Spontaneous splenic rupture following mitral valve replacement for infective endocarditis successfully managed with splenic artery embolisation

We report a rare case of infective endocarditis complicated by postoperative splenic rupture. A patient underwent urgent mitral valve replacement for infective endocarditis believed to be associated with a recent spinal surgical intervention. The patient developed haemodynamic compromise on the third day postoperatively. Computed tomography showed a splenic rupture as the cause. The patient underwent emergency radiological intervention with coil embolization avoiding the need for a splenectomy and was discharged home.     

Active infective endocarditis after mitral valve repair

A 22-year-old man was diagnosed with active mitral endocarditis 14 months after mitral valve repair. The responsible organism was methicillin-resistant Staphylococcus epidermidis. Transthoracic echocardiography showed an 8-mm patch of vegetation adhering to the anterior part of the artifcial ring. Although antibiotics (piperacillin, minocycline, imipenem/cilastatin, and ampicillin) were administered, the vegetation grew to 30 mm. Reoperation was performed 35 days after the diagnosis. Before surgery, there was mild mitral regurgitation without congestive heart failure. Re-repair was performed by removing the vegetation and the artificial ring, and mattress sutures repaired the circumferential sulcus formed by the artificial ring. Teicoplanin and minocycline were administered for 6 weeks. At 20 months, infective endocarditis was absent. Residual mitral regurgitation has been consistently mild. Although active mitral endocarditis after mitral valve repair is rare, prompt reoperation should be considered if the responsible organism is drug-resistant and infection spreads to the artificial ring.     

Aortic valve replacement for late infective endocarditis after heart-lung transplantation

Infective endocarditis is a rare but life-threatening complication of heart and heart-lung transplantation. We describe a 32-year-old woman who developed aortic valvular endocarditis following heart-lung transplantation. Enterococcus was the infective organism. The patient's condition was successfully managed using prolonged intravenous antibiotic therapy and aortic valve replacement.     

Takotsubo syndrome after mitral valve replacement for acute endocarditis

Takotsubo syndrome is characterized by transient and acute left ventricular dysfunction and apical ballooning, with electrocardiographic abnormalities, but without coronary disease. We report a case of Takotsubo syndrome occurring after emergent mitral valve replacement for acute infective endocarditis. The patient is a 66-year-old woman who regained complete recovery of left ventricular function.     

二尖瓣置换术后左室破裂

目的：探讨二尖瓣置换术后左心室破裂的预防措施,方法：对1994年1月－2000年6月二尖瓣置换术的3607例患者的临床资料进行回顾性分析。结果：9例患者发生左心室破裂（发生率0．25％）,其中3例 生手术中,6例发生于ICU;手术抢救成功3例,死亡6例,结论：左心皮裂修补困难,针对其发病机理,采取相应的预防措施可减少其发生率及病死率。预防措施包括：重视诱发因素;防止术中损伤;正确选择和安装人工瓣膜;纠正血液动力学的异常。     

Emergency valve replacement for active infective endocarditis

During the last 12 years, 14 patients were subjected to emergency heart valve replacement in acute bacterial endocarditis. Operative mortality was 21% (3/14); significant postoperative periprosthetic regurgitation or reinfection occurred in none of the survivors. Risk factors with unfavourable prognosis are: (1) virulent pathogens ("Non-Viridans"-germs); (2) previously normal heart valves; (3) acute aortic insufficiency with premature closure of the mitral valve; (4) floating vegetations shown by echocardiography. Our results provide further evidence for the efficacy of early surgical intervention in patients with bacterial endocarditis with an unfavourable etiology or a complicated course.     

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.     

感染性心内膜炎患者二尖瓣置换和成型术的效果

目的比较感染性心内膜炎患者行二尖瓣置换和成型手术的临床特点和转归。方法回顾性分析2013年1月至2016年12月在北京协和医院行手术治疗的、累及二尖瓣的感染性心内膜炎患者55例,男24例,女31例,年龄19～77岁,ASAⅡ-Ⅳ级,根据患者所行手术分为两组:二尖瓣置换术组(Z组,n=15)和二尖瓣成型术组(C组,n=40)。比较两组致病菌、临床表现、超声心动图表现、是否入住ICU、住院时间、术后并发症等。结果链球菌是感染性心内膜炎最常见的病原菌,发热、新出现的心脏杂音和贫血是最常见的临床表现。Z组贫血、心力衰竭、术后入ICU比例明显高于C组(P 0.05)。两组超声心动图表现、住院时间和术后并发症差异无统计学意义。结论对于有手术指征的感染性心内膜炎患者,合理选择手术方式可以改善患者预后。     

Long-term survival after aortic valve replacement for native active infective endocarditis

Background: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. Methods: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 ± 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were unbeatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. Results: Operative mortality was 8% in the majority of cases caused by heart failure or multiorgan failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. Conclusions: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-op-rative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.     

Surgical management of mitral valve infective endocarditis

Active mitral valve infective endocarditis is a challenging clinical problem with a high rate of mortality. Surgery is currently performed in more than 40% of patients, and selecting those patients who will benefit from surgical intervention and performing a technically sound operation at the proper time are keys to optimizing outcomes. Moderate-to-severe and severe mitral regurgitation, large, mobile vegetations, paravalvular abscess, embolic events, failure of antibiotic therapy, and infection with a fungal organism are indications for prompt operation. The use of computed tomography imaging is important to determine whether there are noncardiac sources of infection, and transesophageal echocardiography is essential to delineate valvular dysfunction, identify paravalvular abscesses, rule out involvement of other valves, and plan operative therapy. In most cases, surgery should not be delayed because of cerebrovascular emboli. Mitral valve repair is favored over replacement whenever possible, is associated with superior short- and long-term outcomes, and should be possible in most cases. Operative mortality is <10% and 5-year survival is >80%.     

Delayed left ventricular rupture after mitral valve replacement

Posterior left ventricular rupture (LVR) is a serious complication following mitral valve replacement (MVR), especially if occurring postoperatively with the chest already closed or the patient in the intensive care unit. Only one of the patients with this delayed type of LVR reported earlier has been treated successfully. Our experience consists of 4 such complications among 161 MVR patients, the incidence being 2.5%. Two of these patients survived. Mechanical factors seem to constitute the most important etiologic causes for this complication. Immediate reoperation must be performed, and extracorporeal circulation is generally mandatory for successful repair. The reconstruction of the ruptured posterior left ventricular wall in both surviving patients was performed from the epicardial surface of the heart using pledget sutures. The auricle of the left atrium was used to cover the site of the tear when bleeding was not stopped with pledget sutures. It usually seems possible to avoid this complication if all mechanical etiologic factors are taken into consideration. After successful correction, a pseudoaneurysm may arise and, for that reason, a cardiac echo sonography follow-up is recommended.     

Left ventricular rupture after mitral valve replacement.

BACKGROUND: What are the immediate and long term outcomes of patients who had rupture of the left ventricle after mitral valve replacement? METHODS: Experimental design: A retrospective study with a 20-year follow-up. Setting: Experience in a single tertiary referral cardiothoracic surgery hospital. Participants: 20 out of 3105 patients that received mitral valve replacement. INTERVENTION: All these 20 patients received re-exploration for a trial of repair of left ventricular rupture either by an internal or an external or a combined repair. MEASURES: Operative mortality and long term outcome of the survivals. RESULTS: Most patients (16.80%) were female and had rheumatic mitral valve disease. The mean age of the patients was 58.1 years. All patients underwent attempted repair, usually by removal of the prosthesis and reconstitution of the ventricle from within the left atrium (75%). Thirteen (65%) patients died. Two late deaths were of unrelated cause. One surviving patient developed a late ventricular false aneurysm but did not undergo repeat surgery. One patient developed severe mitral regurgitation due to tissue failure of the bioprosthesis 12 years after surgery and she underwent a successful reoperation. CONCLUSIONS: We believe that all patients should be placed back on cardiopulmonary bypass for an internal repair. The long term outcome of the survivals is satisfactory.     

Posterior midventricular rupture after mitral valve replacement.

Posterior midventricular rupture occurred in 3 patients after insertion of a mitral prosthesis. Iatrogenic surgical trauma was not implicated. There were five clinical factors common to each case: a woman with mitral stenosis; a left ventricle of relatively normal size; the use of intermitent cold cardioplegia; the insertion of a porcine heterograft valve; and transient postoperative hypertension. Rupture in such cases may be caused by hyperdynamic left ventricular contraction against the strut of the prosthesis. Causes of ventricular perforation are discussed.     

Outcome after mitral valve repair for acute and healed infective endocarditis.

OBJECTIVE: To evaluate the long-term clinical and echocardiographic outcomes after mitral valve surgery for acute and healed infective endocarditis. METHODS: Of 37 consecutive patients presenting with native mitral valve endocarditis, mitral valve repair (MVRep) was feasible in 34 (92%) patients. In 17 (50%) patients, surgery was indicated during antibiotic therapy (acute endocarditis), whereas 17 (50%) underwent surgery after antibiotic therapy was completed (healed endocarditis). Patients were evaluated for early and long-term clinical and echocardiographic outcome. RESULTS: In-hospital death occurred in two (6%) patients and two (6%) died during follow-up, with a 2-year survival of 100% in healed endocarditis as compared to 76% (p=0.03) in patients undergoing surgery in acute endocarditis. No patient with acute endocarditis needed repeat mitral valve surgery. Three (9%) patients underwent re-operation because of early mitral regurgitation (n=1) or late recurrent endocarditis (n=2). The average grade of mitral regurgitation was 3.8+/-0.4 (all grades 3 to 4+) before surgery and 0.6+/-0.8 during follow-up (p<0.001). Significant reductions in left atrial (from 52+/-8mm to 46+/-8mm, p=0.004), left ventricular end-diastolic (from 61+/-8mm to 54+/-8mm, p=0.001), and end-systolic dimensions (from 41+/-8mm to 36+/-9 mm, p=0.02) were observed during follow-up, compared to preoperative dimensions. Of note, significant reverse remodeling was only observed in patients undergoing surgery in healed endocarditis. CONCLUSION: MVRep for mitral valve endocarditis is feasible with good clinical results, maintained valve competency with significant reductions in left atrial and left ventricular dimensions after surgery.     

Partial mitral valve replacement for acute endocarditis

We present a case of acute endocarditis involving the posteromedial commissure and both leaflets of the mitral valve, including a vegetation on and perforation of the anterior leaflet, in a young man with active Crohn's disease. Repair was performed using glutaraldehyde-treated bovine pericardium. Competence of the valve was achieved with no recurrence of endocarditis. This case demonstrates that extensive destruction of both leaflets of the mitral valve does not prohibit repair.     

Off-pump tricuspid valve replacement for severe infective endocarditis

A 30-year-old man who is a heroin addict was diagnosed with uncontrolled tricuspid valve endocarditis and repeated lung abscesses. He underwent tricuspid valvectomy for the endocarditis. After surgery the patient had severe tricuspid regurgitation and hypoxemia develop. Due to severe tricuspid regurgitation-induced ventricular distension and persistent low cardiac output, reimplantation of the tricuspid valve was planned for 2 weeks after the first operation. To avoid lung injury caused by the cardiopulmonary bypass and to preserve right ventricular function, a self-made superior and inferior vena cava shunt was connected to the pulmonary artery. The tricuspid valve was implanted without cardiopulmonary bypass.     

Surgical results of active infective native mitral valve endocarditis: repair versus replacement

Objective: The current study compared clinical outcomes after mitral valve repair or replacement in patients with active infective endocarditis involving only the native mitral valve. Methods: From January 1994 to December 2009, 102 patients were identified with active infective native mitral valve endocarditis. Mitral valve repair (MVP) was performed in 41 patients and mitral valve replacement (MVR) in 61 patients. The mean age was 34.4 ± 16.9 years in the MVP group and 43.1 ± 14.9 years in the MVR group (p = 0.007). The composite end points of cardiac death and cardiac-related morbidities were compared in these two groups using the inverse-probability-of-treatment-weighted method. The median follow-up time was 4.7 years (range, 0.1–15.8) and follow-up was possible in 100 (98%) patients. Results: There were three in-hospital deaths (2.9%), all in MVR patients (p = 0.272). The mean cardiopulmonary bypass time and aortic cross-clamping time were 111.4 ± 34.7 min and 72.7 ± 23.7 min in the MVP group and 101.1 ± 42.9 min and 62.9 ± 26.9 min in the MVR group (p = 0.204, p = 0.062). The 1-, 5-, and 10-year survival rates were 97.5%, 97.5%, and 81.1%, respectively, in the MVP group and 90%, 85.8%, and 85.8%, respectively, in the MVR group (p = 0.316). Actuarial event-free survival at 1, 5, and 10 years was 92.7%, 89.5%, and 72.2% in the MVP group, and 94.8%, 81.0%, and 77.3% in the MVR group (p = 0.787), respectively. Conclusions: The present study showed that postoperative long-term survival and event-free survival in patients with active infective endocarditis of the native mitral valve were not statistically significantly different regardless of whether patients underwent MVP or MVR.