Outcomes of surgery for infective endocarditis: a single-centre experience of 801 patients

A nomogram for prediction of early mortality in patients undergoing cardiac surgery for infective endocarditis: a retrospective single-center study

OBJECTIVE

Despite advancements in surgical techniques, operations for infective endocarditis (IE) remain associated with relatively high mortality. The aim of this study was to develop a nomogram model to predict the early postoperative mortality in patients undergoing cardiac surgery for infective endocarditis based on the preoperative clinical features.

METHODS

We retrospectively analyzed the clinical data of 357 patients with IE who underwent surgeries at our center between January 2007 and June 2023. Independent risk factors for early postoperative mortality were identified using univariate and multivariate logistic regression models. Based on these factors, a predictive model was developed and presented in a nomogram. The performance of the nomogram was evaluated through the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA). Internal validation was performed utilizing the bootstrapping method.

RESULTS

The nomogram included nine predictors: age, stroke, pulmonary embolism, albumin level, cardiac function class IV, antibotic use <4weeks, vegetation size ≥1.5 cm, perivalvular abscess and preoperative dialysis. The area under the ROC curve (AUC) of the model was 0.88 (95%CI:0.80-0.96). The calibration plot indicated strong prediction consistency of the nomogram with satisfactory Hosmer-Lemeshow test results (χ2 = 13.490, p = 0.142). Decision curve analysis indicated that the nomogram model provided greater clinical net benefits compared to "operate-all" or "operate-none" strategies.

CONCLUSIONS

The innovative nomogram model offers cardiovascular surgeons a tool to predict the risk of early postoperative mortality in patients undergoing IE operations. This model can serve as a valuable reference for preoperative decision-making and can enhance the clinical outcomes of IE patients.

A Single-Centre Experience of the Management of Infective Endocarditis

BACKGROUND

Treatment for infective endocarditis (IE) is usually medical, with surgery reserved for those failing medical management or developing complications. Currently, 25%-50% of patients undergo surgery for IE with a 70%-80% immediate survival rate. However, there is controversy over the timing of surgery following cerebrovascular events, which occur in 15%-30% of IE patients. This study aimed to investigate whether surgical management is superior to medical management in patients with IE and to determine the optimal timing for surgery following the development of neurological symptoms.

METHODS

Data were collected retrospectively between 2012 and 2018 from 436 patients diagnosed with IE and treated at our tertiary teaching hospital. The authors analysed the type of treatment, the timing of surgery, and the outcomes of these including mortality, IE recurrence, and length of hospital stay.

RESULTS

A total of 421 patients were included in the analysis. More than two-thirds (69.1%) of patients underwent surgical intervention. The survival rate of patients having surgery for IE was 77.2%, compared to 50.7% in patients who did not undergo surgical intervention. 6.8% of patients presented with neurological symptoms; 73.3% of these patients had surgery within 14 days with a 90.9% survival.

CONCLUSION

This study finds surgery to be safe with a seemingly higher survival rate compared to medical management alone, although this may be confounded by patients in the medical group being less likely to have surgery. Surgery in patients presenting with neurological symptoms is safe within 2 weeks from presentation with excellent outcomes.

Sex-related differences in patients with infective endocarditis requiring cardiac surgery: insights from the CAMPAIGN Study Group

OBJECTIVES

Sex-related differences play a role in cardiovascular disease-related outcomes. There is, however, a knowledge gap regarding sex-specific differences in patients with infective endocarditis (IE)-requiring surgical treatment. This study aims to analyse sex-related differences in the clinical presentation, treatment and clinical outcomes of patients with IE-requiring surgical treatment from the multicentric Germany-wide CAMPAIGN registry.

METHODS

Patients with IE who underwent cardiac surgery between 1994 and 2018 at six German centres were retrospectively analysed. Outcomes were compared based on patients' sex. Primary outcomes were 30-day mortality and mid-term survival.

RESULTS

A total of 4917 patients were included in the analysis (1364 female [27.7%] and 3553 male [72.3%]). Female patients presented with more comorbidities and higher surgical risk (EuroScore II 12.0% vs 10.0%, P < 0.001). The early postoperative course of female patients was characterized by longer ventilation times (20.0 h vs 16.0 h; P = 0.004), longer intensive care unit stay (4.0 days vs 3.0 days; P < 0.001), and more frequent new-onset dialysis (265 [20.3%] vs 549 [16.3%]; P = 0.001). The 30-day mortality was 13.8% and 15.5% in female and male patients, respectively (P = 0.06). The estimated mid-term survival was significantly higher amongst male patients (56.1% vs 45.4%; Log-rank P < 0.001). Female sex was an independent predictor of mid-term mortality (HR 1.2 [95% CI 1.0-1.4], P = 0.01).

CONCLUSIONS

Male patients more frequently undergo cardiac surgery for IE. However, female patients have a higher surgical risk profile and subsequently an increased early postoperative morbidity, but with similar 30-day mortality compared with male patients. The estimated mid-term survival is lower amongst female patients.

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

Surgical outcomes and optimal approach to treatment of aortic valve endocarditis with aortic root abscess - systematic review and meta-analysis

BACKGROUND

Data on the postoperative outcomes for patients with infective endocarditis complicated by an aortic root abscess is sparse due to the condition's low incidence and high mortality rates. This systematic review and meta-analysis aims to evaluate existing data on the impact of aortic root abscesses on the postoperative outcomes and to inform optimal surgical approach.

METHODS

The online databases MEDLINE, EMBASE and Cochrane library were searched from 1990 to 2022 for studies comparing cohorts of surgically managed infective endocarditis patients with and without an aortic root abscess. Data was extracted by two independent investigators and aggregated in a random-effects model. Risk of bias was assessed using an adapted version of the Newcastle-Ottawa scale.

RESULTS

Six clinical studies were included in the meta-analysis (n 1982). The abscess group was associated with increased in-hospital mortality (OR 1.74 95%: CI 1.18-2.56) and late mortality (HR 1.27 95% CI:1.03-1.58). The reoperation meta-analysis was complicated by high rates of heterogeneity (I2 = 59%) and found no significant differences in reoperation between abscess and no abscess groups (HR=1.48: 95% CI:0.92-2.40). Post-hoc scatter graph showed a strong linear relationship (r 0.998), suggesting hospitals with higher rates of aortic root replacement achieve lower rates of reoperation for aortic root abscess patients compared with patch reconstruction.

CONCLUSIONS

The presence of an aortic root abscess in aortic valve endocarditis is associated with elevated early and late mortality despite modern standards of care. Additionally, aortic root replacement should be considered to have a favourable postoperative profile for use in this context.

Isolated mitral valve endocarditis: Patient, disease, and surgical factors that influence outcomes

OBJECTIVE

The objectives of this study were to investigate patient characteristics, valve pathology, bacteriology, and surgical techniques related to outcome of patients who underwent surgery for isolated native (NVE) or prosthetic (PVE) mitral valve endocarditis.

METHODS

From January 2002 to January 2020, 447 isolated mitral endocarditis operations were performed, 326 for NVE and 121 for PVE. Multivariable analysis of time-related outcomes used random forest machine learning.

RESULTS

Staphylococcus aureus was the most common causative organism. Of 326 patients with NVE, 88 (27%) underwent standard mitral valve repair, 43 (13%) extended repair, and 195 (60%) valve replacement. Compared with NVE with standard repair, patients who underwent all other operations were older, had more comorbidities, worse cardiac function, and more invasive disease. Hospital mortality was 3.8% (n = 17); 0 (0%) after standard valve repair, 3 (7.0%) after extended repair, 8 (4.1%) after NVE replacement, and 6 (5.0%) after PVE re-replacement. Survival at 1, 5, and 10 years was 91%, 75%, and 62% after any repair and 86%, 62%, and 44% after replacement, respectively. The most important risk factor for mortality was renal failure. Risk-adjusted outcomes, including survival, were similar in all groups. Unadjusted extended repair outcomes, particularly early, were similar or worse than replacement in terms of reinfection, reintervention, regurgitation, gradient, and survival.

CONCLUSIONS

A patient- and pathology-tailored approach to surgery for isolated mitral valve endocarditis has low mortality and excellent results. Apparent superiority of standard valve repair is related to patient characteristics and pathology. Renal failure is the most powerful risk factor. In case of extensive destruction, extended repair shows no benefit over replacement.

Impact of heart failure and preoperative platelet count on the postoperative short-term outcome in infective endocarditis patients

BACKGROUND

Heart failure (HF) and platelet count are often considered risk factors for mortality in patients with infective endocarditis (IE); however, their effects on various complications have not been elucidated.

HYPOTHESIS

We speculated that HF and platelet count have significant impact on the short-term outcomes of IE.

METHODS

This single-center retrospective study analyzed data from 320 IE patients who underwent surgery. A multivariate Cox proportional hazards model was used to identify the risk factors for adverse outcomes. The effect of the platelet count on the prognosis of patients with HF was determined by subgroup analysis and Kaplan-Meier analysis.

RESULTS

The study population was divided into the HF group (n = 102) and the non-HF group (n = 218). The median age of the total population was 44.5 years (31-56 years), of which 227 (70.94%) patients were male. The incidence rates of 1-year all-cause mortality, cardiac outcomes, and composite outcomes were respectively almost sixfold, fourfold, and threefold higher in the HF group than in the non-HF group (all p < 0.001). In multivariate Cox regression analysis, HF was an independent risk factor for 1-year all-cause mortality, cardiac outcomes, cerebral outcomes, and composite outcomes. The Kaplan-Meier survival curves revealed that the patients with both HF and thrombocytopenia demonstrated the worst composite outcomes than the patients of the other groups (log-rank p < 0.001). In the HF group, the platelet count was significantly associated with mortality and composite outcomes.

CONCLUSIONS

HF and preoperative platelet count are significantly associated with 1-year all-cause mortality and adverse outcomes postoperatively in IE patients. Patients with HF and thrombocytopenia have the worst short-term prognosis.

Survival and Recurrence of Endocarditis following Mechanical vs. Biological Aortic Valve Replacement for Endocarditis in Patients Aged 40 to 65 Years: Data from the INFECT-Registry

BACKGROUND

Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years.

METHODS

This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test.

RESULTS

Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (p < 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio [HR] 0.546, 95% CI: 0.322-0.926, p = 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933, p = 0.039).

CONCLUSIONS

The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.

Twenty-Year Experience with Surgery for Native and Prosthetic Mitral Valve Endocarditis

Background and Objectives: To evaluate the early and long-term results of surgical treatment of isolated mitral native and prosthetic valve infective endocarditis. Materials and Methods: All patients undergoing mitral valve repair or replacement for infective endocarditis at our institution between January 2001 and December 2021 were included in the study. The preoperative and postoperative characteristics and mortality of patients were retrospectively reviewed. Results: A total of 130 patients, 85 males and 45 females, with a median age of 61 ± 14 years, underwent surgery for isolated mitral valve endocarditis during the study period. There were 111 (85%) native and 19 (15%) prosthetic valve endocarditis cases. Fifty-one (39%) patients died during the follow-up, and the overall mean patient survival time was 11.8 ± 0.9 years. The mean survival time was better in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (12.3 ± 0.9 years vs. 8 ± 1.4 years; p = 0.1), but the difference was not statistically significant. Patients who underwent mitral valve repair had a better survival rate compared to patients who had mitral valve replacement (14.8 ± 1.6 vs. 11.3 ± 1 years; p = 0.06); however, the difference was not statistically significant. Patients who underwent mitral valve replacement with a mechanical prosthesis had a significantly better survival rate compared to patients who received a biological prosthesis (15.6 ± 1.6 vs. 8.2 ± 0.8 years; p < 0.001). Patients aged ≤60 years had significantly better survival compared to patients aged >60 years (17.1 ± 1.1 vs. 8.2 ± 0.9; p < 0.001). Multivariate analysis showed that the patient's age >60 years at the time of surgery was an independent risk factor for mortality, while mitral valve repair was a protective factor. Eight (7%) patients required reintervention. Freedom from reintervention was significantly higher in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (19.3 ± 0.5 vs. 11.5 ± 1.7 years; p = 0.04). Conclusions: Surgery for mitral valve endocarditis is associated with considerable morbidity and mortality. The patient's age at the time of surgery represents an independent risk factor for mortality. Mitral valve repair should be the preferred choice whenever possible in suitable patients affected by infective endocarditis.

Comparison of valvuloplasty and replacement for surgical treatment of tricuspid infective endocarditis

BACKGROUND

Owing to the increase in both intravenous drug injections and intracardiac and vascular interventional treatments among drug users, the incidence of infective endocarditis (IE) involving the tricuspid valve, which sits between the two right heart chambers, has gradually increased. This study aimed to compare the clinical outcomes of different surgical procedures for tricuspid infective endocarditis (TIE).

METHODS

We retrospectively analyzed fifty-six patients who underwent tricuspid valve surgery at our hospital from January 2006 to August 2019. All patients were diagnosed with TIE and indicated a need for surgery. Perioperative and follow-up data were collected to summarize and analyze the clinical outcomes of different surgical approaches, including tricuspid valvuloplasty (TVP) and tricuspid valve replacement (TVR) for TIE.

RESULTS

Cardiopulmonary bypass (CPB) time, aortic cross-clamp (ACC) time, postoperative mechanical ventilation time, and intensive care unit (ICU) stay time were shorter in the TVP group than in the TVR group. Additionally, the incidence of red blood cell transfusion and postoperative complications was lower in the TVP group than in the TVR group. The postoperative 30-day mortality rates were similar between both the groups. Fifty-two patients were followed up for an average of 5.50 ± 3.79 years. The postoperative 3-, 5-, and 7-year survival rates were 100%, 100%, and 95.5% in the TVP group and 96.7%, 96.7%, and 96.7% in the TVR group, respectively. The 5-year and 10-year reoperation rates were 0% and 0% in the TVP group and 6.7% and 20% in the TVR group, respectively.

CONCLUSION

Both TVR and TVP for TIE significantly improved the functional status of the heart with satisfactory efficacy. TVP was found to be superior to TVR in reducing the need for postoperative blood transfusions, reducing the risk of postoperative complications, and reducing the need for long-term reoperations.

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

Infective endocarditis (IE) is a life-threatening microbial infection of native and prosthetic heart valves, endocardial surface, and/or indwelling cardiac device. Prevalence of IE is increasing and mortality has not significantly improved despite technological advances. This review provides an updated overview using recent literature on the clinical presentation, diagnosis, imaging, causative pathogens, treatment, and outcomes in native valve, prosthetic valve, and cardiac device-related IE. In addition, the experimental approaches used in IE research to improve the understanding of disease mechanisms and the current diagnostic pipelines are discussed, as well as potential innovative diagnostic and therapeutic strategies. This will ultimately help towards deriving better diagnostic tools and treatments to improve IE patient outcomes.

Surgical outcomes and optimal approach to treatment of aortic valve endocarditis with aortic root abscess

OBJECTIVES

To evaluate the impact of aortic root abscess (ARA) on the postoperative outcomes of surgically managed infective endocarditis (IE) and to inform optimal surgical approach.

METHODS

Between 2009 and 2020, 143 consecutive patients who underwent surgical management for aortic-valve IE were included in a retrospective cohort study. Multivariable and propensity-weighted analyses were used to adjust for demographic imbalances between those without (n = 93; NARA) and with an ARA (n = 50). Additionally, empirical subgroup analysis appraised the two most used surgical techniques; patch reconstruction (PR) and aortic root replacement (ARR).

RESULTS

Demographic characteristics were similar between ARA and NARA except for logistic EuroSCORE, previous valve surgery, and multivalvular infection. In-hospital mortality was 8% and 12% in NARA and ARA, respectively (p = .38), with mortality rates consistently nonsignificantly higher in ARA across all time periods. The overall reoperation rate was also higher in ARA (27% vs. 14%; p = .09) and ARA was shown to be associated with late reoperation (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.18-6.36). Patients treated with an ARR showed a 16% increase in late mortality when compared with PR (40% vs. 24%; p = .27) and a 17% lower reoperation rate (14% vs. 31%; p = .24). Propensity-weighted analysis identified ARR as a significant protective factor for reoperation (hazard ratio = 0.05; 95% CI = 0.01-0.34).

CONCLUSIONS

The presence of an ARA in aortic valve endocarditis was not associated with significantly higher early and late mortality but is linked with a higher reoperation rate at our institution. ARR in ARA is protective from reoperation so should be considered best practice in this setting.

Machine Learning-Based Risk Model for Predicting Early Mortality After Surgery for Infective Endocarditis

Background The early mortality after surgery for infective endocarditis is high. Although risk models help identify patients at high risk, most current scoring systems are inaccurate or inconvenient. The objective of this study was to construct an accurate and easy-to-use prediction model to identify patients at high risk of early mortality after surgery for infective endocarditis. Methods and Results A total of 476 consecutive patients with infective endocarditis who underwent surgery at 2 centers were included. The development cohort consisted of 276 patients. Eight variables were selected from 89 potential predictors as input of the XGBoost model to train the prediction model, including platelet count, serum albumin, current heart failure, urine occult blood ≥(++), diastolic dysfunction, multiple valve involvement, tricuspid valve involvement, and vegetation >10 mm. The completed prediction model was tested in 2 separate cohorts for internal and external validation. The internal test cohort consisted of 125 patients independent of the development cohort, and the external test cohort consisted of 75 patients from another center. In the internal test cohort, the area under the curve was 0.813 (95% CI, 0.670-0.933) and in the external test cohort the area under the curve was 0.812 (95% CI, 0.606-0.956). The area under the curve was significantly higher than that of other ensemble learning models, logistic regression model, and European System for Cardiac Operative Risk Evaluation II (all, P<0.01). This model was used to develop an online, open-access calculator (http://42.240.140.58:1808/). Conclusions We constructed and validated an accurate and robust machine learning-based risk model to predict early mortality after surgery for infective endocarditis, which may help clinical decision-making and improve outcomes.

The association between systemic inflammatory response index and in-hospital mortality in patients with infective endocarditis

Background

Infective endocarditis (IE) has a significant mortality, and early identification of high‐risk patients and prediction of poor outcomes is of great significance. In recent years, increasing research has revealed the predictors associated with infective endocarditis prognosis. Systemic inflammatory response index (SIRI) is an important new indicator of inflammation. So far, there have been no reports on the relationship between SIRI and the prognosis of IE patients.

Hypothesis

The purpose of this study was to explore the value of SIRI in predicting in‐hospital death for patients with infective endocarditis (IE), so as to provide reference for improving the prognosis of patients with IE.

Method

A retrospective analysis was performed on the clinical data of patients with IE admitted to the First Affiliated Hospital of Nanjing Medical University from January 2017 to December 2019. SIRI was calculated according to the blood routine results of patients at admission; receiver operating characteristic curve was employed to determined the optimal cutoff value of SIRI. Patients were divided into groups (low SIRI group and high SIRI group; nonsurvivor group and survivor group) according to the levels of SIRI or their prognosis, and the general clinical features of the two groups were compared. Univariate and multivariate logistic regression analysis were performed to analyze the independent prognostic factors of in‐hospital death in IE patients.

Results

A total of 147 IE patients meeting the diagnostic criteria were included, including 102 males (69.4%) and 45 females (30.6%). There was statistically significant difference in SIRI level between nonsurvivor group and survivor group (p < .05). After adjusting for the related factors, the risk of in‐hospital death in the high SIRI was still a risk of in‐hospital death with statistical significance (hazard ratio = 5.053, 95% confidence interval: 1.426‒17.905, p = .012).

Conclusions

Higher SIRI level is independently associated with the risk of in‐hospital death in IE patients, and can be an independent predictor of poor outcome in IE patients.

Anesthesia Considerations in Infective Endocarditis

The management of infective endocarditis is complex and inherently requires multidisciplinary cooperation. About half of all patients diagnosed with infective endocarditis will meet the criteria to undergo cardiac surgery, which regularly takes place in urgent or emergency settings. The pathophysiology and clinical presentation of infective endocarditis make it a unique disorder within cardiac surgery that warrants a thorough understanding of specific characteristics in the perioperative period. This includes, among others, echocardiography, coagulation, bleeding management, or treatment of organ dysfunction. In this narrative review article, the authors summarize the current knowledge on infective endocarditis relevant for the clinical anesthesiologist in perioperative management of respective patients. Furthermore, the authors advocate for the anesthesiologist to become a structural member of the endocarditis team.

Surgical Management of Hypertrophic Cardiomyopathy Complicated by Infective Endocarditis

BACKGROUND

Infective endocarditis (IE) is a serious complication in hypertrophic cardiomyopathy (HCM). Cardiac surgery is often necessary, however, literature assessing surgical outcomes is limited.

METHODS

From December 1995 to September 2018, 43 patients with a history of HCM and native valve IE underwent cardiac surgery at our institution. Relevant data were abstracted from medical records and analyzed.

RESULTS

Median age was 57 years (IQR 45-67), 81% (n=35) were male. IE was active in 21% (n=9) patients at the time of surgery; Of these, the suspected origin of infection was orodental in 19% (n=8) patients. Significant mitral valve regurgitation was detected in 54% (n=23) patients and aortic valve regurgitation in 7% (n=3). Septal myectomy (SM) was performed in 95% (n=41) patients, with concomitant valve surgery in 58% (n=25) including prosthetic replacement in 28% (n=12). Two patients underwent double valve replacement without SM. Outflow gradients improved from median 67mmHg (IQR 34-97 mmHg) to 9mmHg (IQR 6-22 mmHg). One in-hospital death occurred due to uncontrollable pulmonary edema. As of last follow up, seven patients required reoperation and the 5 and 10-year cumulative incidences were 11% and 26%. Ten deaths occurred and overall survival probability at 5 and 10-years was 94% and 78% respectively.

CONCLUSIONS

Valvular complications of IE add complexity to surgical management of HCM. There is an increased need for concomitant valve repairs, prosthetic replacements and reoperation. These data underscore the need for recognition of infection, especially after oral procedures, which preceded majority of the active IE cases.

Long-Term Outcome of Mechanical and Biological Prostheses in Patients with Left-Side Infective Endocarditis: A Systematic Review and Meta-Analysis

Background. Long-term outcomes of patients with infective endocarditis (IE) who received either a mechanical (MP) or biological prosthesis (BP) are conflicting. A meta-analysis of observational studies comparing the long-term outcomes of left-side IE with the use of MP versus BP was performed. Methods. Electronic databases from January 2000 to June 2021 were screened. Studies reporting long-term mortality were analyzed. The primary endpoint was long-term overall mortality. Secondary endpoints were in-hospital/.30-day mortality and freedom from both prosthesis reinfection and reintervention. The pooled hazard ratio (HR) with 95% confidence interval (CI) was calculated for survival according to the random effect model. Results. Thirteen retrospective observational studies reporting on 8645 patients (MP: 4688; BP: 4137) were included for comparison. Twelve studies reported data of long-term survival for a total of 8285 patients (MP: 4517; BP: 3768). The pooled analysis revealed that the use of MP was statistically associated with longer benefits compared to BP (HR 0.74; 95% CI 0.63–0.86; p < 0.0001). The median follow-up time ranged from 1 to 15.3 years. The pooled analysis of five studies reporting data on prosthesis reinfection in 4491 patients (MP: 2433; BP: 2058) did not reveal significant differences (HR 0.60; 95% CI 0.30–1.21; p = 0.15). Five studies reported data on prosthesis reintervention in 4401 patients (MP: 2307; BP: 2094). The meta-analysis revealed a significant difference in favor of MP (HR 0.40; 95% CI 0.29–0.55; p < 0.0001). Meta-regression reported no effect of male gender (p = 0.09) and age (p = 0.77) on long-term survival. Conclusions. In a meta-analysis of retrospective observational studies comparing the long-term outcome of patients who underwent surgery for left-sided IE, the use of MP compared to BP is associated with a significant longer-term survival and with a reduced incidence of late reoperation. The incidence of late reinfection is comparable between the two prostheses.

Infective endocarditis and outcomes of mitral valve replacement

BACKGROUND

We investigated the long-term outcomes of mitral valve replacement (MVR) in native mitral valve infective endocarditis (IE).

METHODS

Multicentre, population-based cohort register study consisted of 1233 consecutive adult patients treated with first-time MVR in Finland. Mitral valve IE was diagnosed in 170 of these patients. Propensity score matching resulted in 134 pairs with balanced baseline characteristics. The median follow-up was 6.1 years.

RESULTS

Pre-operative native mitral valve IE was associated with an increased hazard of 10-year mortality (38.8% vs 30.5%; HR 2.13; CI 1.17-3.85; P = .013) after MVR. Occurrence of major bleeding was higher in IE patients (26.0%) vs non-IE patients (23.4%) during the 10-year follow-up (HR 2.80; CI 1.01-7.77; P = .048). Hospital admission duration after MVR was longer in IE patients (median 28 vs 11 days; P < .0001). Cumulative ischaemic stroke rate was similar between patient groups (12.1% in IE vs 15.1% in non-IE; P = .493). Re-sternotomy was performed in 13.4% of IE patients and 9.0% of non-IE patients (P = .261).

CONCLUSIONS

Patients with native mitral valve IE have a higher risk of death and major bleeding after MVR than matched patients without IE. Results highlight the importance of complication prevention in these patients.

Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis

The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis

BACKGROUND

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.

METHODS

Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.

RESULTS

Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.

CONCLUSIONS

In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

Mechanical versus biological valve prosthesis for surgical aortic valve replacement in patients with infective endocarditis

OBJECTIVES

The optimal choice of valve prosthesis in surgical aortic valve replacement for infective endocarditis (IE) is controversial. We studied outcomes after mechanical versus biological prosthetic valve surgical aortic valve replacement in IE patients.

METHODS

All patients with native-valve IE aged 16-70 years undergoing mechanical or biological surgical aortic valve replacement in Finland, between 2004 and 2014, were retrospectively studied (n = 213). Outcomes were all-cause mortality, ischaemic stroke, major bleeding and aortic valve reoperation at 1 year and 5 years. Results were adjusted for baseline features (age, sex, comorbidity burden, atrial fibrillation, valvular stenosis, concomitant coronary artery bypass grafting, extension, urgency, year and centre of operation). Median follow-up was 5 years.

RESULTS

The 5-year mortality rate was 19.0% with mechanical prostheses and 34.8% with biological prostheses [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.23-0.92; P = 0.03]. Ischaemic stroke rates were 8.3% with mechanical prostheses and 16.8% with biological prostheses at 5 years (HR 0.21, CI 0.06-0.79; P = 0.01). Results were comparable in patients aged 16-59 and 60-70 years (interaction P = 0.84). Major bleeding within 5 years was similar between mechanical (11.3%) and biological valve (13.4%) groups (P = 0.95) with comparable rates of both gastrointestinal and intracranial bleeds. Reoperation rates at 5 years were 5.0% for mechanical prostheses and 9.2% for biological prostheses (P = 0.14). The 1-year ischaemic stroke rate was lower with mechanical prostheses (3.6% vs 11.6%, P =0.03), whereas mortality, major bleeding and reoperation rates were similar between groups.

CONCLUSIONS

The use of mechanical aortic valve is associated with lower mid-term mortality compared to biological prosthesis in patients with native-valve IE aged ≤70 years. Our results do not support the routine choice of a biological aortic valve prosthesis in this patient group.

Age, creatinine and ejection fraction (ACEF) score: a simple risk-stratified method for infective endocarditis

BACKGROUND

Older age, renal dysfunction and low left ventricular ejection fraction are accepted predictors of poor outcome in patients with infective endocarditis (IE). This study aimed to investigate the prognostic significance of the age, creatinine and ejection fraction (ACEF) score in IE.

METHODS

The study involved 1019 IE patients, who were classified into three groups according to the tertiles of ACEF score: low ACEF (<0.6, n = 379), medium ACEF (0.6-0.8, n = 259) and high ACEF (>0.8, n = 381). The ACEF score was calculated as follows: age (years)/ejection fraction (%)+1 (if serum creatinine value was >2 mg/dL). The relationship between ACEF score and adverse events was analyzed.

RESULTS

In-hospital mortality was 8.2%, which increased with the increase of ACEF score (4.2% vs. 5.0% vs. 14.4% for the low-, medium- and high-ACEF groups, respectively; P < 0.001). ACEF score had a good discriminative ability for predicting in-hospital death [areas under the curve (AUC), 0.706, P < 0.001]. The predictive value of ACEF score in surgical treatment was significantly higher than in conservative treatment for predicting in-hospital death (AUC, 0.812 vs. 0.625; P = 0.001). Multivariable analysis revealed that ACEF score was independently associated with in-hospital mortality (adjusted odds ratio, 2.82; P < 0.001) and long-term mortality (adjusted hazard ratio, 2.51; P < 0.001).

CONCLUSION

ACEF was an independent predictor for in-hospital and long-term mortality in IE patients, and it could be considered as a useful tool for risk stratification. ACEF score was more suitable for surgical patients in terms of assessing the risk of in-hospital mortality.

Determinants and consequences of positive valve culture when cardiac surgery is performed during the acute phase of infective endocarditis

The optimal timing of cardiac surgery in infective endocarditis (IE) remains debated: Early surgery decreases the risk of embolism, and heart failure, but is associated with an increased rate of positive valve culture. To determine the determinants, and the consequences, of positive valve culture when cardiac surgery is performed during the acute phase of IE, we performed a retrospective study of adult patients who underwent cardiac surgery for definite left-sided IE (Duke Criteria), in two referral centres. During the study period (2002-2016), 148 patients fulfilled inclusion criteria. Median age was 65 years [interquartile range, 53-73], male-to-female ratio was 2.9 (110/38). Cardiac surgery was performed after 14 days [5-26] of appropriate antibiotics. Valve cultures returned positive in 46 cases (31.1%). Factors independently associated with positive valve culture were vegetation size ≥ 10 mm (OR 2.83 [1.16-6.89], P = 0.022) and < 14 days of appropriate antibacterial treatment before surgery (OR 4.68 [2.04-10.7], P < 0.001). Positive valve culture was associated with increased risk of postoperative acute respiratory distress syndrome (37.0% vs. 15.7%, P = 0.008) but was associated neither with an increased risk of postoperative relapse nor with the need for additional cardiac surgery. Duration of appropriate antibacterial treatment and vegetation size are independently predictive of positive valve culture in patients operated during the acute phase of IE. Positive valve culture is associated with increased risk of postoperative acute respiratory distress syndrome.

Cardiac surgery 2017 reviewed

For the year 2017, more than 21,000 published references can be found in PubMed when entering the search term "cardiac surgery". This review focusses on conventional cardiac surgery, considering the new interventional techniques only if they were directly compared to classic techniques but also entails aspects of perioperative intensive care management. The publications last year provided a plethora of new and interesting information that helped to quantify classic surgical treatment effects and provided new guidelines for the management of structural heart disease, which made comparisons to interventional techniques easier. The field of coronary bypass surgery was primarily filled with confirmatory evidence for the beneficial role of coronary artery bypass grafting for complex coronary disease and equal outcomes for percutaneous coronary intervention for less complex disease including main stem lesions. For aortic valve treatment, the new guidelines provide an equal recommendation for surgical and transcatheter aortic valve replacement for high and intermediate risk giving specific check lists to individualize decision-making by the heart team. For low-risk aortic stenosis, surgical valve replacement remains the primary indication. For the mitral valve, the importance of surgical experience of the individual surgeon on short- and long-term outcome was presented and the prognostic impact of mitral repair for primary mitral regurgitation was emphasized. In addition, there were many relevant and interesting other contributions from the purely operative arena in the fields of tricuspid disease as well as terminal heart failure (i.e., transplantation and ventricular assist devices). While this article attempts to summarize the most pertinent publications, it does not have the expectation of being complete and cannot be free of individual interpretation. As in recent years, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.