Mitral valve repair or replacement in native valve endocarditis? Systematic review and meta-analysis

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.

Early Surgery for Infective Endocarditis Complicated With Neurologic Injury

OBJECTIVES

To estimate the association between early surgery and the risk of mortality in patients with left-sided infective endocarditis in the context of stroke.

DESIGN

Retrospective cohort study.

SETTING

This study was a multiinstitution study based on the Chang Gung Research Database, which contains electronic medical records from 7 hospitals in northern and southern Taiwan; these include 2 medical centers, 2 regional hospitals, and 3 district hospitals.

PARTICIPANTS

Patients with active left-sided infective endocarditis who underwent valve surgery between September 2002 and December 2018.

INTERVENTIONS

The authors divided patients into 2 groups, with versus without preoperative neurologic complications, had undergone early (within 7 d) or later surgery, and with brain ischemia or hemorrhage.

MEASUREMENTS AND MAIN RESULTS

Three hundred ninety-two patients with a median time from diagnosis to surgery of 6 days were included. No significant differences in postoperative stroke, in-hospital mortality, or follow-up outcomes were observed between the patients with and without neurologic complications. Among the patients with preoperative neurologic complications, patients who underwent early surgery had a lower 30-day postoperative mortality rate (13.1% v 25.8%; hazard ratio, 0.21; 95% CI 0.07-0.67). In the subgroup analysis of the comparison between brain ischemia and hemorrhage groups, there was no significant between-group difference in the in-hospital outcomes or outcomes after discharge.

CONCLUSIONS

Early cardiac surgery may be associated with more favorable clinical outcomes in patients with preoperative neurologic complications. Thus, preoperative neurologic complications should not delay surgical interventions.

Surgical repair and replacement for native mitral valve infective endocarditis

AIMS

The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established.

METHODS

Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups.

RESULTS

Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ± 15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94).

CONCLUSIONS

Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Mitral valve surgery in acute infective endocarditis: long-term outcomes of mitral valve repair versus replacement

AIMS

Timing and surgical strategies in acute infective endocarditis are still questionable. We sought to investigate clinical outcomes of patients undergoing mitral valve repair (MVR) compared with mitral valve replacement [mitral valve prosthesis (MVP)] for acute infective endocarditis.

METHODS

From 2004 to 2019, 109 consecutive patients with acute mitral valve infective endocarditis were retrospectively investigated. Patients were divided into two groups according to surgical strategy: MVR 53/109 (48.6%) versus MVP 56/109 (51.4%). Primary end points were in-hospital mortality and overall survival at 10 years. Secondary end point was the freedom from infective endocarditis relapse.

RESULTS

Our institutional surgical approach for infective endocarditis allowed us to achieve MVR in 48.6% of patients. Hospital mortality was comparable between the two groups [MVR: 1/53 (1.9%) versus MVP: 2/56 (3.6%), P  = 1.000]. Overall 10-year survival was 80.0 ± 14.1 and 77.2 ± 13.5% for MVR and MVP, respectively ( P  = 0.648). MVR showed a lower incidence of infective endocarditis relapse compared with MVP (MVR: 93.6 ± 7.1 versus MVP: 80.9 ± 10.8%, P  = 0.041). At Cox regression, infective endocarditis relapse was an independent risk factor for death (hazard ratio 4.03; 95% confidence interval 1.41-11.52; P  = 0.009).

CONCLUSION

The tendency to postpone surgery in stable patients with mitral infective endocarditis allowed achievement of MVR in almost 50% of patients. Although repair remains the approach of choice in our institution, no differences between MVR and MVP were reported in terms of early/late survival. However, MVP had a higher incidence of infective endocarditis relapse that represents an independent risk of mortality.

Surgical Challenges in Infective Endocarditis: State of the Art

Infective endocarditis (IE) is still a life-threatening disease with frequent lethal outcomes despite the profound changes in its clinical, microbiological, imaging, and therapeutic profiles. Nowadays, the scenario for IE has changed since rheumatic fever has declined, but on the other hand, multiple aspects, such as elderly populations, cardiovascular device implantation procedures, and better use of multiple imaging modalities and multidisciplinary care, have increased, leading to escalations in diagnosis. Since the ESC and AHA Guidelines have been released, specific aspects of diagnostic and therapeutic management have been clarified to provide better and faster diagnosis and prognosis. Surgical treatment is required in approximately half of patients with IE in order to avoid progressive heart failure, irreversible structural damage in the case of uncontrolled infection, and the prevention of embolism. The timing of surgery has been one of the main aspects discussed, identifying cases in which surgery needs to be performed on an emergency (within 24 h) or urgent (within 7 days) basis, irrespective of the duration of antibiotic treatment, or cases where surgery can be postponed to allow a brief period of antibiotic treatment under careful clinical and echocardiographic observation. Mainly, guidelines put emphasis on the importance of an endocarditis team in the handling of systemic complications and how they affect the timing of surgery and perioperative management. Neurological complications, acute renal failure, splenic or musculoskeletal manifestations, or infections determined by multiresistant microorganisms or fungi can affect long-term prognosis and survival. Not to be outdone, anatomical and surgical factors, such as the presence of native or prosthetic valve endocarditis, a repair strategy when feasible, anatomical extension and disruption in the case of an annular abscess (mitral valve annulus, aortic mitral curtain, aortic root, and annulus), and the choice of prosthesis and conduits, can be equally crucial. It can be hard for surgeons to maneuver between correct pre-operative planning and facing unexpected obstacles during intraoperative management. The aim of this review is to provide an overview and analysis of a broad spectrum of specific surgical scenarios and how their challenging management can be essential to ensure better outcomes and prognoses.

Limited Versus Radical Resection in Mitral Valve Infective Endocarditis Surgery

Background: Mitral valve repair is preferred in patients undergoing surgical treatment for infective endocarditis (IE) of the native mitral valve, however, radical resection of infected tissue and patch-plasty might potentially lead to low or non-durable repair. We aimed to compare a limited-resection and non-patch technique with the classic radical-resection technique. Methods: Eligible candidates were patients with definitive IE of the native mitral valve undergoing surgery between January 2013 and December 2018. Patients were classified according to the surgical strategy into two groups: limited- versus radical-resection strategy. Propensity score matching was used. Endpoints were repair rate, all-cause mortality (30-day and 2-year), re-endocarditis and reoperation at q-year follow-up. Results: After propensity score matching, 90 patients were included. Follow-up was 100% complete. Mitral valve repair rate was 84% in the limited-resection versus 18% in the radical-resection strategy, p < 0.001. The 30-day and 2-year mortality were 20% versus 13% (p = 0.396) and 33% versus 27% (p = 0.490) in the limited-resection versus radical-resection strategy, respectively. The incidence of re-endocarditis during the 2-year follow-up was 4% in the limited-resection strategy versus 9% in the radical-resection strategy, p = 0.677. Three patients in the limited-resection strategy underwent reoperation of the mitral valve, while there were none in the radical-resection strategy (p = 0.242). Conclusions: Although mortality in patients with IE of the native mitral valve remains high, the limited-resection and non-patch surgical strategy is associated with a significantly higher repair rates with comparable 30-day and mid-term mortality, risk of re-endocarditis and re-operation compared to the radical-resection strategy.

Clinical outcomes following surgical mitral valve plasty or replacement in patients with infectious endocarditis: A meta-analysis

Background

For degenerative mitral disease, more and more evidences support that mitral valve plasty (MVP) has much better clincial outcomes than mitral valve replacement (MVR). However, the advantages of MVP in patients suffering from infectious endocarditis (IE) are unclear. To evaluate the appropriateness of MVP in IE patients, we conducted this meta-analysis. Based on the difference between active and healed phase, we not only compared the result of patients with IE, but also identified the subgroup with active IE.

Methods

We systematically searched the clinical trials comparing clinical outcomes of MVP and MVR in patients suffering from IE. Relevant articles were searched from January 1, 2000 to March 18, 2021 in Pubmed and Cochrane Library. Studies were excluded if they were with Newcastle-Ottawa Scale (NOS) score less than 6 or lacking of direct comparisons between MVP and MVR.

Results

23 studies were involved and 25,615 patients were included. Pooled analysis showed fewer adverse events and early or long-term death in the MVP group. However, more reoperations existed in this patient group. And the reinfection rate was close between two groups. Similar results were observed after identifying active IE subgroup, but there is no difference in the freedom from reoperation due to all-events.

Conclusions

Although limitimations exited in this study, patients suffering from IE can benefit from both MVP and MVR. For surgeons with consummate skills, MVP can be the preferred choice for suitable IE patients.

Should more patients be offered repair for mitral valve endocarditis? a single-centre 15-year experience

Objective

To describe the long-term outcomes of mitral valve repair (MVr) versus mitral valve replacement (MVR) in patients with native valve infective endocarditis (IE) at a centre with high-repair rates.

Methods

We conducted a retrospective single-centre cohort study. From 2005 to 2021, 183 patients with active or healed native valve IE were included. The primary outcome was long-term mortality. Patient status was last confirmed 31 March 2021. Secondary outcomes were post-operative MR, MV reoperation, length of post-operative intensive care stay and total hospital stay.

Results

85 patients (46.4%) underwent MVr and 98 (53.6%) underwent MVR. Follow-up was 98.9% complete. Mean follow-up time was 5.3 years with 17% of patients reaching a follow-up time of over 10 years. There were 47 deaths (25.7%) within the follow-up period. MVR patients were more likely to have higher logistic EuroSCORE, active IE and were less likely to have elective surgery. In multivariate Cox proportional hazards analysis, there was no significant difference in long-term mortality between MVr and MVR groups (hazard ratio 1.09, 95% confidence interval [0.59–2.00]). In Kaplan–Meier analysis, MVR patients had a higher all-cause mortality although there was no significant difference at the endpoint. Propensity score matching analysis showed a significantly higher mortality in the replacement group instead (p = 0.002), Subgroup analysis revealed there remained no significant difference in mortality even in patients with active IE (P-interaction = 0.859) or non-elective surgery (P-interaction = 0.122). MV reoperation (odds ratio 1.00 [0.24–4.12]), post-operative intensive care stay (p = 0.9650) and total hospital stay (p = 0.9144) were comparable.

Conclusions

Our data demonstrates repair was at least non-inferior to replacement in IE, supporting more aggressive use of repair. There is no reason the general principle of why repair is superior to replacement should not hold in IE, with enough operator expertise. Other experienced units should be encouraged to increase repair rates as feasible in line with current guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01997-2.

Dealing with the epidemic of endocarditis in people who inject drugs

North America is facing an opioid epidemic and growing illicit drug supply, contributing to growing numbers of injection drug use-related infective endocarditis (IDU-IE). Patients with IDU-IE have high early and late mortality. Patients with IDU-IE more commonly present with right-sided IE compared to those with non-IDU-IE and a majority are a result of S. aureus. While most patients can be successfully managed with intravenous antibiotic treatment, surgery is often required in part related to high relapse rates, potential treatment biases, and more aggressive pathophysiology in some. Multidisciplinary management as endocarditis teams, including not only cardiologists and cardiac surgeons but also infectious disease specialists, drug addiction experts, social workers, neurologists and/or neurosurgeons, is essential to best manage substance use disorder and facilitate safe discharge to home and society. Structural and population-level interventions, such as harm reduction programs, are necessary to reduce IDU-IE relapse rates in the community and other IDU-related health concerns such as overdoses. In this review, we describe the pathophysiological, clinical, surgical, social, and ethical characteristics of IDU-IE and the management thereof. We present the most recent clinical guidelines for this condition and discuss existing gaps in knowledge to guide future research, practice changes, and policy interventions.

Oral bacteria in infective endocarditis requiring surgery: a retrospective analysis of 134 patients

Objectives

It has been reported that bacteria associated with infective endocarditis originate from the oral cavity in 26–45% of cases. However, little is known on the counts and species of periodontal microbiota in infected heart valves. The aim of this study was to identify these aspects of periodontal microbiota in infective endocarditis and to potentially initiate a dental extraction concept for periodontally compromised teeth concerning patients requiring heart valve surgery.

Materials and methods

The retrospective study group consisted of tissue samples from infected heart valves of 683 patients who had undergone heart valve surgery. Before patients had undergone cardiac surgery, the following laboratory tests confirmed the occurrence of endocarditis in all patients: blood cultures, echocardiography, electrocardiography, chest X-ray, and electrophoresis of the serum proteins. The specimens were aseptically obtained and deep frozen immediately following surgery. Microbiological diagnosis included proof of germs (dichotomous), species of germs, and source of germs (oral versus other).

Results

Microbiota was detected in 134 (31.2%) out of 430 enrolled patients. Oral cavity was supposed to be the source in 10.4% of cases, whereas microbiota of the skin (57.5%) and gastrointestinal tract (GIT, 24.6%) were detected considerably more frequently. Moreover, periodontal bacteria belonged mostly to the Streptococci species and the yellow complex. None of the detected bacteria belonged to the red complex.

Conclusion

Most frequently, the skin and GIT represented the site of origin of the microbiota. Nevertheless, the oral cavity represented the source of IE in up to 10%.

Consequently, it needs to be emphasized that a good level of oral hygiene is strongly recommended in all patients undergoing heart valve surgery in order to reduce the bacterial load in the oral cavity, thereby minimizing the hematogenous spread of oral microbiota. The prerequisites for conservative dental treatment versus radical tooth extraction must always be based on the patient’s cooperation, and the clinical intraoral status on a sense of proportion in view of the overall clinical situation due to the underlying cardiac disease.

Clinical relevance

The oral cavity is a source of oral microbiota on infected heart valves. Patients requiring heart valve surgery should always undergo a critical evaluation of dental treatment affecting periodontally compromised teeth, favoring a systematic, conservative-leaning recall.

Racial Disparities in Mitral Valve Surgery: A Statewide Analysis

OBJECTIVE

Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery.

METHODS

All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated.

RESULTS

A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission.

CONCLUSIONS

Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.

Mid-term results of mitral valve reconstruction with autologous pericardial patch for active infective endocarditis with extensive leaflet destruction

OBJECTIVES

This study aimed to evaluate the outcomes of our repair technique using autologous pericardial patches for active infective endocarditis with extensive mitral valve destruction.

METHODS

From 2009 through 2016, 12 patients with extensive mitral leaflet destruction due to infective endocarditis underwent mitral valve repair with an autologous pericardial patch. Mid-term clinical outcomes and echocardiographic findings of these patients were retrospectively assessed.

RESULTS

The perioperative mortality rate was 8.3% (1/12). Postoperatively, the mitral regurgitation grade was ≤ 1 + in all patients. During 5.0 ± 3.2 years of follow-up, there was no recurrence of infective endocarditis or death. There were no cases of mitral regurgitation grade >  + 1 and pressure gradient > 5 mmHg during follow-up among 6 patients who underwent posterior leaflet reconstruction, whereas elevation of the pressure gradient was observed in patients who underwent reconstruction of two areas of the anterior leaflet and survived up till the follow-up phase among 3 patients who underwent anterior leaflet repair. The mitral regurgitation grade worsened and pressure gradient was elevated during the follow-up phase in the 2 patients who underwent bi-leaflet repair, and reoperation was performed.

CONCLUSION

Mitral valve reconstruction using autologous pericardial patch is a useful treatment option for extensive mitral valve destruction due to active infective endocarditis. Our clinical data revealed that good mid-term results were obtained for posterior leaflet lesions, while extensive anterior leaflet and bi-leaflet lesion repair did not yield satisfactory results. The indication for surgical repair should be carefully evaluated when an extensive anterior region is involved.

Valve endocarditis, to repair or not to repair, is that really the question?

The meta-analysis by He et al. has the worth to cover, as much as possible, a gap of scientific evidence were conducting a randomized trial appears very complex for ethical and logistical reasons. The authors concluded that mitral valve repair (MVP) provides better-pooled results, both early and late, with respect to mitral valve replacement. However, the superiority of MVP is driven by some single large cohort studies where surgeons had wide experience in the field of MVP for infective endocarditis. This finding is also confirmed by other studies. But if mitral repair produces such a better short- and long-term survival than replacement, why are there no clear indications from consensus and guidelines pushing surgeons toward the pursuit of a reconstructive procedure at almost any cost? We wonder to repair or not to repair, is that really the question? The AATS consensus suggests repairing "whenever possible" but without providing more specific indications. If the two primary goals of surgery are total removal of infected tissues and reconstruction of cardiac morphology, including repair or replacement of the affected valve(s), probably MVP should be performed in case of less extensive tissue detriment by the infection. In more wide valve involvement, MVP may be the choice but only in very expert hands and in Centers with a very large volumes of valve repairing. This decision cannot, therefore, be the result of the choice of an individual but must derive from a careful multidisciplinary discussion to be held in an EndoTeam.

Association between Volume and Outcomes of Infective Endocarditis Surgery: A Nationwide Cohort Study

BACKGROUND

To determine the relationship between hospital surgical volume and mortality risk and valve repair rate in infective endocarditis (IE) surgery.

METHODS

Using the Taiwan National Health Insurance Research Database (NHIRD), 3873 patients were identified who underwent surgery between 2000 and 2013. The cumulative hospital volume of valve surgery for IE was calculated, and patients were divided into 4 subgroups according to the quartile. Outcomes were mortality and valve repair rate and the cut point of referral excellence.

RESULTS

The distribution of IE surgery has been shifting to lower volume hospitals over the years. The global disease severity (Charlson's Comorbidity Index score [CCI score]) of patients was greater in the lowest volume hospital than in the highest volume hospital (2.4 vs. 2.0). The crude in-hospital mortality rate was 15.8% and 9.4% for the lowest and highest volume hospitals, respectively, with a significant difference (adjusted odds ratio: 1.86, 95% confidence interval: 1.22-2.85) after adjustment of baseline characteristics including the CCI score. The mitral valve (MV) repair rate increased with the increase in cumulative volume. During a mean follow-up period of 4.4 years, 324 (41.9%) and 254 (30.9%) patients died in the lowest and highest volume subgroups, respectively, and the difference was significant (adjusted hazard ratio: 1.59, 95% CI: 1.21-2.10).

CONCLUSIONS

A higher cumulative volume of IE surgery is associated with a lower risk of mortality and a higher likelihood of successful MV repair. Therefore, interfacility transfer to a high-volume hospital may improve outcomes of IE surgery.

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.

Role of Mitral Valve Repair for Mitral Infective Endocarditis

The 2 primary objectives of surgery in mitral valve infective endocarditis (IE) are total removal of the infected tissue and reconstruction of cardiac morphology, including repair or replacement of the affected valve. Single-institution series have suggested the feasibility and effectiveness of mitral valve repair (MVrep) over replacement in mitral IE in terms of in-hospital mortality and long-term event-free survival. This article reviews the history, details of the relevant repair techniques, and clinical results of MVrep for mitral IE.

Patient and Surgeon Predictors of Mitral and Tricuspid Valve Repair for Infective Endocarditis

Mitral repair (MVr) is superior to replacement for degenerative disease; however, its benefit is less established for endocarditis. We report outcomes of repair or replacement for mitral/tricuspid endocarditis and identify predictors of MVr. Patients undergoing first-time surgery for mitral (n = 260) or tricuspid (n = 71) endocarditis between 1992 to 2018 were identified. Patients with aortic endocarditis were excluded. Primary outcome was all-cause mortality and secondary outcome was MVr. Patients were stratified into active and treated endocarditis separately for mitral and tricuspid groups. Predictors of MVr were assessed through multivariable logistic regression and adjusted likelihood of MVr through marginal effects estimates. A mitral specialist was defined by performing ≥25 annual degenerative MVr. Among 331 patients, 70% (181/260) of those with mitral valve endocarditis and 52% (37/71) of those with tricuspid endocarditis underwent repair. The MVr group compared with replacement had a higher proportion of elective acuity and less diabetes, hypertension, active endocarditis, cardiogenic shock, and dialysis. Estimated 5-year survival did not differ between repair versus replacement for active mitral (68 ± 14% vs 60 ± 14%, P = 0.34) or tricuspid endocarditis (60 ± 17% vs 61 ± 19%, P = 0.67), but was superior after repair for treated mitral endocarditis (86 ± 7% vs 51 ± 24%, P = 0.014). Independent predictors of mortality included dialysis for active and treated mitral endocarditis, and mitral replacement (vs MVr) for treated mitral endocarditis. The likelihood of MVr was 82 ± 5% for mitral specialists and 47 ± 9% for non-specialists (P < 0.001). MVr for endocarditis should be pursued, if feasible. Importantly, achieving MVr was driven not only by patient factors, but also surgeon experience.

Mitral valve diseases: Pathophysiology and interventions

Valvular heart disease is common and increasingly prevalent among the elderly. The end result of valvular pathologies is cardiac failure and can lead to sudden death; thus, diagnosis and interventions are very important in the early stages of these diseases. The usual treatment methods of mitral regurgitation include percutaneous mitral valve repair, mitral valve replacement and minimally invasive surgery, whereas the treatment methods of mitral stenosis include percutaneous transluminal mitral commissurotomy and mitral commissurotomy as well as open surgical repair. Nonetheless, ongoing clinical trials are a clear indicator that the management of valve diseases is ever evolving. The focus of this paper is on the various pathologies of the mitral valve, their etiology and clinical management, offering a comprehensive view of mitral valve diseases.

Surgery for infective endocarditis-analysis of factors affecting outcome

Purpose

Despite advances in medical care, infective endocarditis (IE) has high mortality. Surgery for IE though recommended for complications of the disease is still not commonly offered due to conflicting reports in the literature. We reviewed our results of surgery for IE from the last 5 years to assess their outcome.

Methods

A retrospective review from a single center of consecutive patients who underwent surgery for infective endocarditis from September 2014 to December 2019 was done. Data was collected from hospital records and follow-up done up to May 2020. Outcomes evaluated were mortality, follow-up survival, and postoperative complications. Factors affecting mortality and survival were analyzed.

Results

Ninety-seven patients underwent surgery for IE during this period. Seventy-nine had native valve endocarditis (NVE) and 18 had prosthetic valve endocarditis (PVE). The overall postoperative mortality was 13%, with mortality for native valve endocarditis being 11% and that for prosthetic valve endocarditis being 22%, which was not statistically significant. Three-year survival for the overall group was 88.7% with 88.1% for NVE and 91.7% for PVE. Multivariate predictors of operative mortality were a high EuroSCORE II, diabetes mellitus, and the presence of Staphylococcus organism.

Conclusion

Surgery for infective endocarditis has a very acceptable early outcome and intermediate-term survival.

Comparative Surgical Outcomes of Prosthetic and Native Valve Endocarditis

In the present study, the patterns and clinical outcomes of prosthetic valve endocarditis (PVE) surgery were analyzed as compared with native valve endocarditis (NVE). The proportion of PVE among surgical infective endocarditis increased gradually through the study period. Patients with PVE was characterized by old age and more extensive infective lesions. PVE group showed notably higher early and overall mortality, and valve reinfection as well. PVE carried significant perioperative risks, and was an independent risk factor of overall mortality.

Background and Objectives

As a consequence of a growing number of patients undergoing prosthetic heart valve replacement, the incidence of prosthetic valve endocarditis (PVE) has increased. The study aims to analyze patterns and outcomes of PVE surgery as compared with native valve endocarditis (NVE).

Methods

We enrolled 269 patients (aged 58.0±15.7 years) who underwent valve surgery for infective endocarditis (IE) between 2013 and 2019. Of these, 56 had PVE whereas remainder (n=213) had NVE. Clinical outcomes were compared and multivariable analyses were conducted to determine risk factors for mortality.

Results

The proportion of PVE among surgical IE gradually increased from 15.4% (11/71) in the first time-quartile to 29.5% (18/61) in the last time-quartile (p=0.055). PVE patients were older, and more commonly had aorto-mitral curtain involvement and abscess formation than NVE group. Early mortality was 14.3% and 6.1% in PVE and NVE group, respectively (p=0.049). Postoperatively, PVE group had higher incidences of low cardiac output syndrome (p=0.027), new-onset dialysis (p=0.006) and reoperation for bleeding (p=0.004) compared to NVE group, but stroke rates were comparable (p=0.503). During follow-up (648.8 patient-years), PVE group showed significantly higher risks of overall mortality (p<0.001), valve reinfection (p<0.001) and permanent pacemaker implantation (p<0.001) than NVE group. On multivariable analysis, PVE (hazard ratio, 2.67; 95% confidence interval, 1.40–5.07; p=0.003) along with age, chronic kidney disease, multi-valve involvement, and causative organisms of Staphylococcus aureus or fungus were independent risk factors of overall mortality.

Conclusions

PVE carried significant perioperative risks, and was an independent risk factor of overall mortality.

Feasibility and outcome of mitral valve repair in patients with infective endocarditis

Background

Valve repair is the treatment of choice for native mitral valve regurgitation. The feasibility of repair when the defect is caused by acute infective endocarditis (IE) is debated. This study aims to compare the outcome of repair and replacement procedures, to report the rate of repair in a single surgical center, and to review the literature on this topic.

Results

We retrospectively analyzed 108 patients with native mitral IE, potentially eligible for surgical repair. Of these 108, 90 (83%) underwent surgery, and 18 were treated conservatively. Among the 90 surgical patients, 57 (63%) underwent valve replacement and 33 valve repair (37%). The mean follow-up duration was 3 years. The two primary endpoints were mortality and freedom from recurrent endocarditis. Secondary endpoints were the post-operative incidence of major adverse events (hospitalization for any cause, pacemaker implantation, new onset of atrial fibrillation, sternal dehiscence), left ventricular systolic function (LVSF), and valvular function at 1-year echocardiographic follow-up. All-cause mortality was lower for valve repair, although not significantly (p = 0.86), as well as nonfatal adverse events (p = 0.92) and relapse rate (p = 0.20) at 3 years. We did not find differences between the two groups at echocardiographic follow-up, neither for left ventricular systolic function (p = 0.22), nor for valvular continence (p = 0.28).

Conclusions

In our experience, the mid-term outcome of repair in IE is comparable to valve replacement and should be considered whenever possible, as in degenerative valve disease. The review of the literature supports this strategy.

Outcomes of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis

BACKGROUND

Emergency or urgent surgery is often required in patients with papillary muscle rupture and active mitral valve infective endocarditis. The aim of this study was to analyze the outcomes of patients with active endocarditis who underwent emergency or urgent mitral valve repair.

METHODS

From 2005 to 2014, 154 ischemic mitral regurgitation patients and 41 infective endocarditis patients underwent mitral valve repair in our institution; 23 had emergency operations due to papillary muscle rupture, and 18 with active infective endocarditis underwent urgent surgery.

RESULTS

Cardiopulmonary bypass time (141.4 ± 43.3 versus 145.3 ± 46.5 min) and crossclamp time (77.7 ± 34.1 versus 79.2 ± 33.0 min) were similar in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, and major postoperative complications were comparable. Hospital mortality was 17.4% in the papillary muscle rupture subgroup and 8.4% in the elective ischemic mitral regurgitation subgroup. Cardiopulmonary bypass time (103.6 ± 37.0 versus 75.5 ± 20.8 min) and crossclamp time (61.7 ± 21.2 versus 45.3 ± 18.0 min) were significantly longer in infective endocarditis patients. There were no major complications or hospital deaths. Eight years postoperatively, overall survival was 94.4% and 86.5% in the papillary muscle rupture and elective ischemic mitral regurgitation subgroups, respectively (p = 0.730). Overall survival was 100% in both infective endocarditis subgroups.

CONCLUSION

The feasibility and effectiveness of emergency or urgent mitral valve repair in patients with papillary muscle rupture and active infective endocarditis are satisfactory. Early and mid-term outcomes are comparable to those of elective operations.

Mitral valve repair for infective endocarditis: Kobe experience

Objectives

We retrospectively analyzed our experience of mitral valve repair for native mitral valve endocarditis in a single institution.

Methods

From January 1991 to October 2011, 171 consecutive patients underwent surgery for infective endocarditis. Of these, 147 (86%) had mitral valve repair. At the time of surgery, 98 patients had healed (group A) and 49 had active infective endocarditis (group B). Repair procedures included resection of all infected tissue and thick restricted post-infection tissue, leaflet and annulus reconstruction with treated autologous pericardium, chordal reconstruction with polytetrafluoroethylene sutures, and ring annuloplasty if necessary. Fifty-two (35%) patients required concomitant procedures. The study endpoints were overall survival, freedom from reoperation, and freedom from valve-related events. The median follow-up was 78 months.

Results

There was one hospital death (hospital mortality 0.7%). Survival at 10 years was 88.5% ± 3.5% with no significant difference between the two groups (p = 0.052). Early reoperation was required in 4 patients in group B due to persistent infection or procedure failure. Freedom from reoperation at 5 years was 99% ± 1.0% in group A and 89.6 ± 4.0% in group B (p = 0.024). Event-free survival at 10 years was 79.3% ± 4.8% (group A: 83.4% ± 5.9%, group B: 72.6% ± 6.9%, p = 0.010).

Conclusions

Mitral valve repair was highly successful using autologous pericardium, chordal reconstruction, and ring annuloplasty if required. Long-term results were acceptable in terms survival, freedom from reoperation, and event-free survival. Mitral valve repair is recommended for mitral infective endocarditis in most patients.

The Evolution of Mitral Valve Surgery: the Future in the Hand of Robots

Objective

To examine the current literature behind the evolution of mitral valve surgery techniques and their impact on patient outcomes.

Methods

An electronic literature search among major databases was performed (PubMed, Embase, Scopus, Cochrane, and Google scholar). All the relevant articles were screened and identified to be included in this narrative review. The main outcomes were postoperative morbidity, length of in-hospital stay, and long-term mortality.

Results

Minimally invasive and robot-assisted approach to mitral valve repair and replacements has shown great potential in improving surgical outcomes when compared against traditional midline sternotomy. Selected patients can benefit from percutaneous mitral valve surgery; however, more evidence is required to ascertain its long-term outcomes.

Conclusion

Current evidence suggests that robotic and minimal invasive mitral valve surgeries are increasing in practice with satisfactory perioperative and mortality rates. However, long-term data is yet to be published to support current practice.

Optimizing outcomes in infective endocarditis: A comprehensive literature review

BACKGROUND

Despite being rare, infective endocarditis (IE) is a life-threatening disease with poor prognosis. New diagnostic and therapeutic strategies are emerging; however, predisposing factors and microbiology of the disease are also changing with time. Because of this, there has been a lack of reduction in the disease's incidence and new challenges for clinicians have arisen such as an increasingly aging population and growing antimicrobial resistance.

AIMS

In this paper, we aim to provide an overview of the changing trends in IE, current diagnosis, and management strategies, as well as the emerging role of the infective endocarditis teams in the care of patients with this disease.

MATERIALS & METHODS

A comprehensive electronic search was done utilizing PubMed, Ovid, SCOPUS, Embase and google scholar. The search terms included 'Endocarditis', 'IE', 'Infection', 'Vegetation', 'Duke criteria', 'native valve infection', 'prosthetic valve', 'valve infection', 'endocarditis outcome' and 'endocarditis bacteriology'. The references of the identified articles were then searched for any potential articles that can be included. The inclusion criteria were any article that discussed the evidence behind incidence and management of IE including the role of endocarditis team. The exclusion criteria were case reports, expert opinion, and editorials.

RESULTS

All the relevant findings are summarized in specified tables and within appropriate sections.

DISCUSSION

It is vital to determine the current trends in the epidemiology and microbiology of the condition so that the diagnostic threshold can be adapted, to identify new at-risk groups and achieve an accelerated evaluation strategy that allows for earlier diagnosis and treatment.

CONCLUSION

Management of IE can benefit from the input of different specialties, such as cardiology, cardiothoracic surgery, infectious disease, and microbiology. Therefore, adopting a multidisciplinary approach towards treatment is crucial to reduce morbidity and mortality from preventable complications of this pathology.

Aortic valve repair or replacement in patients with aortic regurgitation: A systematic review and meta-analysis

OBJECTIVE

To systematically compare clinical outcomes between aortic valve repair and replacement in patients with aortic regurgitation.

METHODS

A comprehensive literature search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all published data comparing clinical outcomes of aortic valve repair vs replacement. Database searched from inception to November 2018.

RESULTS

A total of 1071 patients were analyzed in eight articles. Mean age was similar in both groups of patients (47.2 ± 12.8 vs 48.3 ± 12.7 years, P = 0.83, aortic valve repair and replacement, respectively). The preoperative left ventricular ejection fraction was better in the repair group (56.7% ± 4.8 vs 53.3% ± 4.2, P = 0.005). The rate of moderate-to-severe regurgitation and bicuspid aortic valve were similar in both cohorts (81% vs 78%, P = 0.90% and 58% vs 55%, P = 0.46). In-hospital and 1-year mortality was lower in repair cohort, although not reaching statistical significance (1.3% vs 3.6%, P = 0.12; 5.9% vs 9.3%, P = 0.77). Reoperation rate was higher in repair patients at 1 year (8.8% vs 3.7%, P = 0.03).

CONCLUSION

Aortic valve repair offers comparable perioperative outcomes to aortic valve replacement in aortic regurgitation patients at the expense of higher late reintervention rate. Larger trials with long-term follow-up are required to confirm the long-term benefits of aortic valve repair.

Redo mitral valve surgery following prior mitral valve repair

BACKGROUND

The optimal treatment strategy following a failed mitral valve repair remains unclear. This study evaluated early and long-term outcomes of redo mitral valve repair (MVr) and replacement (MVR) after prior mitral valve repair.

METHODS

Patients undergoing redo mitral valve surgery after prior mitral valve repair at a single institution between 2002 and 2014 were reviewed. Primary outcomes included operative mortality (30-day or in-hospital mortality) and long-term freedom from mitral valve reoperation and death. Secondary outcomes included postoperative complications.

RESULTS

305 patients underwent redo MVr (n = 48) or MVR (n = 257) after prior mitral valve repair. Concomitant procedures included tricuspid valve repair or replacement (23%), aortic valve replacement (6%), and coronary artery bypass grafting (4%), with no differences between cohorts. 18% were performed via right mini-thoracotomy (24% MVr vs 18% MVR, P = 0.31). Unadjusted and risk-adjusted operative mortality were lower with MVr (0% vs 8%, P = 0.04). Rates of postoperative complications were similar except for blood product transfusion (35% MVr vs 59% MVR, P = 0.003) and prolonged mechanical ventilation (8% MVr vs 29% MVR, P = 0.003). Long-term freedom from mortality was comparable: 96% MVr versus 86% MVR at 1 year and 78% MVr versus 68% MVR at 5 years (P = 0.29).

CONCLUSIONS

When technically feasible, mitral valve re-repair can be safely performed with outcomes comparable to MVR.

Outcomes of mitral valve surgery during concomitant aortic valve replacement

BACKGROUND

This study evaluates outcomes of mitral valve surgery (MVS), replacement (MVR), and repair (MVr), during concomitant aortic valve replacement (AVR).

METHODS

Patients undergoing MVS with concomitant AVR between 2011 and 2017 at a single center were reviewed. Patients were stratified into MVR versus MVr with concomitant AVR. Outcomes included early and midterm mortality, hospital re-admissions, re-operations, and complications. Multivariable Cox regression analysis was used for risk-adjustment.

RESULTS

Four hundred twenty-four patients underwent MVS with concomitant AVR: 247 (58.3%) MVr and 177 (41.7%) MVR. In unadjusted analysis, there was a non-significant increase in 30-day mortality with MVR, with no differences in 1- and 5-year mortality (30-day: 5.6% vs 10.1%, P = 0.081; 1-year: 14% vs 18.2%, P = 0.181; 5-year: 35.1% vs 37.8%, P = 0.232). Freedom from re-admission and mitral reoperation were comparable. Freedom from at least moderate mitral regurgitation at 5 years was 78% in MVr patients. Those undergoing MVR had increased postoperative blood transfusions, acute renal failure, and pleural effusions requiring drainage (P each <0.05).

CONCLUSIONS

MVr can be performed during concomitant AVR without an adverse impact on longer-term outcomes, including mortality, re-admissions, and mitral reoperations. The majority of patients have durable repairs at 5 years although durability is less than that reported in isolated MVS.