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Ann Thorac Surg 1996;62:48-53
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Long-Term Results of Operation for Paravalvular Abscess

Division of Cardiovascular Surgery, University of Toronto, The Toronto Hospital, Toronto, Ontario, Canada

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Operation for infective endocarditis with paravalvular abscess is reportedly associated with high mortality and morbidity rates. In an attempt to improve surgical outcome, an approach of radical resection of the abscess and inflamed tissues and reconstruction of the heart with either fresh or glutaraldehyde-fixed bovine pericardium was adopted by two surgeons at our institution.

Methods. From 1979 to 1995, 70 consecutive patients with active infective endocarditis and paravalvular abscess underwent operation. Their mean age was 49 years (range, 16 to 75 years), and 50 patients (71%) were men. Thirty-four patients had native and 36 had prosthetic valve endocarditis (8 had had composite replacement of the aortic valve and ascending aorta). Most patients (78%) were in New York Heart Association functional class IV. The principal indication for operation was cardiogenic or septic shock in 11 patients, or one or more of the following: persistent sepsis despite adequate antibiotic therapy in 36, congestive heart failure in 31, and recurrent emboli in 16. Staphylococci were responsible for the infection in 37 patients (53%). The abscess was in the mitral annulus in 11 patients, in the aortic root in 44, and in the aortic root and at least one other annulus in 15. After wide resection of the abscess, we reconstructed the heart and annuli with autologous or bovine pericardium. Mechanical heart valves were implanted in 36 patients, bioprostheses in 30, and aortic homografts in 2; valve repair was possible in 2. Sixteen patients required composite replacement of the ascending aorta and aortic valve.

Results. There were 9 operative deaths (13%). Infections caused by staphylococci and infections in multiple annuli were associated with increased operative mortality rates. Only 1 patient had persistent infection and required reoperation. The mean follow-up was 56 ± 40 months. There were 12 late deaths, mostly cardiac. The actuarial survival including operative deaths was 64% ± 8% at 8 years. In 8 patients, recurrent infective endocarditis developed 10 to 102 months after operation. The freedom from recurrent endocarditis was 76% ± 10% at 8 years.

Conclusions. This experience indicates that radical resection of the abscess and reconstruction of the heart with pericardium yield an excellent chance of eradicating the infection in patients with infective endocarditis and paravalvular abscess. The type of valve implanted may not be as important as radical resection of the abscess. These patients appear to have a greater than average risk of recurrent endocarditis.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 53.

Urgent surgical treatment is recommended for patients with infective endocarditis and paravalvular abscess [1–5]. The results of operation in these patients are often disappointing because of persistent infection, prosthetic valve dehiscence, metastatic infections, multiple organ failure, and death [1,6–10]. This is particularly true when the fibrous skeleton of the heart is extensively destroyed and the reconstructive procedures are complicated and technically demanding. The use of aortic valve homografts has improved the outcome of patients with aortic valve endocarditis with and without aortic root abscess [7,11–13]. However, abscess in the mitral annulus is a complex problem, and the surgical results have been less than satisfactory [8, 9].

This report describes the clinical experience of two cardiac surgeons who have adopted an approach whereby the abscess is radically resected and the fibrous skeleton and other parts of the heart are reconstructed with autologous pericardium or glutaraldehyde-fixed bovine pericardium.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Paravalvular abscess in patients with active infective endocarditis was defined as destruction of the annulus of any heart valve with accumulation of purulent and necrotic material. All of our patients were operated on before completion of a course of appropriate antibiotic therapy.

Seventy consecutive patients with paravalvular abscess were operated on from May 1979 to August 1995. The clinical data on these patients were collected prospectively and are shown in Table 1. A total of 48 heart valve operations had been performed in 36 patients with prosthetic valve endocarditis. Eight of them had had composite replacement of the aortic valve and ascending aorta with a mechanical or bioprosthetic valve. The offending microorganism was isolated from preoperative blood cultures or intraoperative specimens in 66 patients (Table 2). The indication for operation in 11 patients was cardiogenic or septic shock. In the remaining 59 patients, the procedure was performed because of one or more of the following: persistent sepsis despite adequate antibiotic therapy in 36 patients, congestive heart failure in 31, and recurrent emboli in 16 (stroke in 6). Sixty-nine patients had preoperative transthoracic Doppler echocardiography; paravalvular abscess was diagnosed in 19 patients. Thirty-one patients had transesophageal Doppler echocardiography, with the diagnosis of paravalvular abscess made in 22 patients. Preoperative coronary angiography was deemed necessary in 30 patients, and substantial disease was detected in only 5. Table 3 summarizes the locations of the abscesses as described in the operative reports. Eleven patients had mitral annulus abscess, 44 had aortic root abscess, and 15 had aortic root abscess with extension and destruction of at least one other valve annulus.

Patients with isolated mitral annulus abscess were treated by removal of the infected portion of the mitral valve, radical debridement of the abscess in the ventricular wall, and reconstruction of the destroyed annulus with pericardium. When only a small segment of the posterior mitral annulus required reconstruction, a semicircular patch of fresh autologous pericardium was prepared. Its curved side was sutured to the endocardium of the left ventricle with a continuous 3-0 polypropylene suture. In patients with extensive destruction of the mitral annulus, a circumferential reconstruction of the mitral annulus was performed. In these cases, a strip of glutaraldehyde-fixed bovine pericardium 1.0 to 1.5 cm wide was sutured to the endocardium of the left ventricle posteriorly and to the fibrous tissue underneath the aortic valve superiorly. A prosthetic mitral valve was then secured to the mitral annulus and patch or entirely to the patch, depending on the type of annular reconstruction. A detailed description and illustrations of these operative techniques were published recently [14].

Patients with aortic root abscess confined to the aortic annulus in the area of the noncoronary aortic sinus were treated by wide excision, sometimes including the roof of the left atrium, and reconstruction with a properly tailored, glutaraldehyde-fixed bovine pericardial patch [3]. A prosthetic heart valve was secured to this patch and to the aortic annulus.

For patients in whom the aortic root abscess extended into the anterior leaflet of the mitral valve, the roof of the left atrium was opened first for complete assessment and then resection of the abscess. The whole procedure was performed through the aortic root and roof of the left atrium. If less than half of the anterior leaflet of the mitral valve was damaged, it was reconstructed with a pericardial patch before replacing the aortic valve. If more than half of the anterior leaflet of the mitral valve was involved by the abscess, the entire leaflet was removed and both valves had to be replaced. However, before doing so, the fibrous continuity between the aortic and mitral annuli was reestablished with a triangular patch of bovine pericardium [14]. The sides of the patch were sutured to the fibrous trigones and aortic root. The base of the triangular patch served as the anterior portion of the mitral annulus. A prosthetic mitral valve then was secured to the mitral annulus and patch. A separate patch was used to close the roof of the left atrium, and a prosthetic aortic valve endocarditis of the aortic and mitral valves, the mitral annulus contained multiple abscesses, and a circumferential reconstruction of the entire mitral annulus was performed [15].

In patients with interventricular septal abscess, the primary objective was to remove all infected tissues without undue consideration of the conduction pathways. This aggressive approach caused complete heart block in many patients with aortic root abscess extending into the interventricular septum. Reconstruction also was performed with bovine pericardium.

In 3 patients, the aortic root abscess extended into the right side of the heart and resulted in tricuspid annular abscess, pulmonary annular abscess, or both. These patients also were managed by wide excision, reconstruction with bovine pericardium, and valve replacement.

In 8 patients who had endocarditis of a valved conduit, the abscess was located between the prosthetic aortic valve and the aortic annulus. After radical debridement of the abscess, we reconstructed the aortic annulus with a circumferential patch of bovine pericardium and implanted a new valved conduit. In some patients, the coronary arteries had to be extended with a short segment of saphenous vein or a tubular graft of polytetrafluoroethylene. Three of these patients also required mitral valve operations.

Table 4 summarizes the operative procedures performed and the types of valves implanted. In addition to the cardiac procedures, 2 patients required amputation of a leg because of preoperative septic embolization and gangrene, 1 required splenectomy because of a large abscess, and 1 needed a craniotomy for clipping of a mycotic aneurysm.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
There were 9 operative deaths (13%). The causes of deaths were cardiac failure in 3, technical problem in 1, dehiscence of an aortic patch in 1, hepatic failure in 1, gastrointestinal bleeding in 1, and preoperative hemorrhagic stroke in 2. Table 5 shows the operative mortality rates in the various subgroups of patients. Only those patients with infections caused by staphylococci or with infections in multiple annuli had an increased operative mortality rate by univariate and multivariate analyses compared with the rest of the group.

The mean intensive care unit stay was 5.3 ± 5.2 days, and the mean postoperative hospital stay was 28 ± 16 days. All patients received intravenous antibiotics for a total of 6 weeks. No patient received antibiotics permanently.

Patients were followed up for 3 to 183 months, with a mean of 56 ± 40 months. No patient was lost to follow-up. There were 12 late deaths, caused by congestive heart failure in 4, infective endocarditis in 3, anticoagulation-related hemorrhage in 1, sudden death in 1, and noncardiac causes in 3. The actuarial survival rate including operative mortality was 75% ± 6% at 5 years and 64% ± 8% at 8 years (Fig 1).

View larger version (12K): [in this window] [in a new window]   Fig 1. . Actuarial survival after operation.

In 8 patients, recurrent infective endocarditis developed at a mean of 47 months (range, 10 to 102 months) after operation. The microorganisms were the same as in the original infection in 3 patients (Staphylococcus aureus in 2 and Streptococcus viridans in 1) and were different in 5. Seven patients were treated with antibiotics alone because of advanced age or an unacceptably high risk for reoperation; 4 of these patients survived and 3 died. One patient was treated operatively and survived. Figure 2 shows the freedom from recurrent infective endocarditis; it was 89% ± 5% at 5 years and 76% ± 10% at 8 years.

View larger version (12K): [in this window] [in a new window]   Fig 2. . Freedom from recurrent endocarditis.

Of the 49 surviving patients, 45 are in New York Heart Association functional class I or II, and 4 are in class III. Doppler echocardiographic studies performed during the last year of follow-up indicated that no patient had false aneurysms or patch dehiscence, and 2 had hemodynamically insignificant paravalvular leak. In 1 of these 2 patients, the leakage occurred after successful medical treatment of recurrent infective endocarditis.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
There have been several reports on patients with aortic root abscess, but little is known about the long-term results of surgical procedures [2–77]. Even less is known about the late outcomes of operation for mitral annulus abscess [9, 14, 15]. Paravalvular abscess is a common complication of aortic valve endocarditis, but is an uncommon complication of mitral and tricuspid valve endocarditis [1,2,8–10, 16]. Indeed, in our series of 70 patients, the paravalvular abscess was secondary to infective endocarditis of the aortic valve in 59, and of the mitral valve in 11. This is probably one of the reasons why endocarditis of the aortic valve is more likely to require operation than is endocarditis of the mitral valve [8, 10, 16].

Staphylococci were the offending microorganism in more than half of our patients with paravalvular abscess. Other investigators have found the same proportion of staphylococci in their patients [2, 8]. Staphylococcus aureus is an extremely virulent microorganism that is capable of destroying the valve leaflets and rapidly penetrating the paravalvular structures. Antibiotics alone frequently fail to control the infection caused by this microbe in the aortic and mitral valves, and operative intervention is often needed. Paravalvular abscess caused by staphylococci is associated with higher operative mortality and morbidity rates compared with abscesses caused by other microorganisms [8]. In our series, there were eight operative deaths among the 37 patients who had an abscess caused by staphylococci, and only one death among the 33 patients who had an abscess caused by other bacteria. Infection by staphylococci was an independent predictor of poor outcome in our series. This is likely due to their virulence and ability to cause extensive abscesses, and consequently the complexity of the reconstructive procedure required.

Paravalvular abscess is often a fatal complication of infective endocarditis, and operation should be performed soon after diagnosis [1–7]. Transesophageal Doppler echocardiography is a valuable diagnostic tool in these patients. In a report by Daniel and associates [2] on 44 patients with 46 abscesses proven by operation or autopsy, transthoracic echocardiography identified only 13 of the 46 abscesses, whereas transesophageal echocardiography detected 40. The sensitivity and specificity for the detection of abscess associated with infective endocarditis were 87% and 98.9%, respectively [2]. In our series, a much smaller proportion of patients had the diagnosis of abscess made preoperatively by Doppler echocardiography. Of 31 patients who had transesophageal echocardiography, the diagnosis of abscess was made correctly in 22.

An aortic valve homograft has been recommended for patients with aortic root abscess because it appears to be more resistant to both early and late infection compared with prosthetic valves [7, 11–13]. However, persistent infection and false aneurysms can occur even after root replacement with an aortic homograft [17, 18]. In addition, the aortic valve homograft alone may be inadequate to reconstruct extensively destroyed aortic roots. We believe that radical resection of the abscess and all inflamed tissues, followed by reconstruction of the left ventricular outflow tract with glutaraldehyde-fixed bovine pericardium, are the most important components of the operation for paravalvular abscess. Consequently, the type of valve implant is probably of less importance than resection of the abscess and inflamed tissues.

Abscesses in the mitral annulus may pose a complex problem because of the difficulty of securing a prosthetic valve to the surrounding friable tissues. Jault and colleagues [9] described a technique in which the prosthetic mitral valve is secured to the atrial wall by extending its sewing ring with a Dacron collar. They used this approach in 12 patients with mitral annulus abscess and recorded four operative deaths and three reoperations: two for dehiscence and one for persistent infection [9]. We believe that after radical debridement of the abscess, the best treatment for these patients is reconstruction of the mitral annulus with fresh autologous pericardium in areas subtended by myocardium and with glutaraldehyde-fixed bovine pericardium in freestanding areas, such as the space between the fibrous trigones, or when the entire mitral annulus needs reconstruction [14]. We have reconstructed the mitral annulus for a variety of reasons, and the results have been excellent [14]. Patients who have endocarditis of both the mitral and aortic valves and abscess in the fibrous tissue between these valves are among the most difficult to treat, and in our series had the highest mortality and morbidity rates.

Our radical approach to paravalvular abscess was successful in eradicating the infection in all but 1 patient, who needed reoperation for persistent infection. Most patients required complex operative procedures, often associated with substantial morbidity, but the results compare very favorably to those reported by others [2, 4–7, 9]. However, we were disappointed to find a relatively high rate of recurrent infective endocarditis in our patients. Eight of 61 operative survivors experienced recurrent endocarditis 10 to 102 months after the procedure. Because this problem occurred late after operation, we believe that it is likely due to a new microorganism rather than a persistent one, even though in 3 patients the recurrent infection was caused by the same microorganism. We do not have a satisfactory explanation for the latter finding. Other investigators also have found that patients who have had infective endocarditis are at a higher risk of having a second episode than are those patients who never had it [8, 10, 12].

Patients with paravalvular abscess are usually very ill–sometimes moribund–by the time they are referred for operation. In spite of this, the long-term results of operation in our series are very satisfactory, with an actuarial survival rate of 75% ± 6% at 5 years. These results support our conclusion that the treatment of choice for these patients is radical resection of the abscess and anatomic reconstruction of the heart with fresh autologous pericardium in areas subtended by myocardium and with glutaraldehyde-fixed bovine pericardium.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Address reprint requests to Dr David, 200 Elizabeth St, 13EN219, Toronto, Ont, Canada M5G 2C4.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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