Double valve endocarditis

Infective Endocarditis-Characteristics and Prognosis According to the Affected Valves

BACKGROUND

Infective endocarditis (IE) continues to be a disease with high mortality despite medical advances.

OBJECTIVE

The objective of this study was to investigate the characteristics and prognosis of IE according to the affected valves.

MATERIALS AND METHODS

This study was retrospective and single-centered, and it included 270 patients with a diagnosis of IE, for the period 2005-2021, who received treatment at the University Hospital "St. Georgi" in Plovdiv, Bulgaria.

RESULTS

Single-valve IE (SIE) was found in 82.6% (n-223), multivalvular IE (MIE) in 16.66% (n = 45) and device IE (CDRIE) in 0.74% (n = 2) of patients. The most commonly affected valve was the aortic valve, in 44.8% (n = 121). The predominant multivalvular involvement was aortic-mitral valves (AV-MV) (13.7%, n = 37). The patients with tricuspid valve (TV) IE were significantly younger, at 39 (30) years, and were more frequently male (80.8%). Mortality was higher in MIE than in SIE (31.1% vs. 23.8%) and was the highest in multivalve aortic-tricuspid (AV-TV) IE (75%). Early surgery was performed most in AV-MV IE, in 29.7% (n = 11). The Charlson comorbidity index (CCI) was significantly higher in MV 4 (4) and AV 3 (3) vs. TV IE 1 (5) (p = 0.048 and p = 0.011, respectively). Septic shock occurred most frequently in AV-TV involvement (75%; p = 0.0001). The most common causative agents were of the Staphylococcus group. Staphylococcus aureus more often affected TV alone (46.2%, n = 124) vs. AV (9.9%, n = 14; p = 0.0001) and vs. MV (22.6%, n = 17; p = 0.022); Staphylococcus coagulase-negative (CNG) was the prevalent cause of MV IE (22.7%, n = 17) vs. AV-MV (2.7%, n = 1; p = 0.007). Streptococci were represented in a low percentage and only in left-sided IE, more frequently in AV-MV (18.9%, n = 7) vs. AV (6.6%, n = 8; p = 0.025).

CONCLUSIONS

The aortic valve is the most frequently affected valve, as single-valve IE or as multivalve AV-MV, with the predominant causative agents being of the Staphylococcus group. AV-TV IE has the worst prognosis, with the most common complication of septic shock and the highest in-hospital mortality.

Outcomes of double-valve surgery for infective endocarditis are improving in the modern era

BACKGROUND

The incidence of infective endocarditis (IE) is rapidly increasing. Contemporary outcomes following high-risk double valve surgery (DVS) for IE are not well described.

METHODS

Between 2001 and 2021, 211 patients with IE underwent combined aortic and mitral valve surgery at a tertiary care referral center. Data from the Society of Thoracic Surgeons registry, including demographics, operative details, and outcomes, were collected. Risk factors for 30-day and 1-year-mortality were analyzed. Survival was analyzed using Kaplan-Meier and Cox proportional hazards modeling.

RESULTS

The study cohort had a male preponderance (73%), with a median age of 56 years (interquartile range [IQR], 44 to 63 years). Forty-five patients (21%) had a history of intravenous (IV) drug abuse, 50 (24%) were on preoperative dialysis, and 50 (24%) had prosthetic valve endocarditis. Thirty-day and 1-year mortality were 14% (n = 30) and 30% (n = 61), respectively. On multivariable Cox regression adjusting for age, prosthetic valve endocarditis, postoperative intra-aortic balloon pump (IABP), history of dialysis (adjusted hazard ratio [aHR], 1.9; 95% confidence interval [CI], 1.3 to 2.9; P = .002) and IV drug abuse (aHR, 2.0; 95% CI, 1.1-3.5; P = .02) were predictive of decreased survival. Undergoing surgery after 2010 was predictive of improved survival (aHR, 0.5; 95% CI, 0.3 to 0.8; P = .006). These patients were more likely to undergo urgent/emergent surgery (83% vs 29%; P < .001) and less likely to have an aortic root abscess (40% vs 58%; P = .03) or to require the commando procedure (13% vs 33%; P = .002).

CONCLUSIONS

In this large series evaluating outcomes of DVS for IE in the modern era, although the mortality risk remained elevated, improving outcomes may be associated with earlier surgical intervention before significant disease progression. Multidisciplinary evaluation for complex IE may be considered to better understand the optimal timing and repair strategy.

Native and Prosthetic Simultaneously Double Valve Infective Endocarditis with Enterococcus faecalis-Case-Based Review

Infective endocarditis is a severe infective heart disease, commonly involving native or prosthetic valves. It frequently presents with univalvular involvement and simultaneous double valve or multivalvular involvement is rarely described. The third leading cause of infective endocarditis worldwide is Enterococcus faecalis, which is associated with high mortality rates despite important advances in antimicrobial therapy. It develops secondary to enterococcal bacteremia, with its origin from the gastrointestinal or genitourinary tract and predominantly affecting the elderly population with multiple comorbidities. Clinical presentation is usually less typical, and the treatment is challenging. It can be marked by antibiotic resistance, side effects, and subsequent complications. Surgical treatment can be considered if deemed appropriate. To the best of our knowledge, we present the first case-based narrative review of Enterococcus faecalis double valve endocarditis involving both the aortic native and prosthetic mitral valve, highlighting the clinical characteristics, treatment, and complications of this condition.

Multivalvular Endocarditis: A Rare Condition with Poor Prognosis

Background. Infective endocarditis (IE) is a severe condition. Our aim was to describe the profile and prognosis of patients with multivalvular infective endocarditis (MIE) and compare them to single-valve IE (SIE). Methods. We used a retrospective analysis of the Spanish IE Registry (2008−2020). Results. From 4064 definite cases of valvular IE, 577 (14.2%) had MIE. In patients with MIE, the most common locations were mitral (552, 95.7%) and aortic (550, 95.3%), with mitral-aortic involvement present in 507 patients (87.9%). The most common etiologies were S. viridans (192, 33.3%) and S. aureus (113, 19.6%). MIE involved only native valves in 450 patients (78.0%). Compared with patients with SIE, patients with MIE had a similar age (69 vs. 67 years, respectively, p = 0.27) and similar baseline characteristics, but were more frequently men (67.1% vs. 72.9%, p = 0.005) and had a higher incidence of intracardiac complications (36.2% vs. 50.4%, p < 0.001), heart failure (42.7% vs. 52.9%, p < 0.001), surgical indication (67.7 vs. 85.1%, p < 0.001), surgery (46.3% vs. 56.3%), and in-hospital mortality (26.9% vs. 34.3%, p < 0.001). MIE was an independent predictor of in-hospital mortality (odds ratio (OR) 1.3, 95% confidence interval (CI) 1.1−1.7, p = 0.004) but did not have an independent association with 1-year mortality (OR 1.1, 95% CI 0.9−1.4, p = 0.43). Conclusions. About one-seventh of the valvular IE patients had MIE, mainly due to mitral-aortic involvement. MIE is associated with a poor in-hospital prognosis. An early diagnosis and treatment of IE might avoid its spread to a second valve.

Double-valve infective endocarditis: clinical features and prognostic impact-a retrospective study in a surgical centre

Most cases of infective endocarditis (IE) involve a single valve, and little is known concerning IE that simultaneously affects two valves. The involvement of more than one valve may imply more severe and extensive cardiac lesions. In these patients, surgery may be challenging. We aimed to determine the clinical characteristics, the therapeutic strategy, and the prognostic impact of double-valve IE (DVIE). We retrospectively included in the analysis that 440 consecutive patients with definite active IE in a single surgical centre. DVIE occurred in 75 of the total enrolled 440 patients (17%) and involved mostly the combination of mitral and aortic valves (N = 63, 84%). Most patients had double-native IE (N = 45, 60%). Staphylococci were less frequent in patients with double-valve than single-valve IE (SVIE). The proportion of patients undergoing valve repair among those treated surgically was higher for patients with DVIE than for SVIE (p < 0.03). Valve repair of at least one valve was associated with non-significant better survival than double replacement. DVIE was associated with higher all-cause mortality than SVIE (p < 0.013) and a higher relapse rate (p = 0.023). DVIE was not associated with a higher risk of composite non-fatal adverse events. DVIE represents a considerable proportion of overall cases of IE, mainly involving aortic and mitral valves, with a jet lesion on the mitral valve; Staphylococcus is significantly less frequent than in SVIE; DVIE is independently associated with higher mortality and relapse rate; finally, mitral valve repair is feasible in a considerable proportion of surgical cases.

Outcomes of surgery for extensive infective endocarditis

OBJECTIVE

Extensive infective endocarditis (EIE) involving the valve annulus or the intervalvular fibrous body (IFB) is a treatment challenge. We sought to clarify the outcomes of patients undergoing surgery for EIE.

METHODS

We retrospectively reviewed all 197 consecutive patients who underwent an operation for infective endocarditis (IE) between 2005 and 2016 in the Helsinki University Hospital. Thirty-five (18%) patients had EIE, of which 17 (9%) infection extended to IFB.

RESULTS

Patients with EIE had higher EuroSCORE II (24.4% vs. 12.4% p < .001), higher frequency of diabetes (29% vs. 13% p = .017), more often NYHA Class IV (83% vs. 56% p = .02), aortic (97% vs. 45% p < .001), multivalve (40% vs. 11% p < .001), and prosthetic valve IE (37% vs. 9% p < .001), and underwent more often emergency surgery (46% vs. 29% p = .042). Thirty-day mortality was 9% in the EIE group and 7% in the non-EIE group (p = .720). Survival of patients with EIE at 5 years was 60% and with non-EIE 71% (p = .029). The frequency of complications was higher in EIE (54%) than in non-EIE patients (25%) (p < .001), due to the higher need for permanent pacemaker implantations (34% vs. 4% p < .001). Freedom from re-operations at 5 years was 91% in the EIE group and 97% in the non-EIE group (p = .203).

CONCLUSIONS

Early mortality of surgery for EIE was comparable with non-EIE. Midterm survival was lower after surgery for EIE than after surgery for non-EIE but there was no difference in survival of patients with IE limited to the valve annulus amenable to patch repair and patients with endocarditis requiring IFB reconstruction.

Predictors of mortality and adverse events in patients with infective endocarditis: a retrospective real world study in a surgical centre

Purpose

Mortality in infective endocarditis (IE) is still high, and the long term prognosis remains uncertain. This study aimed to identify predictors of long-term mortality for any cause, adverse event rate, relapse rate, valvular and ventricular dysfunction at follow-up, in a real-world surgical centre.

Methods

We retrospectively analyzed 363 consecutive episodes of IE (123 women, 34%) admitted to our department with a definite diagnosis of non-device-related IE. Median follow-up duration was 2.9 years. Primary endpoints were predictors of mortality, recurrent endocarditis, and major non-fatal adverse events (hospitalization for any cardiovascular cause, pace-maker implantation, new onset of atrial fibrillation, sternal dehiscence), and ventricular and valvular dysfunction at follow-up.

Results

Multivariate analysis independent predictors of mortality showed age (HR per unit 1.031, p < 0.003), drug abuse (HR 3.5, p < 0.002), EUROSCORE II (HR per unit 1.017, p < 0.0006) and double valve infection (HR 2.3, p < 0.001) to be independent predictors of mortality, while streptococcal infection remained associated with a better prognosis (HR 0.5, p < 0.04). Major non-fatal adverse events were associated with age (HR 1.4, p < 0.022). New episodes of infection were correlated with S aureus infection (HR 4.8, p < 0.001), right-sided endocarditis (HR 7.4, p < 0.001), spondylodiscitis (HR 6.8, p < 0.004) and intravenous drug abuse (HR 10.3, p < 0.001). After multivariate analysis, only drug abuse was an independent predictor of new episodes of endocarditis (HR 8.5, p < 0.001). Echocardiographic follow-up, available in 95 cases, showed a worsening of left ventricular systolic function (p < 0.007); severe valvular dysfunction at follow-up was reported only in 4 patients, all of them had mitral IE (p < 0.03).

Conclusions

The present study highlights some clinical, readily available factors that can be useful to stratify the prognosis of patients with IE.

Characteristics and Prognosis of Patients With Left-Sided Native Bivalvular Infective Endocarditis

BACKGROUND

Most cases of left-sided native valve infective endocarditis (IE) involve a single valve and little is known concerning IE that simultaneously affects the aortic and mitral valves.

METHODS

We aimed to determine the characteristics, identify the prognostic factors, and define the effect of early surgery for patients with left-sided native bivalvular IE. This analysis included 1340 consecutive patients who presented with definite acute left-sided native valve IE in a 2-centre cohort study.

RESULTS

A bivalvular involvement was present in 257 patients (19%). Patients with bivalvular IE had more embolic events (P = 0.044), congestive heart failure (P = 0.016), vegetations, and perivalvular complications (both P < 0.001) than those with monovalvular IE. Early surgery was more frequent for patients with bivalvular IE (P < 0.001). Thirty-day mortality was higher for patients with bivalvular IE than for those with monovalvular IE (24.5% vs 17.6%; P = 0.008), even after adjustment (odds ratio, 1.86 [95% confidence interval, 1.26-2.73]; P < 0.001). Estimated 10-year survival was 70% ± 1% for monovalvular IE and 59% ± 3% for bivalvular IE (P = 0.002). Bivalvular IE was still associated with mortality in multivariable Cox analysis, after adjustment for covariates including age, neurological events, congestive heart failure, Staphylococcus spp infection, perivalvular complications, and early surgery (hazard ratio, 1.70 [95% confidence interval, 1.31-2.11]; P < 0.001). Early surgery was associated with increased survival for patients with bivalvular IE (79% ± 4% vs 35% ± 6%; P < 0.001).

CONCLUSIONS

Bivalvular involvement is frequent in left-sided native valve IE, is associated with more embolic events and congestive heart failure than monovalvular IE, and patients are at a high risk of death. Early surgery is associated with improved survival and should be systematically discussed in the absence of contraindication.

[Aortic infective endocarditis: Value of surgery. About 48 cases]

INTRODUCTION

Infective endocarditis (IE) is a serious disease whose prognosis depends on early management. Aortic location is characterized by its evolution toward myocardial failure and the high number of complications reasons for early surgery.

AIM

To compare the short- and mid-terms results of surgery for aortic infective endocarditis (IE) in the active phase and the healed phase.

PATIENTS AND METHODS

We analyzed retrospectively the data of 48 consecutive patients operated for aortic infective endocarditis between January 2000 and January 2012. The data on operative mortality, morbidity and major cardiovascular events (mortality, recurrent endocarditis, reintervention, and stroke) were analyzed.

RESULTS

Twenty-three patients (48%) underwent surgery during the active phase (group I), 19 on native and 4 on prosthetic valves, and 25 patients (52%) were operated during healed endocarditis (group II) only on native valve. Mean age was 39 years (12-81) with a male predominance (83%). Rheumatic valvular disease was the main etiology of underlying valvular disease in both groups (85%). The clinical feature was dominated by signs of cardiogenic shock in group I and dyspnea exertion stage III-IV NYHA in group II. Streptococcus and Staphylococcus germs were most frequently encountered. Indication for surgery was heart failure in group I, it was related to the symptoms, the severity of valvular disease and its impact on the left ventricle in group II. An aortic valve replacement with a mechanical prosthesis was performed in the majority of cases (83%). Postoperative mortality concerned only one patient in group I. Twenty-one patients (44%) were followed for a mean of 30 months (1-72). One patient in group II died following cerebral hemorrhagic stroke related to accident with vitamin K antagonist. In both groups, there was an improvement in the functional class. No recurrence of endocarditis was noted in both groups during follow-up.

CONCLUSION

The prognosis of infective endocarditis of the aortic valve is severe due to the fast progression to heart failure. Early medical and surgical approach provides good results on morbidity and mortality in the short- and mid-terms.

Surgical treatment of aortic valve endocarditis: a 26-year experience

Objective

We have retrospectively analyzed the results of the operations made for aortic valve endocarditis in a single center in 26 years.

Methods

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

Current readings: Status of surgical treatment for endocarditis

Valve endocarditis is associated with high morbidity and mortality and requires a thorough evaluation including early surgical consultation to identify patients who may benefit from surgery. We review 5 recent articles that highlight the current debates related to best treatment strategies for valve endocarditis. Recent publications have focused on neurologic risk assessment, timing of surgery, and prognostic factors associated with native and prosthetic valve endocarditis. The initial patient assessment and management is best performed by a multidisciplinary team. Future investigations should focus on identifying surgical candidates early and the outcomes affected by replacement valve choice in both native and prosthetic valve endocarditis.

Surgical treatment of double valve endocarditis

BACKGROUND

We have retrospectively analyzed the results of the operations made for aortic infective endocarditis with mitral involvement in a single center in 19 years.

METHODS

From May 1992 to January 2011, we have operated on 72 patients with infective endocarditis of the aortic valve with mitral valve involvement. Fifty-two patients (72.2%) were male and the mean age was 40.5 ± 15.5 (9-73) years. The blood cultures were positive in 33 patients (45.8%) and the most commonly identified microorganism was Streptococcus. Nine patients (12.5%) had prosthetic valve endocarditis. The mean duration of follow-up was 6.8 ± 4.7 (0.1-16.9) years, adding up to a total of 156.1 patient/years.

RESULTS

A total of 155 procedures were performed on these 72 patients. The most commonly performed procedure was aortic valve replacement, in 63 patients (87.5%). Aortic annular involvement was present in 9 cases (12.5%). In-hospital mortality was seen in 13 patients (18.1%). Postoperatively, 13 (18.1%) patients had low cardiac output, 9 (12.5%) had heart block, and only 1 of them required permanent pacemaker implantation. The actuarial survival rates for 1, 5, and 10 years were 96.4% ± 2.5%, 84.4% ± 5.1%, and 77.4 ± 6.7%, respectively.

CONCLUSIONS

Double-valve endocarditis is a serious condition and the surgeon must be aware of the high rates of mortality and morbidity in these patients. Although no association was found, heart blocks and septic embolization must be handled with caution. The patients generally do well after surgery, and recurrences and reoperations decrease by the second year after operation.

Single and multiple valve surgery in native valve infective endocarditis

Background

Surgical treatment of infective endocarditis (IE) remains a challenge, especially in cases of multiple valve surgery. We evaluated the clinical outcomes of native valve IE and compared the outcomes of single valve surgery with those of multiple valve surgery.

Materials and Methods

From 1997 to 2011, 90 patients underwent surgery for native valve IE; 67 patients with single valve surgery (single valve group) and 23 patients with multiple valve surgery (multiple valve group). The mean follow-up duration was 73.1±47.4 months.

Results

The surgical mortality in the total cohort was 4.4%. The overall survival (p=0.913) and valve-related event-free survival (p=0.204) did not differ between the two groups. The independent predictor of postoperative complications was New York Heart Association class (p=0.001). Multiple valve surgery was not a significant predictor of surgical mortality (p=0.225) or late mortality (p=0.936). Uncontrolled infection, urgent or emergency surgery, and postoperative complications were identified as independent predictors of valve-related morbidity, excluding multiple valve surgery (p=0.072).

Conclusion

In native valve IE, multiple valve surgery as a factor was not an independent predictor of mortality and morbidity. The number of surgically corrected valves in native IE seems to be unrelated to perioperative and long-term outcomes.

Double valve replacement and reconstruction of the intervalvular fibrous body in patients with active infective endocarditis

OBJECTIVES

Destruction of the intervalvular fibrous body, though uncommon, occurs due to paravalvular abscess formation following active infective endocarditis. This warrants a highly complex operation involving radical surgical debridement of the intervalvular fibrous body, followed by double valve (aortic and mitral) replacement with patch reconstruction of the anterior mitral annulus, the left ventricular outflow tract and the left atrial roof. The objective of this study was to review the early and mid-term outcomes in patients undergoing this operation.

METHODS

A total of 25 patients underwent double valve replacement with reconstruction of the intervalvular fibrous body for extensive infective endocarditis between January 1999 and March 2012. The mean age was 64.3 ± 10.5 years. Most of the patients (60%) were in New York Heart Association Class III-IV, 12% and in cardiogenic shock. Associated comorbidities like acute renal insufficiency and cerebrovascular accidents were observed in 40 and 20% of patients, respectively. Twenty patients had previous heart valve surgeries. The logistic EuroSCORE predicted risk of mortality was 55.1 ± 22.9%.

RESULTS

Overall, 30-day mortality was 32%. Postoperative complications like low cardiac output, stroke and acute renal failure developed in 16, 28 and 56%, respectively. Thirty-two percent of patients required re-exploration for bleeding. Nine patients were alive at a mean follow-up of 406 days (0-8 years). The 2- and 5-year survivals were 37.0 ± 11.1 and 24.6 ± 12.5%, respectively.

CONCLUSIONS

Double valve replacement with reconstruction of the intervalvular fibrous body for infective endocarditis is a complex, technically challenging operation associated with high perioperative morbidity and mortality. Nevertheless, being the only option available for such complex disease, it should be performed in these patients who, otherwise, face 100% mortality.

Clinical and microbiologic features of multivalvular endocarditis

Multivalvular endocarditis accounts for 15% of all endocarditis. The mechanisms of spread of the infection differs whether endocarditis is only left-sided (involving both the mitral and aortic valves) or bilateral. In left-sided bivalvular endocarditis, it is often a secondary mitral lesion following a primary aortic endocarditis. Multivalvular endocarditis often results in severe and extensive cardiac lesions, well described at echocardiography and frequently responsible for severe heart failure. Patients often need surgery, which consists of radical debridement of all the infected tissue with reconstruction using different types of prostheses; therefore, the surgery may be very complex. The goal should be an early diagnosis of endocarditis to avoid spread of the infection to more than one valve, to improve the prognosis for those patients.

Atrial endocarditis--the importance of the regurgitant jet lesion

The jet lesions of valvular regurgitation or intracardiac shunts have been hypothesized to play an important role in the pathogenesis of endocarditis for many years. We describe a case of mitral valve endocarditis that involved the left atrium along the path of a jet lesion. This resulted in atrial endocarditis and pericarditis, both of which complicated her presentation and hospital course. Using transesophageal echocardiography, we were able to directly visualize the path and full extent of infection prior to surgery. Special attention should be focused upon the path of eccentric jets in order to fully define the extent of endocarditis.

Mitral valve repair with aortic valve replacement is superior to double valve replacement

OBJECTIVES

Double valve replacement has been advocated for patients with combined aortic and mitral valve disease. This study investigated the alternative that, when feasible, mitral valve repair with aortic valve replacement is superior.

PATIENTS AND METHODS

From 1975 to 1998, 813 patients underwent aortic valve replacement with either mitral valve replacement (n = 518) or mitral valve repair (n = 295). Mitral valve disease was rheumatic in 71% and degenerative in 20%. Mitral valve replacement was more common in patients with severe mitral stenosis (P =.0009), atrial fibrillation (P =.0006), and in patients receiving a mechanical aortic prosthesis (P =.0002). These differences were used for propensity-matched multivariable comparisons. Follow-up extended reliably to 16 years, mean 6.9 +/- 5.9 years.

RESULTS

Hospital mortality rate was 5.4% for mitral valve repair and 7.0% for replacement (P =.4). Survivals at 5, 10, and 15 years were 79%, 63%, and 46%, respectively, after mitral valve repair versus 72%, 52%, and 34%, respectively, after replacement (P =.01). Late survival was increased by mitral valve repair rather than replacement (P =.03) in all subsets of patients, including those with severe mitral valve stenosis. After repair of nonrheumatic mitral valves, 5-, 10-, and 15-year freedom from valve replacement was 91%, 88%, and 86%, respectively; in contrast, after repair of rheumatic valves, it was 97%, 89%, and 75% at these intervals.

CONCLUSIONS

In patients with double valve disease, aortic valve replacement and mitral valve repair (1) are feasible in many, (2) improve late survival rates, and (3) are the preferred strategy when mitral valve repair is possible.