Risk factors for prosthetic valve endocarditis—A case control study

Objective  

Prosthetic valve endocarditis is a catastrophic complication of cardiac valve replacement associated with significant morbidity and high mortality. The aim of this study was to assess the risk factors leading to the development of prosthetic valve endocarditis.     

Is thrombolysis or surgery the best option for acute prosthetic valve thrombosis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the optimal treatment strategy for acute prosthetic valve thrombosis (PVT) is surgical management or thrombolytic therapy. Using the reported search 96 papers were identified. Twelve papers represented the best evidence on the subject, and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. Recent AHA/ACC guidelines were also included, as were two large case series of surgical management for comparison. We conclude that the management of obstructive PVT remains widely debated due to a lack of randomised controlled trials. Surgery has been the traditional management of choice, but thrombolysis has recently been proposed as a first-line therapy. Both surgery and thrombolysis can be used with high rates of success and relatively low complication rates, though NYHA class at presentation has a significant bearing on surgical mortality and thrombus size affects complication rates with thrombolysis. Thrombolysis appears particularly favoured when the thrombus area as assessed by transoesophageal echocardiography is small (<0.8 cm(2)), as high success rates and low complication rates have been reported, and thrombolysis does not preclude the patient from proceeding to surgery if it fails. Presentation in a high NYHA class of heart failure or cardiogenic shock is the most difficult patient to decide between surgery and thrombolysis. Surgery for these patients may remain the mainstay of treatment unless the clot burden is particularly small or the patient's co-morbidities make surgery unacceptably high-risk.     

Impact of small prosthetic valve size on operative mortality in elderly patients after aortic valve replacement for aortic stenosis: does gender matter?

OBJECTIVE: Ideal management of the elderly patient with a small aortic root remains controversial. This retrospective analysis was performed to determine whether small prosthetic valve size is related to outcome in patients 70 years of age or older undergoing aortic valve replacement for aortic stenosis. METHODS: Between December 1991 and July 1998, 366 patients 70 years of age or older (median age 77 years, range 73-81 years, 49% male) underwent isolated aortic valve replacement or aortic valve replacement with coronary bypass grafting with standard Carpentier-Edwards bovine pericardial valves (Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) (n = 277; 76%) or St Jude Medical mechanical valves (St Jude Medical, Inc, St Paul, Minn) (n = 89; 24%). Propensity scoring and multivariable regression models were used to evaluate the risks associated with implantation of 19-mm valves. RESULTS: Operative mortality was 16.7% (17/102) in patients who received 19-mm valves and 3% (8/264) among those receiving >/=21-mm valves (P /=21-mm valves was 6.4 (95% CI 2.7, 15.4; P 相似文献   

Reinforced mitral valve replacement using a xenopericardium collared prosthetic valve for a heavily calcified or disrupted mitral annulus: a simple “Dumpling technique”

Heavy mitral annular calcification or severe destruction of the mitral annulus in the setting of mitral valve replacement may result in fatal complications, such as atrioventricular disruption, ventricular rupture, valve dehiscence, and perivalvular leakage. Collar-reinforced mitral valve replacements with xenopericardium have been reported to prevent perivalvular leakage and valve detachment. We herein describe our experience with an easy method of handling the modified collar-reinforced prosthetic valve, which we call the “Dumpling technique”, in six patients.     

Fundamentals of prosthetic urology

The field of prosthetic urology demonstrates the striking impact that simple devices can have on quality of life.Penile prosthesis and artificial urinary sphincter implantation are the cornerstone procedures on which this specialty focuses.Modern research largely concentrates on decreasing the rates of complication and infection,as the current devices offer superior rates of satisfaction when revision is not necessary.These techniques are also able to salvage sexual function and continence in more difficult patient populations including female-to-male transgender individuals,those with ischemic priapism,and those with erectile dysfunction and incontinence secondary to prostatectomy.This review summarizes modern techniques,outcomes,and complications in the field of prosthetic urology.     

Epidemiology regarding penile prosthetic surgery

With the onset of a metabolic syndrome epidemic and the increasing life expectancy,erectile dysfunction(ED)has become a more common condition.As incidence and prevalence increase,the medical field is focused on providing more appropriate therapies.It is common knowledge that ED is a chronic condition that is also associated with a myriad of other disorders.Conditions such as aging,diabetes mellitus,hypertension,obesity,prostatic hypertrophy,and prostate cancer,among others,have a direct implication on the onset and progression of ED.Characterization and recognition of risk factors may help clinicians recognize and properly treat patients suffering from ED.One of the most reliable treatments for ED is penile prosthetic surgery.Since the introduction of the penile prosthesis(PP)in the early seventies,this surgical procedure has improved the lives of thousands of men,with reliable and satisfactory results.The aim of this review article is to characterize the epidemiology of men undergoing penile prosthetic surgery,with a discussion about the most common conditions involved in the development of ED,and that ultimately drive patients into electing to undergo PP placement.     

Future considerations in prosthetic urology

Since their popularization,genitourinary prosthetics have remained a gold-standard therapy for the treatment of erectile dysfunction and stress urinary incontinence and in cases of testicular loss or dysfunction.They have also represented an area of significant innovation,which has contributed to excellent long-term outcomes.Given this history,the objective of the current review was to provide a 5-10-year outlook on anticipated trends and developments in the field of genitourinary prosthetics.To accomplish this objective,a PubMed and patent search was performed of topics relating to penile and testicular prostheses and urinary sphincters.In regard to penile prostheses,findings demonstrated several new concepts including temperature-sensitive alloys,automated pumps,devices designed specifically for neophalluses,and improved malleable designs.With artificial urinary sphincters,new concepts include the ability to add or remove fluid from an existing system,two-piece systems,and new mechanisms to occlude the urethra.For testicular prosthetics,future implementations may not only better replicate the feel of a biological testicle but also add endocrinological functions.Beyond device innovation,the future of prosthetics is also one of expanding geographic boundaries,which necessitates variable cost modeling and regulatory considerations.Surgical trends are also changing,with a greater emphasis on nonnarcotic,postoperative pain control,outpatient surgeries,and adjunctive techniques to lengthen the penis and address concomitant stress incontinence,among others.Concomitant with device and surgical changes,future considerations also include a greater need for education and training,particularly given the rapid expansion of sexual medicine into developing nations.     

What is the optimal level of anticoagulation in adult patients receiving warfarin following implantation of a mechanical prosthetic mitral valve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what is the optimal target INR for warfarin therapy in patients who have undergone implantation of a prosthetic mechanical mitral heart valves? Altogether 894 papers were identified on Medline and 1235 on Embase using the reported search including all major international guidelines. Twelve papers and publications represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that after implantation of new generation prosthetic mechanical mitral valves, patients should receive warfarin to a target INR of 2.5-3.5. For older types of valve the target INR should be 3.5-4.5. Warfarin therapy should be administered to maintain stable INR values ensuring lowest possible variation in the intensity of anticoagulation. In selected patients with a history of thromboembolic disease and/or coronary artery disease warfarin therapy consideration should be given to supplementing warfarin with low-dose aspirin.     

In patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve repair superior to double valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve plasty (MVP) superior to double valve replacement (DVR) in terms of improved long-term survival? Altogether 156 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Out of seven papers, that simultaneously compare these two treatment modalities, three favor MVP combined with aortic valve replacement (AVR) over DVR, two papers advocate the opposite and two failed to find any significant difference in long-term survival, freedom from reoperation and thromboembolic and bleeding complications between these two surgical options. All data presented derive from level 2b evidence. Critical appraisal of these studies is constricted by the large heterogeneity of the patients, diversity in treatment protocols and inherent selection bias. We conclude that currently the available evidence is insufficient to prove that AVR with MVP is superior to DVR in patients with double valve disease.     

Is prophylactic aortic valve replacement indicated during mitral valve surgery for mild to moderate aortic valve disease?

BACKGROUND: Determining the need for surgical treatment of coexisting mild to moderate aortic valve disease in patients referred for mitral valve surgery is often difficult. The purpose of this study was to assess long-term clinical outcome and the need for subsequent aortic valve replacement in patients with mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery. METHODS: A total of 275 patients (90 men and 185 women, mean age 43 years) with rheumatic disease who underwent mitral valve surgery were followed up for an average of 9 years. Patients were classified into two groups: those with coexisting mild to moderate aortic valve disease at the time of mitral valve surgery (141 patients, group A) and those without (134 patients, group B). Primary outcomes (death and subsequent aortic valve surgery) were compared between the two groups. RESULTS: At the time of mitral valve surgery, 104 patients (74%) in group A had mild aortic regurgitation, 37 (26%) had moderate aortic regurgitation, 5 had (4%) mild aortic stenosis, and 2 (1%) had moderate aortic stenosis. At the end of follow-up, no patient had severe aortic valve disease. In all, 12 patients (5%) in group A had primary events (eight deaths and four subsequent aortic valve replacements), and 12 patients (9%) in group B had such events (12 deaths). According to Kaplan-Meier analysis, neither the survival rate nor the event-free survival rate differed significantly over the follow-up period between the two groups. CONCLUSIONS: In most patients who have mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery, the long-term outcome is comparable to that of subjects without aortic valve disease at the time of mitral valve surgery. Subsequent aortic valve replacement is rarely needed after a long follow-up period.     

Is repair of aortic valve regurgitation a safe alternative to valve replacement?

OBJECTIVE: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. METHODS: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). RESULTS: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. CONCLUSIONS: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.     

Should the tricuspid valve be replaced with a mechanical or biological valve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Using the reported search, 561 papers were identified. Thirteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, weaknesses, results and study comments were tabulated. We conclude that there are no major differences between the insertion of a mechanical or biological tricuspid valve. Aggregating the available data it is found that the reoperation rate is similar with bioprosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely up to 95% of patients with a bioprosthesis still receive anticoagulation. Survival in over 1000 prostheses pooled by meta-analysis was equivalent between biological and mechanical valves.     

Successful management of multiple permanent pacemaker complications – infection, 13 year old silent lead perforation and exteriorisation following failed percutaneous extraction, superior vena cava obstruction, tricuspid valve endocarditis, pulmonary embolism and prosthetic tricuspid valve thrombosis

A 59 year old man underwent mechanical tricuspid valve replacement and removal of pacemaker generator along with 4 pacemaker leads for pacemaker endocarditis and superior vena cava obstruction after an earlier percutaneous extraction had to be abandoned, 13 years ago, due to cardiac arrest, accompanied by silent, unsuspected right atrial perforation and exteriorisation of lead. Postoperative course was complicated by tricuspid valve thrombosis and secondary pulmonary embolism requiring TPA thrombolysis which was instantly successful. A review of literature of pacemaker endocarditis and tricuspid thrombosis along with the relevant management strategies is presented. We believe this case report is unusual on account of non operative management of right atrial lead perforation following an unsuccessful attempt at percutaneous removal of right sided infected pacemaker leads and the incidental discovery of the perforated lead 13 years later at sternotomy, presentation of pacemaker endocarditis with a massive load of vegetations along the entire pacemaker lead tract in superior vena cava, right atrial endocardium, tricuspid valve and right ventricular endocardium, leading to a functional and structural SVC obstruction, requirement of an unusually large dose of warfarin postoperatively occasioned, in all probability, by antibiotic drug interactions, presentation of tricuspid prosthetic valve thrombosis uniquely as vasovagal syncope and isolated hypoxia and near instantaneous resolution of tricuspid prosthetic valve thrombosis with Alteplase thrombolysis.     

Is the valve OK or not? Immediate evaluation of a replaced aortic valve

Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.