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 treatment of infective aortic valve endocarditis.

Fifty-eight adult patients treated with aortic valve replacement for infective endocarditis were retrospectively reviewed. The operation was performed during antibiotic therapy (group I, n = 25) or after completion of such therapy, on average 17 months after diagnosis (group II, n = 33). Preoperatively 68% of group I and 24% of group II were in NYHA class IV. Bacterial aetiology was verified in 78% of all cases. Preoperative embolic complications occurred in six group I and three group II cases, causing hemiplegia in eight. At operation the aortic valve was bicuspid in 29 of the 58 patients. Vegetations and cusp perforation were present in most cases. Bacteria were demonstrated in 11 of the excised specimens. A mechanical valve prosthesis was inserted in all cases. Three patients died, one perioperatively and two during their time in hospital (2 from group I). Low-output syndrome was the commonest postoperative complication. During follow-up averaging 66 months, 12 patients died (6 of cardiac causes). Late complications were periprosthetic leakage (2 cases), significant embolism (5), and prosthetic valve endocarditis (4), causing periprosthetic leakage in one case.     

Surgical treatment of active infective mitral valve endocarditis.

Although infective endocarditis is primarily treated conservatively with antimicrobial therapy, early surgical intervention is often mandatory when various complications arise. These include intractable heart failure, persistent uncontrollable infection, large mobile vegetations, peripheral embolism and prosthetic valve endocarditis. Optimal timing of surgical intervention in patients with infected heart valves results in reduced early and late mortality. In the context of healed infective endocarditis, mitral regurgitation is treated with mitral valve repair, which produces long-term results similar to those seen for treatment of degenerative mitral regurgitation. Mitral valve repair should also be considered for patients with mitral regurgitation due to active infective endocarditis. Superficial infection without valve destruction is the best candidate for valve repair. Discrete vegetations on the valve leaflets are excised along with underlying leaflet tissue (vegetectomy). Although valve lesions can be repaired by standard techniques, particular care (e.g., reinforcement with a pericardial patch) should be taken to avoid excess tension on the suture line. The feasibility of valve repair depends on the extent of tissue destruction. Large defects of the anterior leaflet, due to transmural infection or lesions that encompass greater than one-third of the entire posterior leaflet with annular abscess, are not amenable to repair. Also, the involvement of the aortic valve frequently necessitates valve replacement. Further, unstable preoperative hemodynamics leads to the decision to perform valve replacement immediately rather than complicate valve repair in an attempt to avoid prolonged operation time for life salvage. In the context of the feasibility of valve repair, timely surgical intervention and precise repair technique are essential.     

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.     

Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis

Delayed diagnosis or surgery sometimes causes more extensive destruction of aortic periannular abscess, or pseudoaneurysm, resulting in left ventricular–aortic discontinuity, particularly in patients with prosthetic valve endocarditis. The condition complicates the surgical procedures and causes worsening of short- and long-term outcomes. In-hospital mortality in patients with prosthetic valve endocarditis has been reported to be as high as 15–20 %, even at leading hospitals in the world. Contemporary modes of surgery for periannular abscess/pseudoaneurysm involve drainage of the cavity, radical debridement of necrotic tissue, annular reconstruction of the destroyed annulus, and root replacement using an optimal conduit. Radical debridement is of primary importance and is the universally accepted procedure, which frequently requires annular reconstruction using a pericardial patch. Conventional aortic valve replacement using a mechanical or stented biological valve, aortic valve replacement with translocation, aortic root replacement using an allograft, pulmonary autograft (Ross procedure), stentless biological valve, or a composite graft are conduits of choice. All things considered, allograft is believed to be the best conduit for a destroyed annulus because of better fit and its resistance to infection; however, recent reports have failed to confirm the superiority of allograft over other conduits in terms of long-term survival and freedom from reoperation/recurrence of infection. Short- and long-term outcomes have been studies for every type of conduit, but the selection of conduits for aortic root replacement is still controversial.     

Surgical treatment of active infective endocarditis and prosthetic valve endocarditis]

Fifteen patients with active native valve endocarditis (NVE) and 5 with prosthetic valve endocarditis (PVE) were subjected to this study. Among the patients with NVE, one of 10 with simple destruction of leaflets and 2 of 5 with annular infection died postoperatively of cerebral bleeding and persistent infection. Five patients with annular infection, whose microorganisms were Streptococcus faecalis, Staphylococcus epidermidis and gram-negative coccus, had a shorter duration from onset to operation (mean 38 days) compared with the others (mean 85 days). A patient with NVE requires an urgent operation, especially when these microorganisms are identified. Among those with PVE, 3 underwent operation at the active phase and one at the chronic phase. Two patients with mechanical valve endocarditis by Staphylococcus and Candida died, but the other 2 with bioprosthetic valve endocarditis by alpha-Streptococcus survived, because infection was localized in the leaflets. Another patient with mechanical valve endocarditis by alpha-Streptococcus survived with conservative management. While a patient with bioprosthetic valve endocarditis requires an early operation as well as NVE, a patient with mechanical valve endocarditis requires selected management considering the microorganism and general condition.     

Early valve replacement in active infective endocarditis

Infective endocarditis is associated with a high mortality, but previous studies have suggested that the major complications of the condition might be prevented by early surgery. Of 50 patients treated for infective endocarditis at the Montreal Heart Institute from 1977 to 1982, 30 were treated nonsurgically and the remaining 20 underwent early valve replacement before preoperative antibiotic therapy was completed. Of these 20, 14 had native valve endocarditis and 6 prosthetic valve endocarditis. The organisms involved were Streptococcus sp in 11, Staphylococcus aureus in 2, gram-negative organisms in 3 and Candida parapsilosis in 1. Blood cultures remained negative in three patients. There were three early deaths (15%) following operation and one late death (5%). Infection on implanted prostheses did not recur, but reoperation was required in one patient because of prosthetic dehiscence 7 months after initial implantation. All resected valves displayed evidence of infection. Follow-up was obtained in all survivors. After an average follow-up of 26 months, 12 patients remained in functional class I and 4 in class II (New York Heart Association classification). Early valve replacement has resulted in improved survival of patients with infective endocarditis and is now associated with a low operative mortality and morbidity.     

活动期感染性自然心内膜炎的外科治疗

目的　总结活动期感染性自然心内膜炎外科治疗的经验。方法　自 1996年 10月 1日至 2003年 12月 31日,阜外心血管病医院外科共手术治疗活动期感染性自然心内膜炎 54例。有明确感染诱因的 21例,先天性心内结构畸形 23例,风湿性瓣膜病 1例。术前心功能NYHA分级:Ⅰ级6例,Ⅱ级 12例,Ⅲ级 7例,Ⅳ级 29例。术前左心室舒张末径 ( 63±11 )mm。发病至手术间隔 8 ~629d(中位数 125d)。行主动脉瓣置换 25例,主动脉瓣及二尖瓣置换 15例,二尖瓣置换 6例,二尖瓣成形 3例,肺动脉瓣置换 1例,单纯心内分流修补 4例。术后应用足量敏感抗生素 6 ~8周。结果手术死亡 5例,死因均为感染,术后即失访 4例,手术死亡率 17% (9 /54)。14例 ( 26% )发生手术并发症。45例随访 6~67个月,平均(31±19)个月。术后心功能NYHA分级Ⅰ级 41例,Ⅱ级 3例,Ⅲ级 1例,左心室舒张末径 (52±8)mm。2例病人接受再次手术,术后康复;有再次手术指征但未手术者 3例。术后晚期意外死亡 1例,抗凝过量致颅内出血 1例。结论　活动期感染性自然心内膜炎经积极的外科治疗能够取得较好的治疗效果。     

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.     

Emergency aortic valve replacement in active infective endocarditis in a chronically hemodialyzed patient

A 36-year-old housewife, who had been treated with hemodialysis for 15 years is reported. She had suffered from active infective endocarditis of the aortic valve caused by blood access infection for several weeks. She rapidly fell into severe cardiac failure. Five days after the onset of the cardiac failure she was transferred to our hospital. The aortic valve was replaced using #21 Bj?rk-Shiley aortic valve prosthesis shortly after the arrival to the hospital. Postoperatively she was treated with vigorous antibiotics and was anticoagulated. Seven months after the surgery, patient is back to an active life with hemodialysis 3 times a week.     

Left ventricular outflow tract pseudoaneurysm complicated with prosthetic valve endocarditis after aortic valve replacement

A rare case of left ventricular outflow tract (LVOT) pseudoaneurysm complicated with prosthetic valve endocarditis was reported herein. A 78-year-old male previously underwent aortic valve replacement (AVR) with a bioprosthesis. Four years after the initial operation, he presented with prolonged high fever and bloody sputum. Multi-detector row computed tomography (MDCT) clearly showed LVOT pseudoaneurysm originating from a subvalvular fibrous region. The patient underwent re-AVR and repair of pseudoaneurysm. The postoperative course was uneventful, and the patient recovered good condition.     

Rare complication of dissection of valsalva sinus with aorto-left atrial fistula in active aortic valve endocarditis

We present a rare case of dissection of the sinus of Valsalva associated with an aortic annular abscess that perforated into the left atrium. A 61-year-old patient with infective endocarditis underwent emergent operation due to progressive heart failure, in whom echocardiography showed the dissection of sinus of Valsalva with aorto-left atrial communication. Procedure included autologous pericardial patch repair of the dissecting sinus of Valsalva and bioprosthetic valve replacement with a successful outcome. Microscopic examination showed excessive neutrophil infiltration in the aortic valve and annulus without involvement of the sinus of Valsalva.     

Results of homograft aortic valve replacement for active endocarditis

Since July 1985, cryopreserved homograft prostheses have been used for aortic valve replacement in 10 patients, aged 2 to 77 years, with active endocarditis. Five patients had positive bacterial cultures from excised valves, and all had clinical findings of uncontrolled infection while receiving appropriate antibiotics. Homograft valves (four) or valved conduits (six) were implanted for treatment of sepsis (6 patients), congestive heart failure (3) or recurrent emboli (1 patient), and complicating native (5 patients) or prosthetic valve (5) endocarditis. Staphylococci (6 patients), streptococci (3), and Candida (1) were infecting organisms. Preoperatively, Doppler echocardiography showed aortic regurgitation in all patients. At operation, 9 patients had gross vegetations, 9 had single or multiple abscess cavities, and 5 had pericarditis. Complex reconstruction of the aortic valve and annulus with homograft conduits was necessary in 6 patients (3 with previous aortoventriculoplasty). Two early deaths (ventricular failure, perioperative stroke) occurred. Mean follow-up of all operative survivors was 2.1 years (range, 0.6 to 3.6 years), and one late death resulted from arrhythmia. Homograft valve regurgitation increased in 1 patient, and 7 late survivors are asymptomatic. No patient has had recurrence of endocarditis. We conclude that cryopreserved homograft aortic valve/root replacement is an effective method for management of active endocarditis complicated by annular destruction.     

Brucellosis relapse causing prosthetic valve endocarditis and aortic root infective pseudoaneurysm

We report a previously treated case of brucellosis and aortic root replacement, which became complicated by prosthetic valve endocarditis and a massive aortic root pseudoaneurysm. Preoperative blood and intraoperative pseudoaneurysm wall cultures were positive for Brucella, and the patient was managed successfully with a combination of surgical and medical treatment. Brucella endocarditis is further discussed.