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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes in minimally invasive double valve surgery

OBJECTIVE

To review current literature evidence on outcomes of minimally invasive double valve surgeries (MIS).

METHODS

A comprehensive electronic literature search was done from inception to 20th June 2020 identifying articles that discussed outcomes of minimally invasive approach in double valve surgeries either as a solo cohort or as comparative to conventional sternotomies. No limit was placed on time and place of publication and the evidence has been summarized in narrative manner within the manuscript.

RESULTS

Majority of current literature reported similar perioperative and clinical outcomes between MIS and conventional median sternotomy; except that MIS has better cosmetic effects and pain control. Nevertheless, minimal invasive techniques are associated with longer cardiopulmonary bypass and aortic cross-clamp times which may have impact on the reported outcomes and overall morbidity and mortality rates.

CONCLUSION

Minimally invasive double valve surgery continues to develop, but scarcity in the literature suggests uptake is slow, possibly due to the learning curve associated with MIS. Many outcomes appear to be comparable to conventional sternotomy. There is need for larger, multi-center, and randomized trial to fully evaluate and establish the early, mid- and long-term morbidity and mortality rates associated with both techniques.

Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis

BACKGROUND

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD.

METHODS

PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated.

RESULTS

Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay.

CONCLUSIONS

MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.