Mitral valve repair for infective endocarditis

OBJECTIVE: This study investigated the feasibility of mitral valve (MV) repair in patients with active or healed infective endocarditis (IE) with mitral regurgitation and evaluated effects on left ventricular (LV) function and structure. METHODS: Subjects comprised 19 patients who underwent MV operations for IE between December 2004 and September 2007. MV repair was performed for acute IE in 10 of 15 patients (67%) and for healed IE in 4 of 4 patients (100%). RESULTS: No early or late postoperative deaths were encountered. One patient underwent redo MV repair owing to severe mitral regurgitation 1 month postoperatively. Postoperative echocardiography after MV repair demonstrated less than trivial (acute IE in seven, healed IE in three) or mild (acute IE in three, healed IE in one) mitral regurgitation. In patients with MV replacement, the postoperative left atrial dimension (LAD) was decreased (51.5 +/- 39.2 vs. 39.2 +/- 1.9 mm, P = 0.007); however LV end-diastolic dimension (LVDD) and LV end-systolic dimension were unchanged. In patients with MV repair, LVDD (57.5 +/- 6.5 vs. 46.0 +/- 5.6 mm, P < 0.001), LV end-systolic dimension (36.1 +/- 5.2 vs. 32.4 +/- 6.2 mm, P = 0.04), LAD (43.1 +/- 8.1 vs. 33.6 +/- 7.7 mm, P = 0.003) were reduced. Postoperative ejection fraction (55.3 +/- 13.5% vs. 41.8% +/- 10.0%, P = 0.03) and fraction shortening (30.1% +/- 9.2% vs. 20.7% +/- 5.5%, P = 0.03) were better in patients with MV repair than those with MV replacement. CONCLUSIONS: MV repair is feasible in patients with both active and healed IE. MV repair preserves better LV function and structure postoperatively.     

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。     

Isolated tricuspid valve stenosis caused by infective endocarditis in an adult: Report of a case

We report herein the case of a 42-year-old man in whom dyspnea on exertion was found to be caused by isolated tricuspid stenosis. Two-dimensional echocardiogram showed thickening of the tricuspid valve with a markedly enlarged right atrium. A color-flow Doppler examination-revealed severe tricuspid stenosis without regurgitation and a Doppler-derived tricuspid diastolic pressure gradient of 23 mmHg. At the time of surgery, the patient was noted to have a stenotic tricuspid valve with thickened leaflets, fused commissures, and almost normal chorda tendineae. The valve leaflets were teased apart to the scattered specimen, and tricuspid valve replacement was successfully performed. Microscopic examination of the specimen demonstrated infective endocarditis. Isolated acquired tricuspid stenosis is extremely rare and, to our knowledge, this is the first case of infective endocarditis being involved as the primary cause.     

二尖瓣修复术治疗感染性心内膜炎所致二尖瓣反流患者

目的探讨二尖瓣修复及置换术对感染性心内膜炎所致二尖瓣反流患者的疗效。 方法选取2014年1月至2016年1月于淄博市中心医院就诊的126例感染性心内膜炎所致二尖瓣反流患者为研究对象,根据治疗过程中手术方式不同分为研究组和对照组（各63例）,研究组患者采取二尖瓣修复术进行治疗,对照组患者采取二尖瓣置换术进行治疗。详细记录入组患者的气管插管时间、入住重症加强护理病房（ICU）时间、感染发生率、手术患者病死率、住院天数、住院花费等;记录患者心脏超声检查结果：左心室射血分数、左心室舒张末期直径、左心室收缩末期直径、左心房直径及二尖瓣反流得分,并记录随访指标。 结果与对照组患者相比,研究组患者气管插管时间[（16.48 ± 8.06）h]、入住ICU时间[（2.12 ± 0.86）h]、术后病死率（1.59%）、住院时间[（22.46 ± 10.34）d]、栓塞发生率（4.76%）以及住院花费[（10.63 ± 3.57）万元]差异均有统计学意义（t = 1.35、P = 0.04,t = 3.68、P = 0.02,χ² = 4.67、P = 0.01,t = 4.03、P = 0.01,χ² = 1.69、P = 0.04,t = 3.06、P = 0.03）;研究组患者术后左心室射血分数[（49.06 ± 10.24）%]、左心房直径[（43.25 ± 8.98）mm]和二尖瓣反流得分[（1.12 ± 0.31）分]均小于对照组患者,左心室舒张末期直径[（52.46 ± 7.42）mm]和左心室收缩末期直径[（39.70 ± 8.09）mm]均大于对照组患者,差异均有统计学意义（t = 1.23、2.84、3.89、1.34、2.01,P = 0.04、0.02、0.01、0.03、0.02）。随访显示,研究组患者左心室射血分数[（61.38 ± 8.61）%]大于对照组患者（t = 5.31、P = 0.01）,左心室舒张末期直径[（48.69 ± 9.57）mm]和随访病死率（4.76%）均小于对照组,差异有统计学意义（t = 3.24、P = 0.02,χ² = 2.91,P = 0.03）。单因素方差分析显示入住ICU时间、插管时间和心功能衰竭史均为感染性心内膜炎患者手术死亡危险因素（t = 2.34、P = 0.01,t = 1.09、P = 0.03,χ² = 1.61、P = 0.02）。 结论二尖瓣修复术对感染性心内膜炎所致二尖瓣反流疗效和预后较好,能够缩短患者住院时间和降低入院费用。     

亚甲蓝在感染性心内膜炎患者行心脏瓣膜置换术中的应用效果

目的观察亚甲蓝在感染性心内膜炎患者行心脏瓣膜置换手术中的应用效果。方法选择2016年10月至2018年11月拟行心脏瓣膜置换术的感染性心内膜炎患者30例,男21例,女9例,年龄38～67岁,ASAⅡ—Ⅳ级,采用随机数字表法分为两组:亚甲蓝组(MB组)和对照组(C组),每组15例。MB组于CPB停机前10 min开始泵注亚甲蓝2.0 mg/kg持续20 min,C组于相同时点注入等剂量生理盐水。记录术中总输液量、术后机械通气时间、ICU停留时间;分别于给肝素前(T_1)、CPB停机后10 min(T_2)以及静注完亚甲蓝后1 h(T_3)、3 h(T_4)、6 h(T_5)和12 h(T_6)时记录HR、MAP、CVP、HR与SBP的乘积(RPP)、正性肌力药物评分(IS)和血管活性药物评分(VIS)以及血糖和乳酸浓度。结果与T_1时比较,T_2—T_6时两组IS、VIS、血糖和乳酸浓度明显升高(P0.05);与C组比较,T_3—T_6时MB组IS、VIS、RPP和乳酸浓度明显降低(P0.05),术中总输液量明显减少(P0.05),术后机械通气时间和ICU停留时间明显缩短(P0.05)。结论亚甲蓝在感染性心内膜炎患者行心脏瓣膜置换手术中早期预防应用,可减少术中液体输注量和术后血管活性药物应用,降低心肌氧耗,缩短术后机械通气时间和ICU停留时间。     

Double valve replacement for infective endocarditis in a hemodialysis patient: A case report

A 57-year-old man who was in end stage renal failure underwent an aortic and mitral valve replacement for the progression of cardiac dysfunction, secondary to Staphylococcus aureus infective endocarditis. Cardiac surgery was performed using a Hemo-Concentrator during cardiopulmonary bypass, 82 months following the initiation of hemodialysis. This is the second report in the literature of a successful double valve replacement for infective endocarditis and congestive heart failure in a chronic hemodialysis patient.     

Emergency valve surgery for infective endocarditis complicated by acute intracranial hemorrhage: A case report

IntroductionOptimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial.Presentation of caseA 43-year-old man with IE received appropriate antibiotic therapy but had recurrence of cerebral infarction and intracranial hemorrhage (ICH). Emergency valve surgery was performed 2 days after ICH onset because of heart failure and recurrence of cerebral complications. Postoperatively, he showed no neurologic symptoms; neuroimaging showed no enlargement of ICH.DiscussionPostoperative risk of neurologic deterioration may be relatively lower than previously thought in patients with IE who undergo surgery within 1 month after ICH onset.ConclusionsEmergency surgery in patients with ICH is justified in cases of multiple indications for such small ICH. Further evaluation regarding the risk of subsequent hemorrhage in patients with ICH who require emergency valve surgery is warranted.     

Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium

Objective

We had previously reported the short-term results of the aortic valve neocuspidization (AVNeo) procedure. We have now evaluated the midterm results with the longest follow-up of 118 months.

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.     

Combined aortic and mitral valve repair in active infective endocarditis

We describe a case of successful combined repair of the aortic and mitral valves for an indication of active infective endocarditis involving both valves. Mitral valve repair was achieved by vegetation debridement, fixation of the anterior mitral commissure, resection and suturing of the posterior mitral leaflet, and posterior annuloplasty with autologous pericardium. Aortic valve repair was achieved by vegetectomy and commissural plication. Postoperative clinical course was without signs of recurrent infection, and echocardiogram demonstrated mitral valve competence with trivial aortic regurgitation. We concluded that simultaneous valve repair is a viable option in the context of active endocarditis.     

85例感染性心内膜炎的临床诊断与外科治疗

【摘要】 目的 总结感染性心内膜炎(IE)的临床诊断、外科手术和围手术期处理的经验。方法 回顾性分析2004年9月至2012年12月在我院接受手术治疗的85例IE患者的临床资料。其中男52例,女33例,年龄15~71岁,平均年龄35±16.2岁。85例患者中,12例患者接受了急诊手术治疗;71例患者术前进行了血培养检查,其中阳性18例(阳性率25.4%);超声心动图检查发现赘生物患者73例。所有患者均经外科手术清除感染病灶,纠治瓣膜病变及心脏畸形。结果 全组无手术死亡,均痊愈出院。随防72例,随防时间2~95月,平均53.3±26月,1例因自行停服抗凝药导致机械瓣栓塞死于出院后半年。其余71例术后感染性心内膜炎均未复发。术后心功能恢复至I级61例,心功能恢复至II级24例。结论 早期诊断、适时手术,彻底清除感染病灶,和正确使用抗生素是治疗感染心内膜的重要措施。     

Impact of aortic root repair or replacement in severe destructive aortic valve endocarditis with paravalvular abscesses on long-term survival

 Open in a separate windowOBJECTIVESSurgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis.METHODSA total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63).RESULTSPatients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39–0.95; P = 0.031).CONCLUSIONSAortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis.Clinical trial registrationUN4232 382/3.1 (retrospective study).     

Surgical treatment of right-sided infective endocarditis

Objective

Right-sided infective endocarditis is increasing because of increasing prevalence of predisposing conditions, and the role and outcomes of surgery are unclear. We therefore investigated the surgical outcomes for right-sided infective endocarditis.

61例感染性心内膜炎的诊断与治疗总结

目的 探讨感染性心内膜炎的诊断与外科治疗特点,分析外科治疗对术后短、中期疗效.方法 回顾性分析1995年1月～2008年4月期间61例感染性心内膜炎患者接受手术治疗的临床资料,总结外科治疗经验.结果 术后早期死亡4例(6.6%),术后随访6月～13年.出院患者死亡5例,其他生存患者中心功能Ⅱ级43例,Ⅲ级9例.结论 早期明确诊断、选择合适的手术时机及内、外科综合治疗是感染性心内膜炎成功治疗的关键.     

Extracardiac aneurysm of the interleaflet triangle above the aortic-mitral curtain due to infective endocarditis of the bicuspid aortic valve

A previously healthy 33-year-old man presented to our hospital with fever, left hemiparalysis, motor aphasia, and clouding of consciousness. Echocardiography revealed vegetation attached to the bicuspid aortic valve as well as an aneurysm originating below the annulus. Head computed tomography showed multiple infarctions. Under the diagnosis of infective endocarditis and perivalvular aneurysm, operation was performed because of the risk of further embolization. Operative findings showed an extracardiac aneurysm of the interleaflet triangle above the aortic-mitral curtain. Because there was no sign of active inflammation, the orifice was closed with an autologous pericardial patch, and the aortic valve was replaced with a mechanical valve. We should be aware of extracardiac aneurysm of the interleaflet triangle when dealing with infective endocarditis, which should be operated as soon as it is found because of the risk for extracardiac aneurysmal rupture.     

Aortic valve neocuspidization with in-body tissue-engineered autologous membranes: preliminary results in a long-term goat model

 Open in a separate windowOBJECTIVESAortic valve neocuspidization has shown satisfactory clinical outcomes; however, autologous pericardium durability is a concern for young patients. This study applied an autologous collagenous membrane (Biosheet^®), produced by in-body tissue architecture, to aortic valve neocuspidization and investigated its long-term outcome in a goat model.METHODSMoulds were embedded subcutaneously in 6 goats. After 2 months, Biosheets formed in the moulds. We performed aortic valve neocuspidization using a portion of the sheets with a thickness of 0.20–0.35 mm, measured by optical coherence tomography. Animals were subjected to echocardiography and histological evaluation at 6 months (n = 3) and 12 months (n = 3). As a control, the glutaraldehyde-treated autologous pericardium was used in 4 goats that were similarly evaluated at 12 months.RESULTSAll animals survived the scheduled period. At 6 months, Biosheets maintained valve function and showed a regeneration response: fusion to the annulus, cell infiltration to the leaflets and appearance of elastic fibres at the ventricular side. After 12 months, the regenerative structure had changed little without regression, and there was negligible calcification in the 1/9 leaflets. However, all cases had one leaflet tear, resulting in moderate-to-severe aortic regurgitation. In the pericardium group, three-fourths of the animals experienced moderate-to-severe aortic regurgitation with a high rate of calcification (9/12 leaflets).CONCLUSIONSBiosheets may have regeneration potential and anti-calcification properties in contrast to autologous pericardium. However, in order to obtain reliable outcome, further improvements are required to strictly control and optimize its thickness, density and homogeneity.     

Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic

Objective

To study mid-term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft.

Crescentic glomerulonephritis in a child with infective endocarditis

Renal manifestations associated with infective endocarditis (IE) may present with different clinical patterns, and the most common renal histopathological finding is diffuse proliferative and exudative type of glomerulonephritis, leading to hematuria and/or proteinuria. Renal failure due to crescentic glomerulonephritis (CGN) in children with IE is a very rare condition. We report here a 6-year-old boy, who had a history of cardiac surgery for pulmonary atresia and ventricular septal defect, presenting with the clinical findings of IE and hematuria associated with renal failure due to CGN. He was treated with a combination of intravenous (IV) methylprednisolone pulses and appropriate antibiotics, but also received one dose of IV cyclophosphamide. Complete serological, biochemical, and clinical improvement was achieved after 2 months of follow-up. Antibiotic therapy is the essential part of the treatment of IE-associated glomerulonephritis; however, this case also highlights the importance of aggressive immunosuppressive therapy to suppress the immunological process related with infection in this life-threatening condition leading to renal failure.