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Original Articles: Adult Cardiac

Mitral Valve Infective Endocarditis: Benefit of Early Operation and Aggressive Use of Repair

^a Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland
^c Emergency Department, University of Maryland Medical Center, Baltimore, Maryland
^e Division of Epidemiology, University of Maryland Medical Center, Baltimore, Maryland
^f Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland
^b Division of Infectious Diseases, The Oregon Health & Science University, Portland, Oregon
^d Division of Cardiac Surgery, The Oregon Health & Science University, Portland, Oregon

Accepted for publication February 3, 2009.

^_* Address correspondence to Dr Gammie, Division of Cardiac Surgery, University of Maryland Medical Center, N4W94, 22 S Greene St, Baltimore, MD 21201 (Email: jgammie{at}smail.umaryland.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.

Background: In-hospital mortality rates for left-sided infective endocarditis (IE) exceed 20%. We investigated the outcomes of an aggressive approach to mitral valve IE that emphasizes early surgical intervention and preferential performance of mitral valve repair.

Methods: We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression.

Results: Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89).

Conclusions: These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.