort in preventing this avoidable form of ectopic calcification may reduce the risk of developing IE.     

Aortic valve reconstruction using autologous pericardium (Ozaki procedure) for active infective endocarditis: a case report

Approximately one-third of patients with infective endocarditis require surgical treatment, but the ideal procedure that prevents infection ensures long durability and maintains quality of life remains unclear. A 21-year-old man who was diagnosed with aortic active infective endocarditis was referred to our hospital for surgical treatment. Echocardiography showed bicuspid aortic valve, severe aortic regurgitation, a large vegetation, and a paravalvular abscess. We planned to perform elective surgical treatment after antibiotic therapy; however, progression to heart failure required urgent operation. Aortic valve reconstruction (AVr) using autologous pericardium was performed. Perioperative and postoperative courses were uneventful. No recurrence of infection or adverse events were observed 4 years postoperatively. Considering prosthetic valve infection and redo operation, AVr may be considered among young patients.