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.     

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.     

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.     

主动脉窦瘤的外科治疗

本文报告32例主动脉窦瘤的手术治疗，窦瘤发生及破入心腔部位不同，手术方法不尽相同，1例左冠窦窦瘤破入左房属罕风类型。本文着重探讨窦瘤破裂并发感染性心内膜炎（IE）的手术方法，作者认为瓣叶损害轻或右心IE行瓣膜修复术优于人互瓣膜置换术，1例并发IE，施行AVR后又发生人互心瓣膜IE患者猝死。     

Factors affecting the surgical management of infective endocarditis

Congestive heart failure and septic embolism complicate the clinical course of patients with infective endocarditis (IE). This study reviews the clinical records of patients with systemic disease secondary to IE and stratifies their disease severity according to individual risk factors and medical, and surgical interventions. The hospital records of all patients presenting to our institution from 1992 through 1997 with heart valve destruction secondary to IE were reviewed. Ten patients with hemodynamically significant valve lesions were included in this study: seven with aortic valve disease and two with mitral valve disease, and one with combined aortic and mitral valve lesions. All were diagnosed by echocardiogram. All ten patients experienced systemic septic arterial emboli: four intracranial lesions, four visceral lesions, and three extremity arterial occlusive events. Two patients required peripheral arterial repair. Cultures revealed infection secondary to Staphylococcus aureus in five, Streptococcus species in three, Coxiella species in one, and an unidentified organism in one patient. Seven patients underwent valve replacement. Three patients died from their disease processes. Statistical significance was established by Wilcoxon rank analysis with a two-tailed P < 0.05. Patients with IE secondary to staphylococcal infections suffered a more acute and virulent disease process (P = 0.04), with a 40 per cent mortality rate in the first 48 hours. There was no increased incidence of embolization associated with longer duration of symptoms (P = 0.32). Surgical repair conferred improved clinical outcome as compared with no surgical intervention (P = 0.03). Improved patient outcome was associated with nonstaphylococcal infection (P = 0.02), and a successful initial antibiotic regimen (P = 0.03). Peripheral arterial repair was successful in both cases.     

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.     

60例感染性心内膜炎的临床诊断与外科治疗

目的总结感染性心内膜炎的临床诊断和外科治疗经验。方法回顾分析2000年1月～2006年8月在我院接受手术治疗的60例感染性心内膜炎患者的临床资料,其中男46例,女14例;年龄9～58岁,平均年龄34.3岁。术前血培养60例,阳性25例(41.7%),其中链球菌12例,葡萄球菌6例,其他细菌7例。超声心动图提示有心内膜赘生物或瓣膜穿孔42例,其中累及二尖瓣9例,主动脉瓣26例,二尖瓣主动脉瓣同时受累6例,三尖瓣1例。合并原发心脏疾病28例,其中先天性心脏病16例,风湿性心脏病9例,二尖瓣脱垂3例。对60例患者全程采用大剂量敏感抗生素治疗。择期手术55例,急诊手术5例。手术中清除所有感染灶,同期矫治心内畸形16例,行心瓣膜置换术41例,三尖瓣修复成形术1例。结果术后早期死亡3例。随访51例(89.5%),随访时间5～71个月,无心内膜炎复发,心功能恢复至级38例,级13例。结论早期诊断,掌握适当的手术时机,联合内科治疗和外科手术,可取得较好的治疗效果。     

32例感染性心内膜炎治疗的临床分析

目的探讨左心IE与右心IE两者临床表现及治疗上的差异。方法对中山大学第二附属医院2000年1月～2004年12月住院的32例IE病人分成左心IE组、右心IE组进行回顾性对照分析。结果左心IE中内科治疗15例,其中治愈4例;外科治疗10例并全部治愈,其中行瓣膜置换术9例,瓣膜修复整形术1例;右心IE中内科治疗2例,其中治愈1例;外科治疗5例,其中行三尖瓣置换术4例,三尖瓣膜修复整形术1例;手术治疗5例中治愈4例,1例因术后多器官功能障碍综合症死亡。结论右心IE与左心IE临床表现不同,突出表现在肺部病变:右心IE表现为急性肺炎或肺栓塞的临床症状;左心IE表现为瓣膜功能障碍。对于IE瓣膜病变的手术方式应根据瓣膜损坏程度来决定,左心IE以瓣膜置换为主,右心IE尽量争取瓣膜修复整形。     

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.     

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.     

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.     

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.     

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.     

静脉注射吸毒者感染性心内膜炎的外科治疗

目的 探讨静脉注射毒品所致感染性心内膜炎的外科治疗经验.方法 17例患者静脉注射毒品史2～10年,均有心脏瓣膜赘生物;其中三尖瓣赘生物并关闭不全16例,二尖瓣赘生物并关闭不全合并室间隔缺损1例,术前血培养阳性8例.三尖瓣置换术8例,三尖瓣成形术8例,二尖瓣置换同期室间隔缺损修补术1例.术后平均随访(44.7 ±19.1)月.结果 全部患者治愈出院,心功能明显改善,随访期间抗凝不当致大咯血1例,三尖瓣重度返流1例.结论 外科手术修复受累瓣膜或置换瓣膜是治疗静脉吸毒性感染性心内膜炎的有效手段.     

Repair of infected mitral valves: what have we learned?

Infective endocarditis (IE) is associated with high mortality and morbidity and requires surgical intervention in about half of all patients. Mitral valve repair (MVrep) is reported to achieve better results than mitral valve replacement because the insertion of a prosthesis during active infection is avoided. However, MVrep in active IE is complicated and no definitive guidelines have been compiled. The current study reviews the literature from 2000 to 2016 and summarizes the surgical details of MVrep for IE.     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.     

Is There an Advantage to Repairing Infected Mitral Valves?

Background. The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment.

Methods. Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis.

Results. There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance.

Conclusions. We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.     

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.

Infective endocarditis with congenital heart disease

From 1988 to 2005, seven patients were operated at our hospital because of infectious endocarditis (IE) with congenital heart disease (CHD). Underlying CHD included ventricular septal defect (VSD) in 4 (2 previous operations with residual region), atrial septal defect (ASD) in 2 and bicuspid aortic stenosis (AS) in 1. No cases had preventive antibiotic prophylaxis for dental procedures. We could confirm bacteria origin from blood culture in all cases, but two patients had operations without gaining control of the infection. VSD or ASD closure and valve surgery were performed in four patients. One patient had a VSD closure, two patients had valve surgery. There were no operative or hospital deaths and there were no recurrences of IE during the study period. We successfully treated IE with CHD by enough debridement of the infective focus of IE, and valve surgery. It is important for patients with CHD to have preventive antibiotic prophylaxis for dental procedures.     

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.