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Ann Thorac Surg 2000;70:1219-1223
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis

^a Department of Surgery, Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada
^b Department of Medicine, Montreal Heart Institute and the University of Montreal, Montreal, Quebec, Canada

Address reprint requests to Dr Carrier, Montreal Heart Institute, 5000 East Belanger Street, Montreal, QC, H1T 1C8, Canada
e-mail: carrier{at}icm.umontreal.ca

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis.

Methods. A retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute.

Results. Seventy-seven patients (57 men and 20 women, mean age 48 ± 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% ± 6%, 76% ± 6%, and 76% ± 6% for NVE and 70% ± 9%, 59% ± 10%, and 55% ± 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% ± 6%, 76% ± 6%, and 76% ± 6% for NVE and 45% ± 10%, 40% ± 10%, and 36% ± 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% ± 9% following aortic valve replacement and 79% ± 9% following mitral valve replacement. Five-year survival for PVE averaged 66% ± 12% following aortic valve replacement and 43% ± 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2.

Conclusions. Prosthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.

	Introduction

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Prolonged antibiotic therapy remains the treatment of choice for native valve endocarditis (NVE) once the causative organism has been identified. Although appropriate medical treatment can sterilize the vegetative lesions, complications such as extension of infection in the surrounding tissues, valvular dysfunction, or recurrent embolic events often precipitate operation. On the other hand, patients with prosthetic valve endocarditis (PVE) almost always need to undergo replacement of the infected prosthesis because success with medical treatment alone is unusual [1].

Although several researchers have reported success with valvular repair and homografts in patients with acute infective endocarditis, valve replacement remains the standard surgical approach [2, 3]. Most researchers have also reported cohorts of patients recruited in the early 1970s and 1980s using various antibiotic regimens, undefined methods of myocardial protection, and older generations of valve prostheses [4–6]. In a study of patients undergoing valve replacement during the course of acute endocarditis, Pelletier and coworkers [7] concluded that earlier valve replacement played a major role in improving outcomes and that valve replacement could be achieved with reasonable mortality (15%) and a low risk of reinfection (0%). The objective of the present study was to compare current results following prosthetic valve replacement in patients with acute infective endocarditis of native valves to that of patients with PVE treated in the last decade with standardized medical and surgical approaches.

	Material and methods

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We retrospectively reviewed 77 patients who underwent prosthetic valve replacement for treatment of NVE or PVE between 1988 and 1998 at the Montreal Heart Institute. All patients with PVE had undergone primary valve replacement in our institution. During that period, 2,806 patients underwent single, double, or multiple valvular replacement. Thus, 2.7% (77 of 2,806) of our patients underwent valvular replacement for acute infective endocarditis. There were 20 women and 57 men averaging 48 ± 16 years of age (Table 1). All patients had acute infective endocarditis. Only 1 patient was an active intravenous drug user. Diagnosis was based on an infectious episode followed by the appearance of new valvular lesions on echocardiography. In most cases, blood cultures allowed identification of the germ. All patients received at least 6 weeks of postoperative multidrug antibiotic treatment directed against the offending organism. All patients underwent operation before completion of the antibiotic treatment. Early PVE was defined as an infection occurring up to 1 year after valve replacement [8].

	Results

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Hospital mortality and morbidity
Four patients died early following valve replacement for NVE (in-hospital mortality of 8%). One of these patients died intraoperatively of left ventricular rupture following mitral valve replacement and 3 other patients died within 30 days of operation from cardiogenic shock, multiple organ failure, and rupture of a mycotic aneurysm of the splenic artery. There was no hospital death among patients operated for PVE (Table 5), although 7 patients with PVE died during the first year following operation (Table 6).

Long-term follow-up
Patient survival 1, 5, and 7 years following valve replacement for NVE averaged 80% ± 6%, 76% ± 6%, and 76% ± 6% compared with 70% ± 9%, 59% ± 10%, and 55% ± 10% in patients with PVE, respectively (p = 0.15) (Fig 1). Reoperation-free survival 1, 5, and 7 years following valve replacement for NVE averaged 80% ± 6%, 76% ± 6%, and 76% ± 6% compared with 45% ± 10%, 40% ± 10%, and 36% ± 9% in patients with PVE, a significant difference (p = 0.003) (Fig 2). Five-year survival averaged 75% ± 9% following aortic valve replacement, 79% ± 9% following mitral valve replacement, and 71% ± 17% following double valve replacement among patients with NVE (p = 0.9). Five-year survival averaged 66% ± 12% following aortic valve replacement, 43% ± 19% following mitral valve replacement, and 60% ± 20% following double valve replacement among patients with PVE (p = 0.8). Following aortic, mitral, and double valve replacement, reoperation-free survival averaged 75% ± 9%, 79% ± 9%, and 71% ± 17%, respectively, in patients with NVE (p = 0.6) and 53% ± 13%, 14% ± 13%, and 40% ± 22% in patients with PVE (p = 0.2).

View larger version (19K): [in this window] [in a new window]   Fig 1. Patient survival following valve replacement for native valve endocarditis (NVE) and for prosthetic valve endocarditis (PVE). Patients with NVE had a higher survival rate following valve replacement compared with PVE patients, but the difference was not statistically significant.

View larger version (19K): [in this window] [in a new window]   Fig 2. Reoperation-free survival following valve replacement for native valve endocarditis (NVE) and for prosthetic valve endocarditis (PVE). Patients with NVE had a higher reoperation-free survival rate following valve replacement compared with PVE patients. The difference was statistically significant.

Overall, 5-year survival averaged 61% ± 13% in patients who underwent valve replacement with biologic prostheses compared with 71% ± 6% among those with mechanical valve replacement (p = 0.7). Reoperation-free survival averaged 59% ± 12% in patients with biologic prosthesis compared with 64% ± 6% among those with mechanical prosthesis 5 years following operation (p = 0.7).

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Surgical treatment of acute infective valvular endocarditis is a necessary adjunct to medical therapy in many cases. Although several researchers have recommended the use of homografts [9–12], prosthetic valve replacement for NVE resulted in excellent long-term survival without reoperation in both aortic and mitral position. In the present study, hospital mortality averaged 8% and patient 5-year survival following valve replacement for NVE averaged 76%, results that compare favorably with experience of others [6, 13–15], including those favoring routine use of homografts in all aortic valvular endocarditis patients. Moreover, there was no recurrence of endocarditis during follow-up in our later group of patients.

Although there was no hospital mortality among patients who underwent valve replacement for PVE, the 5-year patient survival and survival without reoperation averaged 59% and 40% respectively, a significant difference compared with patients undergoing valve replacement for NVE. Edwards and coworkers [16], in a survey from the United Kingdom heart valve registry, reported a higher 30-day mortality averaging 20% and a similar 5-year survival averaging 55% following operation for PVE. Other researchers have also reported high hospital mortality, poor long-term survival, and a high rate of recurrent endocarditis among patients who underwent operation for PVE [17, 18]. In the present series, 9 patients underwent reoperation following valve replacement for PVE, 5 patients with recurrent endocarditis and 4 patients with significant noninfective periprosthetic dehiscence mostly in mitral position. This finding is in contrast with our earlier experience when no reinfection of implanted prosthesis occurred [7]. This result may be related to the microorganisms involved. In our previous series, most (55%) of the infections were due to Streptococci and only 2 (10%) were due to Staphylococci. In the present series, the organism most commonly involved was Staphylococci (48%), particularly among the PVE group in which it was responsible for about 60% of the infections, whereas Streptococci were involved in only 27% of the cases. It is well known that Staphylococci cause an extensive tissue destruction and require a very aggressive debridement to eradicate all contaminated material.

Early PVE is defined as an infection occurring during the first year following valve replacement. Sixteen of 27 patients (59%) underwent reoperation for early PVE an average of 7 ± 4 months following the initial valve replacement, and 11 of 27 patients (41%) underwent reoperation for late endocarditis an average of 82 ± 97 months following initial valve implantation. In the early PVE group, Staphylococcus epidermidis infections were highly predominant and probably caused by germs seeded during operation, emphasizing the need for strict sterile technique during prosthetic valve operation.

Abscess debridement followed by autologous pericardial patch, bovine pericardial patch, or Dacron annular reconstruction was common in both groups of patients. Several researchers have also reported excellent results with the later technique [18, 19]. Only 1 patient required the use of an aortic homograft reconstruction after two attempts to eradicate the infection with prosthetic valve replacement. Aortic homograft remains a useful option in patients with infective aortic endocarditis and extensive annular destruction, as suggested by several researchers [20,21]. However, because of the limited availability of homografts for urgent or emergent operation, the role of homografts should probably be limited to extended reconstruction of aortic annulus in patients with recurrent PVE.

In a critical appraisal of the quality of the medical management of infective endocarditis in clinical practice, Delahaye and colleagues [22] showed that undue delay of operation was common and is a major source of concern. The present results combined with those of our former report [7] suggest that a more aggressive approach to PVE treatment with early operation could lead to better long-term results in these seriously ill patients, as one third of the patients already had annular or intramyocardial abscesses at the time of operation.

In the present study, prosthetic valve replacement for NVE carried a low perioperative mortality risk and was associated with good long-term survival and minimal risk of reoperation. Contrary to the experience of several other researchers, we found that valve replacement for PVE can be performed without hospital mortality, yet the long-term results indicate an increased risk of reoperation for recurrent endocarditis or periprosthetic leaks. Early reoperation, extensive tissue debridement with annular reconstruction, and the use of aortic homografts could improve the results of the treatment of PVE, but stringent prevention measures of intraoperative contamination during valve replacement remains the optimal goal to decrease the incidence and the dismal outcome of PVE.

	References

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