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Ann Thorac Surg 2002;73:1813-1816
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Endocarditis after mitral valve repair

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^b Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^c Department of Infectious Disease, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^d Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Accepted for publication February 17, 2002.

* Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Ave, Cleveland, OH 44195 USA
e-mail: gillinom{at}ccf.org

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Native valve endocarditis is frequently managed with antibiotics alone, but prosthetic valve endocarditis usually requires an early operation. What is the best treatment of endocarditis after mitral valve repair?

Methods. From 1986 to 2000, 22 patients were treated for endocarditis affecting a previously repaired mitral valve. Causes of mitral valve dysfunction that led to repair were degenerative (11 patients), ischemic (5 patients), endocarditic (3 patients), rheumatic (2 patients), and functional (1 patient). Endocarditis was active in 21 patients and healed in 1. Interval from initial mitral valve repair to onset of endocarditis ranged from 1 week to 10.3 years (median, 6 months). Pathology included leaflet vegetation (15), annuloplasty vegetation (4), leaflet perforation (5), and abscess (3). Mean follow-up was 3.9 ± 3.3 years.

Results. Fifteen patients underwent repeat mitral valve operations with freedom from mitral valve reoperation of 65%, 41%, and 26% at 30 days, 1 year, and 5 years after onset of endocarditis. After a high early hazard, risk of reoperation fell to 10.8% per year. Seven patients, all with a leaflet vegetation, were treated with antibiotics alone. Antibiotics eradicated infection in all; however all had mitral regurgitation 2+ to 4+. Survival was 96%, 74%, and 68% at 30 days, 1 year, and 5 years. Endocarditis recurred in 1 patient (92% free of event).

Conclusions. Most patients that have endocarditis develop after mitral valve repair require reoperation. However if infection is limited to a leaflet, early reoperation may be unnecessary because antibiotics alone can eradicate infection.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Mitral valve repair is the treatment of choice to correct mitral regurgitation of all causes [1, 2]. A purported advantage of mitral valve repair over replacement is higher freedom from valve-related morbidity, including endocarditis [1, 2]. Ten-year freedom from endocarditis after mitral valve repair is 95% to 99% [2, 3]. Although this complication is uncommon, the increasing prevalence of mitral valve repair has resulted in a larger number of patients at risk for postrepair endocarditis. Native valve endocarditis is frequently managed with antibiotics alone, whereas prosthetic valve endocarditis usually requires an operation. What is the best treatment of endocarditis after mitral valve repair?

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
From 1986 to 2000, 22 patients were treated at The Cleveland Clinic Foundation for endocarditis affecting a previously repaired mitral valve. Patients were identified by examining databases from cardiac operations, echocardiography, and infectious disease. In addition, records of all patients undergoing reoperation after mitral valve repair were screened. Initial cause of mitral valve dysfunction was degenerative in 11 patients (50%; Table 1). Initial mitral valve repairs were performed at our institution in 18 patients and elsewhere in 4. At the initial operation, mitral valve repair procedures included posterior leaflet resection (50%), sliding repair (23%), chordal transfer (18%), chordal shortening (5%), and Alfieri edge-to-edge repair (5%). Twenty-one patients (95%) received an annuloplasty; annuloplasty techniques were posterior pericardial band (9 patients), Cosgrove-Edwards annuloplasty system (7 patients, Edwards Lifesciences LLC, Newport Beach, CA), Carpentier-Edwards classic ring (4 patients, Edwards Lifesciences LLC, Newport Beach, CA), and Duran ring (1 patient, Medtronic Inc, Minneapolis, MN). Concomitant procedures performed at the initial operation were coronary artery bypass grafting (32%), aortic valve replacement (14%), and tricuspid valve repair (14%). Twenty patients had intraoperative echocardiography. Postrepair echocardiography in 20 patients demonstrated no mitral regurgitation in 14 patients, 1+ in 5, and 2+ in 1.

Putative sources of infection were pneumonia (3 patients), dental procedures (2 patients), intravenous drug use (2 patients), cystoscopy (1 patient), dialysis (1 patient), mediastinitis (1 patient), and unknown (12 patients). Characteristics of the infection are detailed in Table 2. Responsible organisms were staphylococcal species in the majority of patients. Of the 3 patients who had initial mitral valve repair for endocarditis, the organism at re-infection was the same in 1. Vegetations were the most common pathologic finding, with the majority of vegetations present on the leaflets rather than the annuloplasty band or ring. Seventeen patients (77%) had 3+ or 4+ mitral regurgitation.

Methods of analysis
Events after diagnosis of endocarditis were analyzed in a time-related manner. Nonparametric estimates were obtained by the Kaplan-Meier method and are presented with asymmetric confidence limits equivalent to 1 standard error (68%) [6]. A parametric method was used to resolve the number of phases of instantaneous risk of events (hazard functions) and to estimate their shaping values [7]. Both the parametric and hazard function estimates are presented with confidence limits equivalent to one standard error (68%). The small numbers of patients and events precluded identification of risk factors for various events.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Initial treatment strategy
All patients except 1 were treated with antibiotics once the diagnosis of endocarditis was suspected; in 1 patient anterior leaflet perforation caused by healed endocarditis was identified unexpectedly at operation, and that patient did not require antibiotic therapy.

Fifteen patients underwent repeat mitral valve operations with freedom from mitral valve reoperation of 65%, 41%, and 26% at 30 days, 1 year, and 5 years after onset of endocarditis (Fig 1A). Indications for surgical therapy included severe mitral regurgitation (87%), congestive heart failure (47%), persistent sepsis (13%), and thromboemboli (13%). After a high early hazard rate, risk of reoperation fell to 10.8% per year (Fig 1B). Only 3 patients with active endocarditis had an operation within 1 week of diagnosis. Mitral valve reoperations were mitral valve replacement in 11 patients and re-repair in 4. None of these patients required subsequent mitral valve operations.

View larger version (15K): [in this window] [in a new window]   Fig 1. Reoperation after onset of endocarditis. (A) Freedom from reoperation. Each circle represents a reoperation. Vertical bars represent 68% confidence limits of the Kaplan-Meier estimates. Numbers in parentheses represent patients traced beyond the designated event. The solid line is the parametric estimate and is enclosed within 68% confidence limits (dashed lines). (B) Hazard of mitral valve reoperation. The dashed lines enclose the 68% confidence limits.

Seven patients, all with a leaflet vegetation, were treated with antibiotics alone. Surgical therapy was withheld for several reasons. Three patients were turned down for operations because of comorbidities. Two patients, both intravenous drug users, chose not to have repeat operations. Two patients declined operations because they felt clinically well. Antibiotics eradicated infection in all patients; however all had grades of 2+ to 4+ mitral regurgitation. One of these patients required a subsequent mitral valve operation that is described as follows.

Late results
Survival after onset of endocarditis was 96%, 74%, and 68% at 30 days, 1 year, and 5 years (Fig 2). Endocarditis recurred in 1 patient (92% free of event). This patient had a second episode of streptococcal endocarditis 2 years after successful antibiotic therapy for a similar episode. She responded to antibiotic therapy again, but 1 year later had mitral valve replacement for severe mitral regurgitation.

View larger version (13K): [in this window] [in a new window]   Fig 2. Survival after onset of endocarditis. Each circle represents a reoperation. Vertical bars represent 68% confidence limits of the Kaplan-Meier estimates. Numbers in parentheses represent patients traced beyond the designated event. The solid line is the parametric estimate and is enclosed within 68% confidence limits (dashed lines).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

Endocarditis affecting repaired mitral valves has elements of similarity to both native valve and prosthetic valve endocarditis. Leaflet vegetations are a common finding, resembling the pathology of native valve endocarditis [8–10]. However, the organisms identified are usually staphylococcal species, similar to those causing prosthetic valve endocarditis [11, 12].

Treatment strategy also lies somewhere between that for native and prosthetic valve endocarditis. Whereas native valve endocarditis can frequently be treated by medical therapy alone [11, 13, 14], prosthetic valve endocarditis usually requires early operation [11–13, 15]. There is growing support for an aggressive surgical approach to patients with native left-sided endocarditis [16]. When an operation is indicated for native mitral valve infection, valve repair is often possible [8–10]. In these patients, mitral valve repair may confer a survival advantage compared with valve replacement [10]. The high probability of mitral valve repair supports an aggressive approach and early operations in patients with native valve endocarditis.

Treatment for endocarditis occurring after mitral valve repair begins with antibiotic therapy. The majority of patients eventually require operations for severe mitral valve dysfunction, and this usually entails valve replacement. However, an operation is rarely emergent. Antibiotic therapy alone can successfully sterilize many valves in which the only pathology is a leaflet vegetation. Therefore, in patients with a leaflet vegetation who have no clear surgical indication or relative contraindications to operations, a trial of antibiotic therapy alone is reasonable. It is important to note, however, that these patients will be left with moderate to severe mitral regurgitation.

Limitations
This is an observational clinical study examining presentation, treatment strategies, and results in a relatively small group of patients. We have made every effort to identify all patients that presented to The Cleveland Clinic Foundation with endocarditis affecting a repaired mitral valve; nevertheless, it is possible that the diagnosis was missed in some patients. The small numbers of patients and events and the study design do not permit conclusive statements concerning the superiority of medical or surgical therapy in patients with endocarditis after mitral valve repair. Furthermore, the choice of therapy and the timing of surgical intervention were determined by the team of physicians caring for each patient. Examination of this decision-making and the results of therapy permit general conclusions concerning treatment of this disease. No attempt was made to determine the incidence and risk factors for endocarditis after mitral valve repair. This information is provided elsewhere [2, 3].

In conclusion, the majority of patients with endocarditis after mitral valve repair require mitral reoperation. However when infection is limited to a leaflet, early operation may not be necessary, because antibiotic therapy alone can eradicate infection.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph F. Sabik Gosta Pettersson Steven M. Gordon Delos M. Cosgrove, III Eugene H. Blackstone Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gillinov, A. M. Articles by Blackstone, E. H. Search for Related Content PubMed PubMed Citation Articles by Gillinov, A. M. Articles by Blackstone, E. H.