[HSF] Endocarditis with splenic infarct
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Eur J Cardiothorac Surg 2007;31:592-599. doi:10.1016/j.ejcts.2007.01.002
Copyright © 2007, European Association for Cardio-Thoracic Surgery.
Published by Elsevier B.V. All rights reserved
Reconstructive surgery in active mitral valve endocarditis: feasibility,
safety and durability
Laurent de Kerchovea,*, Jean-Louis Vanoverscheldeb, Alain Ponceleta,
David Glineura, Jean Rubaya, Francis Zechc, Philippe Noirhommea, Gebrine
El Khourya
a Division of Cardiothoracic and Vascular Surgery, Université Catholique
de Louvain, Brussels, Belgium
b Division of Cardiology, Université Catholique de Louvain, Brussels,
Belgium
c Division of Internal Medicine, Université Catholique de Louvain,
Brussels, Belgium
Received 16 September 2006; received in revised form 19 December 2006;
accepted 4 January 2007.
* Corresponding author. Address: Division of Cardiothoracic and Vascular
Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200
Brussels, Belgium. Tel.: +32 2 764 6111; fax: +32 2 764 8960. (Email:
Laurent.DeKerchove at clin.ucl.ac.be; ldekerchove at hotmail.com).
Abstract
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
Objective: To evaluate timing for surgery and management of complex
valve lesions in patients with active mitral valve (MV) endocarditis.
Results are based on 13 years of experience with MV repair in active
endocarditis. Method: Between 1993 and 2005, 81 patients were operated
for active MV endocarditis, of which 63 (or 78%) had MV repair. For all
patients, the median time between diagnosis and surgery was 10 days.
Diverse surgical techniques were applied to restore MV competence. In
59% of the patients, pericardial patches, tricuspid autograft or partial
MV homografts were used as leaflet substitutes. In addition, prosthetic
rings were employed in 44% of the patients. Results: The overall
operative mortality was 17.5%. However, considering only patients in
preoperative NYHA class I or II, the operative mortality could be
reduced to 4.8%. NYHA class ?3, elevated age (above 70 years) and
history of valvular were the three independent risks factors for early
mortality in our multivariate analysis. The average follow-up time was
60 ± 37 months. During this period, five late deaths occurred, two of
which were cardiac-related. The overall 5- and 10-year survival rate was
73 ± 12% and 69 ± 13%, respectively. In hospital survivors, freedom from
cardiac death after 5 and 10 years was 93 ± 8%. Three early and five
late MV reoperations occurred in seven patients, of them four could have
MV re-repair. Only one endocarditis recurrence occurred after 4 months
in a chronic haeamodialysed patient. Freedom from MV reoperation was 89
± 10% and 72 ± 24% at 5 and 10 years, respectively. Ten-year freedom
from MV replacement and from endocarditis recurrence were 95 ± 5% and 98
± 1%, respectively. Annular abscesses and calcified or rheumatic MV
disease were two independent risk factors associated with reoperation in
our multivariate analysis. During the follow-up period, all patients
were in NYHA class I or II; 89% of patients had mitral regurgitation
grade ?I, only 11% had grade II on transthoracic echocardiography.
Conclusion: Using diverse and advanced techniques of MV repair, a
reparability rate of 80% can be reached among patients with active
endocarditis. We demonstrate that a high level of safety and excellent
durability of MV repair can be obtained even for complex repairs.
Key Words: Mitral valve repair • Active endocarditis • Native valve
endocarditis
1. Introduction
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
Since the early nineties, many authors have reported the excellent
results of mitral valve (MV) repair [1–4] in acute and healed
endocarditis. However, severity and heterogeneity of endocarditis
lesions, multiple valves endocarditis and precarious haemodynamic status
are all conditions that explain the relatively low rate of MV repair in
this aetiology. In degenerative disease, reparability rate ranges from
80 to 90% [5], whereas in endocarditis, it ranges from 35 to 50%
[2,4,6–10] with only few exceptions [1,3,11,12]. The advantages of MV
repair over replacement, also reported by some authors in the setting of
endocarditis [4,7,10], promote the efforts to increase the reparability
rate in this challenging indication.
In patients with MV infective endocarditis, indication and timing of
surgery are typically determined by the clinical presentation of the
disease. It is usually recommended to delay surgery until completion of
antibiotic therapy. However, recent guidelines have been defined to
describe situations that mandate urgent surgery. These specific cases
are (i) the presence of heart failure due to severe MV regurgitation,
(ii) persistent sepsis despite adequate antibiotic therapy, (iii) the
involvement of resistant or aggressive microorganisms, (iv) locally
uncontrolled infection, (v) septic emboli and finally (vi) large
vegetations (>10 mm) [13].
The objective of this study was to review 13 years of our experience in
reconstructive surgery for active MV endocarditis.
2. Material and methods
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
Between 1993 and 2005, 81 patients underwent surgery for active native
MV endocarditis. The following study is based on 63 of these patients
(78%) that had MV repair. Endocarditis was defined as active when (i)
positive cultures were obtained (by preoperative haemoculture or
intraoperative culture) or when a macroscopically infected valve was
detected and (ii) for patients operated within 6 weeks after diagnosis
during the antibiotic therapy [14–17].
All patients diagnosed with endocarditis were preoperatively assessed
with transthoracic (TTE) and transoesophagial echocardiography (TEE). If
necessary, repeated TEE were performed in order to follow the lesions
and to support a decision for surgery.
In presence of preoperative neurologic complication, indication for
surgery was discussed by a multidisciplinary team of neurologist,
intensivist, cardiologist and cardiac surgeon. Patients’ age, type and
severity of neurologic deficit and long-term functional prognosis were
the principal factors guiding the therapeutic attitude. Early surgery
was advised in patients with small non-haemorragic lesion and few
neurologic deficit. In case of intracranial bleeding or massive stroke,
surgery was delayed to avoid anticoagulation drugs during a 10–15 days
period and to allow appropriate follow-up of the neurologic status.
Patients in coma with poor prognosis of recovery were excluded for surgery.
2.1 Timing of surgery
During the study period, we progressively performed surgery earlier
during the course of endocarditis (Fig. 1 ). This approach is believed
to avoid further destruction of the valve as previously suggested by
Dreyfus et al. [1]. In our current protocol, under appropriate
indication, surgery was promptly performed; this implies that in some
situations preoperative antibiotics were administered for only a few
days prior to surgery. Following this approach, the mean and median
times between the first and the last third of the study period were
decreased from 18 ± 10 to 10 ± 9 days and from 17 to 6 days,
respectively (Fig. 1). Twenty-six patients (41% of the patient
population) were operated on during the first week of antibiotic
therapy, 12 patients (20%) during the second week, 9 patients (14%)
during the third week and 16 patients (25%) within the fourth to the
sixth week. For all patients, antibiotic therapy started at diagnosis
was completed after surgery, with a total duration of 6–8 weeks as
recommended by current guidelines [13].
Figure 1
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Fig. 1. Mean and median length of preoperative antibiotic therapy
(y-axis) according to the study periods (x-axis).
2.2 Patient characteristics
Preoperative patient characteristics are listed in Table 1 . Average
patient age was 56 ± 14 years (ranging between 19 and 77 years) and the
male:female ratio was 7:3. Pre-existing MV disease was identified for 19
(30%) of our patients. Twelve patients (19%) underwent previous cardiac
surgery including seven aortic valve replacements (five mechanical
prosthesis and two bioprosthesis), three MV repairs, two CABG's and one
atrial septal defect closure.
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Table 1 Preoperative patient characteristics
Indications for surgery were (i) severe congestive heart failure (NYHA
class ?III) in 21 patients (32%) and cardiogenic shock in nine of them
(14%), (ii) septic emboli in 22 patients (35%) including 10 cases (16%)
of stroke with no intracranial bleeding, five cases (8%) of TIA's and
three cases (4.7%) of cerebral abscesses and (iii) persistent sepsis in
11 patients (17%). Preoperative transoesophagial echocardiography
revealed vegetations in 51 patients (81%), mitral regurgitation (MR)
grade ?3 in 40 patients (63.5%) and intracardiac abscesses or fistulas
in 17 patients (27%). Forty-two patients (67%) had isolated mitral valve
endocarditis, 20 (32%) had both mitral and aortic valve endocarditis and
one had mitral and tricuspid valve endocarditis.
The most common microorganisms responsible for endocarditis were
Streptococcus (for 29 patients, 46%) and Staphylococcus (for 20
patients, 32%) species. No microorganism could be identified in five
patients (Table 2 ).
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Table 2 Pre- and intraoperative bacteriology
2.3 Operative findings
Endocarditis lesions were equally located on either the anterior or
posterior mitral leaflets and less frequently at the level of the
commissures. Vegetations were the most commonly found lesions (80%).
Other lesions such as prolapses (40%), perforation (where the defect
respects the leaflet free edge) or destructions (where the defect
includes the leaflet free edge) (38%) and abscesses (35%) were also
observed. Annular abscesses that were slightly underestimated by
preoperative echocardiography were equally located at the level of the
anterior or posterior mitral annulus. In addition to the endocarditis
lesions, an underlying degenerative, rheumatic or congenital MV disease
was observed in 37 patients (59%) (Table 3 ).
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Table 3 Description of the mitral valve lesions
2.4 Operative findings and techniques
All patients were operated on by median sternotomy with cardiopulmonary
bypass. Antegrade cold crystalloid cardioplegia was initially used (18
patients, 28%) for the first 3 years of the study, and was then replaced
by normothermic blood cardioplegia (45 patients, 72%).
After careful examination of the valve and the complete resection of
infected tissues, the feasibility of MV repair was evaluated. Extensive
destruction of a single leaflet or the presence of abscess did not
contraindicate MV repair. However, the extensive destruction of both
leaflets or poor quality of the remaining tissues (through
calcification, retraction or thickening) did usually prompt MV replacement.
A list of the techniques used to repair the MV is provided in Table 4 .
In half of the patients, several techniques had to be applied to achieve
MV continence. Biological patches were used as a substitute for the
leaflet defect in 37 patients (59%). Glutaraldehyde-treated autologous
pericardium or bovine pericardium, due to increased availability, were
the most used patches (22 patients). The tricuspid valve autograft,
preferred for commisural reconstruction, was used in six patients.
Posterior leaflet transposition, commonly known as the flip-over
technique, was performed in five patients with destruction of the
anterior leaflet free edge. A posterior MV homograft was only used once.
Finally, in 11 patients with destruction of the basis of anterior
leaflet by mitro-aortic abscess, mitro-aortic continuities were repaired
with bovine pericardium (in eight patients) or anterior mitral leaflet
from aortic homograft (in three patients).
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Table 4 Techniques used to repair the mitral valve
Prosthetic rings were implanted in 30 patients (48%) and pericardial
bands in 6 patients (9%). In three patients (5%), infected
calcifications of the posterior annulus were resected. Following
decalcification, the atrio-ventricular disjunction was reconstructed
with bovine pericardium.
Associated procedures were performed in 24 patients (38%) and were
mostly related to concomitant aortic valve endocarditis (seven
homografts, four AV repair, four Ross, four bioprosthesis and one
Bentall). Nine patients, for whom infection had spread deeply through
perivalvular tissues, bovine pericardium was used to reconstruct the
cardiac cavities and fibrous skeleton of the heart. Eight patients had
TV repair and four had CABG. The mean aortic cross-clamp and
cardio-pulmonary bypass times were 130 ± 42 and 100 ± 34 min, respectively.
2.5 Follow-up data
Mean follow-up period was 59 ± 37 months (ranging between 9 and 156
months). Survival status was obtained by telephone contact with the
patients, their relatives or the referring physician, and from review of
visit or hospital records. Cause of death was categorized between
cardiac or non-cardiac. Cardiac death was defined as related to
congestive heart failure, myocardial infarction, cardiac arrest or
sudden death.
2.6 Statistical analysis
Data are reported as mean ± standard deviation. Survival curves were
computed with the Kaplan–Meier method (Prism 2.0, GraphPad Software
Inc., CA, USA). A log-rank test was used to compare curves. Twenty-four
variables, listed in the Appendix A, were tested in uni- and
multivariate analysis for calculating endpoints, operative mortality and
MV reoperation. In bivariate analyses, the association of continuous
independent variables with each outcome variable was tested with
Student's t-test for independent samples. The association of binary
independent variables with outcome variables was tested with
Cochran–Mantel–Haenszel statistics. Multiple logistic regression
modelling was then performed. Statistical as well as clinical criteria
were used in the model: first, variables significant at the p < 0.1 were
entered and second, clinically meaningful variables were added. A
stepwise strategy was used. Results were considered statistically
significant at the p ? 0.05 level. All p-values are two-tailed. The SAS
software (release 9.1) was used in the statistical analysis (SAS
Institute Inc., Cary, NC, USA).
3. Results
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
3.1 Early postoperative outcomes
Immediate postoperative transoesophagial echocardiography indicated no
residual MR in 48 patients (76.2%) and MR grade 1 in 13 patients
(21.6%). In only two patients (3.2%), a residual MR of grade 2 was
accepted because of advanced age. No MV stenosis was observed at this time.
Eleven patients (17.4%) died either during their hospital stay or within
30 days from their operation. The causes of death were congestive heart
failure (2), sepsis (2), multiple organ failure (2), perioperative
stroke (2), sudden death (2) and respiratory failure (1). In univariate
analysis, criteria such as female gender (p = 0.008), older than 70
years (p = 0.0015), history of valve disease (p = 0.07), diabetes
mellitus (p = 0.008), renal dysfunction (plasma creatinine >2 mg/dl, p =
0.005) and severe symptomatic heart failure (NYHA class ? III and
cardiogenic shock, p = 0.0001) were predictive for early death. In
multivariate analysis, only criteria such as severe symptomatic heart
failure (NYHA class ? III and cardiogenic shock) (p = 0.009), older than
70 years (p = 0.02), history of valve disease (p = 0.045) and female
gender (p = 0.049) were independent risk factors. Considering severity
of congestive heart failure, operative mortality was 4.8% (2 out of 42
patients) in patients with preoperative NYHA class I or II, 30% (4 out
of 12 patients) in class III and IV and 55% (5 out of 9 patients) in
patients with congestive heart failure.
Twenty patients (31.7%) had postoperative complications. Three patients
(4.7%) needed an early MV reoperation during the first postoperative
week. The cause of failure of the repair was identified as suture
dehiscence in three of them. One had dehiscence of a posterior
quadrangular resection, another of a pericardial patch and the last one
of a papillary muscle of a tricuspid autograft. The last two patients
died, one from mediastinitis that was present at reoperation and the
second from multiple organ failure. Other significant complications
included reoperation for bleeding or tamponnade (seven cases), prolonged
artificial ventilation (four cases), permanent pacemaker implantation
(two cases), mediastinitis (one case), myocardial infaction (one case)
and stroke (one case).
3.2 Long-term outcomes
Five patients died during follow-up: two from sudden cardiac death and
three from cancer. At 5 and 10 years, overall survival was 73 ± 12% and
69 ± 13%, respectively, and freedom from cardiac death in hospital
survivors showed to be 93 ± 8%. (Fig. 2a and b).
Figure 2
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Fig. 2. (a) Kaplan–Meier overall actuarial survival; (b) Kaplan–Meier
actuarial survival showing freedom from late cardiac death in hospital
survivors; (c) Kaplan–Meier curve for freedom from MV reoperation in the
all population and in the subgroups of patients having MV repair with or
without patch; (d) Kaplan–Meier curve for cardiac-related event-free
survival.
Five patients (8%) needed MV reoperation during the follow-up. One
patient, in chronic haemodialysis, needed MV replacement following an
endocarditis recurrence 3 months after MV repair. The four other
patients had recurrence of MV regurgitation, which was successfully
re-repaired at 22, 55, 71 and 103 months, respectively.
One patient required aortic valve replacement and coronary artery bypass
graft surgery after 3 months. All patients with late reoperations had an
uneventful postoperative course. At 5 and 10 years, freedom from MV
reoperation was 89 ± 10% and 72 ± 24%, respectively (Fig. 2c). At 10
years, freedom from MV replacement and endocarditis recurrence were 95 ±
5% and 98 ± 1%, respectively. In univariate analysis, renal failure
(need for haemodialysis, p = 0.03), calcified or rheumatic MV disease (p
= 0.012) and MV annular abscess (p = 0.003) were significantly
associated with MV reoperation. Only calcified or rheumatic MV disease
(p = 0.02) and MV annular abscess (p = 0.01) were identified as
independent risk factors in multivariate analyses. The patients having
MV repairs using patches had a slightly higher (8% vs 13%), but not
significant (p = 0.7), reoperation rate compared to the patients having
repair without a patch.
During follow-up, one thromboembolic event (TIA) and one anticoagulation
related bleeding occurred. Cardiac event-free survival – defined as
survival without endocarditis recurrence, cardiac related death, cardiac
reoperations, bleeding or thromboembolic events – was 81 ± 13% and 66 ±
23% at 5 and 10 years, respectively (Fig. 2d).
At follow-up, among the 47 patients, 33 (74%) were in NYHA class I and
14 (26%) were in class II. Among the 46 patients free from MV
replacement, transthoracic echocardiograpy showed no or residual MR
grade 1 in 41 patients (89%) and residual MR grade 2 in the remaining 5
patients (11%). One patient, who died from cancer, had a pericardial
patch perforation (at basis of anterior leaflet) with moderate
regurgitation.
4. Discussion
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
In a multicentric study conducted in North America, Gammie et al. [14]
recently reported a 20% and 48% feasibility rate of MV repair in active
and healed endocarditis, respectively, with a progressive increase of
both rates during the last decade. However, we showed that using a wide
armamentarium of repair techniques, including a liberal use of
biological patches (in 50% of the patients), we could realistically
achieve a 78% feasibility rate. Similar rates have been reported by
other groups implementing the same or slightly different techniques for
repair [1,3,11,12]. Depending on the size and location of the lesions,
we relied on a large variety of patch materials, such as autologous or
bovine pericardium, tricuspid autographs, transposed posterior leaflets,
and mitral homografts, as leaflet substitutes. The reliability of each
of these techniques has been previously demonstrated [18–21]. In our
experience, the use of a patch to restore leaflet defect was not
predictive for MV reoperation, and only the presence of paravalvular
abscesses and calcified or rheumatic MV disease was considered
significant risk factors for MV reoperation.
In 1990, Dreyfus et al. [1], who were the first to demonstrate the
feasibility of MV repair in active endocarditis, introduced the concept
of early surgery to prevent further destruction of the valve. We firmly
believe in that concept and we observe that, during the early course of
the disease, margins of infectious lesions are clearer than later on.
This situation facilitates the resection of the diseased area,
preserving healthy tissues in order to increase the possibilities of
valve repair. In this series, in which 40% of the patients were operated
within the first week after diagnosis, the short preoperative antibiotic
therapy (<1 week vs >1 week) was shown to have no significant impact on
either operative mortality (p = 0.8), endocarditis recurrence (p = 1) or
MV reoperations (p = 0.1), as has been previously observed by Jault et
al. [17] and Balasubramanian et al. [22]. However, at the current stage
of our research, we are unable to evaluate any specific decrease in the
rate of occurrence of postoperative complications which could be related
to early surgery.
The 17.4% operative mortality rate reported in this study can be
considered as high when compared to the average rate of 10% recently
reported in a multicentric study by Gammie et al. [14]. However, our
reported mortality rate remains within the common range of 3–21%
published in other unicentric studies [1–4,6–12]. The degree of
preoperative heart failure has been shown to be an important factor
influencing operative mortality for degenerative MV disease. The low
operative mortality rate of 4.8% in the subgroup of NYHA class I or II
patients is indicative of the advantage to operate on patients with
severe regurgitation before they develop severe symptomatic heart failure.
When compared to studies which primarily include remplacement in native
MV endocarditis, our overall survival rates (of 73% at 5 years and 69%
at 10 years) and survival rates in hospital survivors (of 88% at 5 years
and 84% at 10 years) are comparable to those reported by Alexiou [23]
(79% and 61%) and Aranki [15] (87% and 74%), respectively. However, the
low incidence of late cardiac death in our series (93% freedom from
cardiac deaths at 10 years) can support the benefits of MV repair that
appear during the long-term follow-up. Excellent late survival rates
after MV repair for active or healed endocarditis have also been
reported by Lung [12] (93% at 7 years) and Zedgi [24] (80% at 10 years).
Such results reflect the advantages of the preservation of the left
ventricular function associated with MV repair.
We reported in our series 89% 5-year freedom from reoperation. In
literature, such rate varies between 84% and 100% for MV repair
[1,2,7,10,12] and between 76% and 94% for replacement [15,16,23]. At 10
years, this rate is reduced to 72%, which is lower [23] or equivalent
[16,25] to the rates reported in patients with mechanical valve
replacements in endocarditis. However, our 10-year freedom from
reoperation remains higher than the reoperation rate obtained in
patients with biological valve replacement [15,25]. Zedgi [24] also
confirmed the excellent long term durability rate (91% at 10 years) of
MV repair in acute endocarditis, which supports our results.
Our low rates of re-infection and thrombo-embolic events demonstrate the
resistance and safety of MV repair. Prosthetic ring annuloplasty was
never associated with high re-infection rates (even in active
endocarditis); therefore, we advise its use when the annulus is dilated
and to stabilize complex repairs. In addition, a pericardial band may be
used as an alternative in the situation of severe contamination of the
operative field by pus. Finally, our findings support the use of
artificial chordae in PTFE Goretex as a safe technique that does not
increase the risk of infection recurrence.
4.1 Study limitations
Our study does not include details of patients having MV replacement in
order to focus on the techniques and results of MV repair in acute
endocarditis. Moreover, the number of patients having replacements was
small when compared to the number of those receiving MV repair (18 vs 63
patients), and these patients were significantly older with higher
severity of illness compared to those having MV repair. Those
differences could explain the advantage of MV repairs when compared to
MV replacements: (i) 17.4% versus 44% operative mortality and (ii) 73 ±
12% versus 38 ± 23% 5-year overall survival. We are aware that the lack
of comparable groups limits the conclusions of our data. However, our
reconstructive approach has enabled us to show the results of complex MV
repair in situations of severe endocarditis lesions.
Further studies incorporating a larger number of patients and extended
follow-up period are necessary to assess the advantage of MV repair over
replacement. With additional studies, we could more accurately define
the best timing as well as the technical limits of MV repair in this
challenging aetiology. The widespread use of reconstructive mitral
surgery should provide in the future materials for large multicentric
studies.
5. Conclusions
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
Diverse repair techniques are needed to overcome the heterogeneities of
endocarditis lesions. We demonstrated that combining early surgery and
diversity in repair techniques resulted in a reparability rate of 80%.
Even in situations of complex repairs, excellent long-term outcomes of
MV repair were observed. However, we also demonstrated that the risk of
reoperation remains higher in patients with calcified or rheumatic
disease. We suggest that patients with active endocarditis and severe MV
regurgitation could benefit from early surgery to avoid development of
symptomatic heart failure. Finally, we found that the completion of
short preoperative antibiotics therapy after surgery does not affect the
postoperative survival or endocarditis recurrence rates.
Appendix A
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
Conference discussion
Dr H. Siniawski (Berlin, Germany): I have two questions.
First of all you reported that 33% of patients received double valve
surgery, if I understood, concomitant mitral valve surgery was required
to aortic replacement in these 33% of patients. My question is, was it
secondary infected mitral valve disease to primary aortic endocarditis
or whether there were the cases of parallel infected double valves?
The second question deals with indication for surgery in your
institution. What is your policy, especially according to mitral
regurgitation? Do you operate with a grade 1, 2 or 3? And is an
assessment of regurgitation important in the cases when two valves are
involved in a destructive form of endocarditis?
Dr de Kerchove: To answer your first question: yes, some reoperated
patients already had aortic valve endocarditis before but no mitral
valve endocarditis. So for all patients that was the first episode of
mitral valve endocarditis.
And to your second question: yes, for sure the mitral regurgitation is
very important for us. In patients who present indication of surgery
like a septic emboli or an abscess or refractory sepsis, even if the
patient has mitral regurgitation grade 1 or 2, we indicate surgery to
resect the vegetation which provoked the embolism, or to resect the
abscess, and in the case of refractory sepsis to take out infected
tissues. But in patients who do not present those symptoms and without
any other symptoms, we indicate surgery in presence of a mitral
regurgitation grade 3.
Dr C. Mestres (Barcelona, Spain): I have a couple of questions. Number
one, you have not shown data on cultures of the valves. I presume that
you did culture of the tissue that you removed from the mitral valve,
correct?
Dr de Kerchove: Yes.
Dr Mestres: So the question is, do you think that if cultures were
positive, should this be related to the very early problems that you had
in some valves, number one? And number two, in these cases that you
reoperated on because of late endocarditis, was this endocarditis a
relapse or a recurrence?
Dr de Kerchove: To answer to your first question, I would say that,
surprisingly, even when we operate early, we observe that the valve
tissue is very quickly sterilized. So we have very few positive
intraoperative cultures. Majority of the positive cultures were coming
from preoperative blood cultures. So even after few days of antibiotics
therapy we saw that the valve was almost sterilized and the germ didn’t
grow on the culture.
To your second question, all patients who had endocarditis on the aortic
valve were completely cured from their endocarditis, because it was a
long delay between the two operations, and I would say all the
mechanical biological valves were newly infected.
Dr Mestres: Thank you, because at least in our experience, the culture
positive rate of explanted second inserted valves continues to be quite
high, especially in the first 2 weeks of antibiotic therapy.
Dr N. Shikhverdiev (St. Peterburg, Russian Federation): Did you have any
neurological complications before the operation? If yes, what was the
surgical strategy? Did you have embolic complications into the brain
before the operation?
Dr de Kerchove: Yes, for sure.
Dr Shikhverdiev: You operated on 22 patients with embolic complications.
I am interested – did you have embolic complications into the brain and
what was the surgical strategy?
Dr de Kerchove: Of course, we had embolic stroke preoperatively, and I
didn’t give the number but it was about 10 patients, and when a patient
has a stroke preoperatively, the guidelines recommend that if the stroke
is very recent and is hemorrhagic, you can operate. So we can go very
fast. It is between 48 or 72 h after the stroke. And if the clinical
situation allowed it, that is obvious. If somebody is in a coma and we
are not sure about the neurological outcome of the patient, we wait. But
if it is a limited stroke, we can go before hemorrhagic complications of
the stroke.
Dr N. Alotti (Zalaegerszeg, Hungary): My main question is, what is your
strategy in timing the operation? We have noticed in one of your data
that about a quarter of your patients were operated late. Second
question. What is your strategy after the operation with anticoagulant
therapy?
Dr. de Kerchove: As you have seen with this approach, when indication is
present, we don’t wait too much and we operate quite early. Doing so,
80% of the patients with active mitral valve endocarditis are operated
during the course of the first hospitalization.
And for the second question about anticoagulant therapy, for a patient
with prosthetic mitral ring annuloplasty, all patients have two months
of anticoagulation, with marcoumar, and for the patient who doesn’t have
a prosthetic ring, we give nothing.
Dr O. Alfieri (Milan Italy): This paper is introducing a very important
change in the strategy of the treatment of endocarditis. If I understood
well, even in patients who respond well to antibiotic therapy since the
very beginning, you go ahead, and operate. This is an innovative concept
that you introduce, but this is not acceptable, according to the guidelines.
Dr de Kerchove: In a patient who is responding to antibiotics but with
severe mitral regurgitation and no other complications, the guidelines
recommend to complete antibiotics therapy and to wait until the patient
develops symptoms of heart failure or left ventrical dilatation. We
think that it could be maybe better to operate before the patient
becomes symptomatic because operative mortality is, in the present
study, tightly correlated to the grade the preoperative NYHA functional
class. So, the ’good responders’ with mitral regurgitation grade >2 will
be operated during the same hospitalization.
Dr T. Folliguet (Paris, France): I have a technical question. When you
have free edge defect on the anterior valve, I think it is very
difficult to fix, and you mentioned three techniques, pericardial patch,
flip-over and tricuspid transplantation. We found that sometimes when
you do a pericardial patch, we have non good coaptation of the free
edge, and I have seen you reoperate on three of the different
techniques. But in your experience, what would be the best technique to
correct someone with a large defect on the free edge, which in our hands
is one of the most difficult problems we have?
Dr de Kerchove: To answer to your interesting question, I would prefer
to give the words to Professor El Khoury, who is the principal
investigator and surgeon in this study.
Dr M. Mahgoub (Zagazig, Egypt): Will you use any local disinfectant like
glutaraldehyde or something if there is an abscess or a localized
infection in the valve? And the second question is, the pericardium that
you use, do you use fresh pericardium or fixed pericardium?
Dr de Kerchove: We usually use diluted Betadine to disinfect the
operative field. We also impregnate prosthetic rings with ryfamicine
solution before we implant it.
And about the pericardial patches, autologous pericardial patches are
mostly treated.
Dr El Khoury (Bruxelles, Belgium): One answer to Dr Alfieri first about
our studies in patients who had severe mitral regurgitation and do we
have to go for surgery or not? We are now more and more taking the same
approach as in degenerative disease. In agreement with our cardiologist,
if the severity of the mitral regurgitation has to be surgically
treated, we go for surgery, we don’t wait. I mean, we are not changing
the indications, but when the indication is there for hemodynamics or
for something else, we go for surgery. I repeat, we don’t change the
indications; only the timing of surgery is shorter.
Now, concerning the second question about if you have a large
destruction of the free margin, I think the best way to do it, I mean if
it is only out on the free margin, not on the tissue, one is the
flip-over technique, which is really very, very consistent and very
durable, and the other technique is the implantation of Gore-Tex. Don’t
be afraid to use it in case of endocarditis because you already remove
largely the infected tissues and the antibiotics continued during
postoperative period will take care of what we leave as microbes behind us.
Dr J. Pomar (Barcelona, Spain): One question is, and a short answer, how
do you repair the tricuspid when you remove the posterior leaflet? Do
you just make a bicuspid valve or you repair it and have another
extension patch there or do you do something else?
Dr de Kerchove: It can be repaired using plication. Professor El Khoury
what would you answer to this question?
Dr Pomar: Did you hear the question, Gebrine? How do you repair the
tricuspid when you remove the posterior leaflet to be used as a graft on
the other side?
Dr El Khoury: We have two situations. When we have enough tissue on the
tricuspid valve left, I like to do a sliding plasty, slide the anterior
towards the septal. Now, if we don’t have enough tissue, I put a small
piece of pericardial patch with Gore-Tex suspension of the free margin.
Dr Pomar: My short comment was the last conclusion. Officially you
should not say that unless you have a control group. You cannot say you
do not impair that.
Appendix B
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
(List of variables tested in uni- and multivariate analysis)
Age >70 years, gender, history of valve disease, previous heart surgery,
multiple valves endocarditis, diabetes mellitus, impaired renal function
(plasma creatinine >2 mg/dl), the need for haemodialysis, septic emboli,
severe congestive heart failure (NYHA ?3 including cardiogenic shock),
persistent sepsis, MR grade ?3, Staphycoccus aureus endocarditis, <1
week of preoperative antibiotics therapy, rheumatic or calcified
underlying MV disease, repair of anterior MV leaflet, presence of MV
abscess, MV repair using patch, deep infection spreading, absence of
annuloplasty, associated procedure, Aortic cross clamp time>120,
postoperative residual MR grade 2, early MV reoperation.
Footnotes
\#9734; Presented at the joint 20th Annual Meeting of the European
Association for Cardio-thoracic Surgery and the 14th Annual Meeting of
the European Society of Thoracic Surgeons, Stockholm, Sweden, September
10–13, 2006.
References
Top
Abstract
1. Introduction
2. Material and methods
3. Results
4. Discussion
5. Conclusions
Appendix A
Appendix B
References
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erdinç naseri wrote:
> Hal,
> can you please elaborate on the choice of the repair versus replacement regarding the follwing parameters:1.Location of the vegetation:annular versus leaflet
> 2.Extense of the involvement:how many scallops,single leaflet versus bileaflet
> 3.Etiologic microrganism
> 4.Size of the vegetation
> 5.Peripheral embolization of the septic material
> 6.whatever else you consider in th e choice of surgical treatment.
> erdinc
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