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Ann Thorac Surg 1998;65:1087-1092
© 1998 The Society of Thoracic Surgeons

Conservative Operation for Infective Endocarditis of the Mitral Valve

^a Regional Cardiac Unit, Papworth Hospital, Cambridge, United Kingdom

Accepted for publication November 27, 1997.

Address reprint requests to Dr Lee, c/o Dr Shapiro, Regional Cardiac Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, United Kingdom
e-mail: (lmshapiro{at}fendon.win-uk.net)

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Subvalvular preservation is necessary to maintain left ventricular function, but accidental retention of infected tissue could cause postoperative endocarditis.

Methods. We examined 71 consecutive patients who underwent operation for mitral endocarditis. Endocarditis was uncontrolled and active in 24 patients, partially treated (unfinished antibiotic course) in 17, and healed in 30.

Results. Valves were repaired in 17% versus 59% versus 63% and replaced with subvalvular preservation in 25% versus 6% versus 3% of the uncontrolled active, partially treated, and healed groups, respectively. Thirty-day mortality was 29% versus 0% versus 3.3% (p = 0.003), total mortality was 46% versus 18% versus 17% (p = 0.035), and complications-related mortality was 38% versus 11% versus 13% (p = 0.054), respectively. There was a trend toward lower complications-related mortality with subvalvular preservation than without. Postoperative endocarditis occurred in 3 of 30 patients without and 1 of 41 patients with subvalvular preservation.

Conclusions. Postoperative mortality in uncontrolled active mitral endocarditis remains high, but results are good with partially treated or healed endocarditis. Subvalvular preservation improves outcome, does not increase postoperative endocarditis rates, and should be performed whenever feasible.

	Introduction

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Mitral valve repair is the operation of choice for severe mitral regurgitation [1–3], as outcome is superior to that of valve replacement. The cause of mitral regurgitation significantly affects valve pathology and left ventricular function, and consequently also affects the complexity and outcome of mitral valve repair [4, 5]. Results are best with degenerative mitral regurgitation [6], less good in rheumatic disease [7], and worst in ischemic heart disease [8]. Although patients with infective endocarditis have been included in many studies of mitral valve repair, few studies have specifically assessed this group.

There are conflicting concerns in conservative operations for mitral valve endocarditis. Preservation of the subvalvular apparatus is necessary to maintain left ventricular function [3, 9]. However, accidental retention of infected valve tissue could lead to postoperative endocarditis, particularly if prostheses (annuloplasty ring in valve repair or prosthetic valve in mitral valve replacement [MVR] with subvalvular preservation [SVP]) are used. We therefore performed a retrospective study of postoperative outcome in 71 consecutive patients who underwent mitral valve operations for infective endocarditis.

	Material and methods

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Patients
The study population comprised 71 consecutive patients who underwent mitral valve operations for infective endocarditis at our institution between 1987 and 1994. Twenty-four (uncontrolled active group) underwent operation while endocarditis was still uncontrolled and active with continued fever, septicemia, or septic emboli. Indications for operation were lack of response to antibiotics, severe heart failure requiring an emergency operation, or both. Seventeen patients (partially treated group) were no longer febrile or septicemic but required an operation for deteriorating mitral regurgitation or heart failure before completion of a 6-week course of antibiotics. Thirty (healed group) had healed endocarditis but severe mitral regurgitation. The mean age in the uncontrolled active, partially treated, and healed groups was 57.7 ± 15.5, 64.9 ± 8.6, and 62.4 ± 10.8 years, respectively. The mean follow-up was 20.0 ± 23.1, 39.9 ± 21.1, and 31.8 ± 23.8 months, respectively. One patient left the country and was lost to follow-up 2 months after the operation. One could not be contacted after discharge but had not been reported to the national registry of deaths at 10 months postoperatively. Baseline group characteristics and the organisms responsible for endocarditis are shown in Tables 1 and 2, respectively.

Statistical analysis
Results were analyzed using the Statistical Package for Social Sciences, version 6.0. Patient numbers were compared by the ² test. Survival was calculated by life-table analysis and compared by the Wilcoxon (Gehan) statistic. Death caused by myocardial failure was included in complications-related mortality.

	Results

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Mortality and functional outcome
Thirty-day mortality was 29.2% versus 0.0% versus 3.3% (7/24 versus 0/17 versus 1/30 patients; p = 0.003), total mortality was 45.8% versus 17.6% versus 16.7% (11/24 versus 3/17 versus 5/30 patients; p = 0.035), and complication-related mortality was 37.5% versus 11.0% versus 13.3% (9/24 versus 2/17 versus 4/30 patients; p = 0.054) in the uncontrolled active, partially treated, and healed groups, respectively. Actuarial survival at 6.5 years was, respectively, 52.7% ± 10.4% versus 78.1% ± 11.7% (p = 0.010) versus 67.5% ± 13.7% (p = 0.002) for death of all causes and 61.2% ± 10.2% versus 87.8% ± 8.1% (p = 0.022) versus 71.5% ± 13.9% (p = 0.005) for complications-related death (p values are given for comparison with the uncontrolled active group). Complications-related mortality was lower with subvalvular preservation than without, at 30.0% versus 50.0% (not significant [NS]), 9.1% versus 16.7% (NS), and 5.0% versus 30.0% (p = 0.058) in the uncontrolled active, partially treated, and healed groups, respectively. Causes of death are summarized in Table 4. Survival curves are shown in Figure 1. Of 52 surviving patients, 48 (92.3%) are in New York Heart Association class I or II.

View larger version (39K): [in this window] [in a new window]   Fig 1. Survival curves in the groups with uncontrolled active, partially treated, and healed endocarditis.

Fifteen patients suffered systemic emboli, including 4 of 33 patients who underwent repair, 2 of 9 patients with bioprosthetic MVR, and 9 of 29 patients with mechanical MVR. Four patients were in the uncontrolled active group, 3 in the partially treated group, and 8 in the healed group. Six patients died, 2 of perioperative bowel infarction, 1 of diffuse cerebral air emboli after reoperation for paraprosthetic mitral regurgitation, 2 of major strokes 6 months or more after operation, and 1 of bronchopneumonia after he fell during a transient ischemic attack and fractured his hip. Two patients had moderately disabling strokes, 2 had mild strokes, and 5 had transient ischemic attacks without long-term sequelae.

Anticoagulation-related hemorrhage occurred in 5 patients and caused 2 deaths, both in the uncontrolled active group. One patient remained in multiorgan failure after valve repair for acute Staphylococcus aureus endocarditis with subsequent loss of anticoagulant control, hemopericardium, and fatal cardiac tamponade. The second underwent St. Jude MVR with SVP and died of cerebral hemorrhage 1 month after the operation. Two patients bled from active duodenal ulcers perioperatively and 1 from a malignant gastric ulcer 44 months postoperatively.

Determinants of outcome
Uncontrolled active endocarditis, particularly acute Staphylococcus aureus endocarditis, remains strongly associated with poor outcome as operation is performed in severely ill, septicemic patients. Thirty-day mortality in the uncontrolled active group was 29.2% overall, 42.9% in the Staphylococcus aureus endocarditis subgroup, and 23.5% in the subgroup with other infecting organisms. Of 7 patients with acute Staphylococcus aureus endocarditis, 3 died in the hospital, 1 died of subdural hematoma 4 months later, 1 remained in renal failure requiring dialysis and died of stroke 6 months later, and 1 suffered a mildly disabling stroke and required reoperation for paraprosthetic leak 3 months later. The seventh patient could not be contacted after discharge but was thought to be alive 10 months later. The importance of continued septicemia and poor preoperative patient condition is clear, even if subgroup analysis is performed in patients with less virulent organisms than Staphylococcus aureus. In-hospital mortality in these patients was 23.5% (4/17) in the uncontrolled active group versus 0% (0/17) in the partially treated group versus 3.3% (1/30) in the healed group (p = 0.017). Patient numbers were too small to assess the impact of other variables by Cox regression analysis.

Determinants of conservative operation
It is not appropriate to comment on the feasibility of conservative operations using the entire study population owing to the differences in experience of conservative operations between surgeons. In the hands of our one surgeon who specializes in conservative mitral valve surgery, the feasibility of such operation and the techniques used were determined by the type and extent of underlying valve disease (eg, rheumatic valvular and subvalvular fibrosis, myxomatous leaflet degeneration, chordal elongation and thinning, calcification), extent of infection and valve destruction, and the involvement of annulus and subvalvular structures by disease. Regardless of infecting organism, patients in the uncontrolled active group had more advanced infection and extensive valve destruction, because of either the virulence of S aureus or late presentation with less virulent organisms. Conservative operation was attempted whenever possible by our specialized surgeon, who performed the operation in 62.5% (15/24) of the uncontrolled active group, 58.8% (10/17) of the partially treated group, and 73.3% (22/30) of the healed group. In these patients, conservative operation was found to be feasible but more difficult in the uncontrolled active group than the other two groups (53.3% versus 87.5%, respectively; NS), and more frequently required MVR with SVP rather than valve repair (26.6% versus 84.4% underwent repair, respectively; p = 0.0001). Conservative operation was performed in 40% (2/5, both repairs) of patients with S aureus versus 60% (6/10, two repairs, four MVR with SVP; NS) of patients with other organisms in the uncontrolled active group, 100% (10/10, all repairs) of the partially treated group, and 82% (18/22, 17 repairs, one MVR with SVP) of the healed group.

	Comment

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Few series of mitral valve repair for infective endocarditis have been reported, but all have shown good outcomes, supporting the view that mitral valve repair is both feasible and desirable in these patients. Dreyfus and associates [12] reported a series of 40 patients with mean follow-up of 30 months who had mitral valve repair for ongoing endocarditis. In-hospital mortality was only 2.5%, as was late mortality. The reoperation rate was 2.5%, and there were no instances of recurrent endocarditis. Hendren and colleagues [13] reported a series of 22 patients with mean follow-up of 24 months. Six had ongoing endocarditis and 16 had healed endocarditis. Perioperative mortality was higher at 9% but there were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related mortality. Pagani and coworkers [14] reported a series of 22 patients with mean follow-up of 20 months, 7 of whom had ongoing endocarditis and 15 of whom had healed endocarditis. They had no cases of recurrent endocarditis, no operative deaths, and only one late death. Studies of MVR have shown a high rate of prosthetic valve endocarditis of 9% to 15% [15, 16] and a perioperative mortality of 6% to 26% [15–19] in MVR for ongoing endocarditis.

These studies have not differentiated between operation for uncontrolled active endocarditis and partially treated infection. This distinction is important. Postoperative mortality after emergency operation for uncontrolled active endocarditis remains very high because of poor preoperative patient condition, particularly in patients with S aureus infection. There were 7 in-hospital deaths (29.2%) in this group, including 3 of 7 patients (42.9%) with acute S aureus endocarditis and 4 of 17 patients (23.5%) with other infecting organisms. However, results are good with partially treated or healed endocarditis. Thirty-day mortality was 29% versus 0% versus 3.3% (p = 0.003), total mortality was 46% versus 18% versus 17% (p = 0.035), and complication-related mortality was 38% versus 11% versus 13% (p = 0.054) in the uncontrolled active, partially treated, and healed groups, respectively. Patients requiring operation while infection is still uncontrolled also have more advanced and extensive infection and valve destruction, making a conservative operation, especially repair, more difficult and less feasible. In the subgroup of patients under the care of our one surgeon who specializes in conservative surgery, only 27% of the uncontrolled active group underwent successful repair compared with 100% of the partially treated group and 82% of the healed group. This difference in type of operation will also influence outcome.

Although it is considered preferable to avoid the use of any prosthetic material in the presence of ongoing infection, insertion of a prosthetic ring is frequently necessary to achieve a satisfactory repair, as was the case in 47.5%, 68.0%, and 90.1% of patients in the studies by Dreyfus and associates [12], Hendren and colleagues [13], and Pagani and coworkers [14], respectively, and in 81.8% of our patients with repair. The incidence of residual or recurrent endocarditis in our study was low and similar to that of MVR without SVP despite the use of prosthetic rings in valve repair and MVR prostheses in replacement with SVP. Our study confirms the safety of SVP in conjunction with the use of prosthetic inserts.

Repaired valves are less thrombogenic than mechanical valve replacements. Unlike bioprostheses, they have excellent long-term durability [20]. We have previously demonstrated that the risk of thromboembolism is significantly lower with repair than with mechanical MVR [3]. This study suggests that the same is true in the subgroup of patients undergoing operation for endocarditis. There was a trend toward fewer thromboembolic events with repair (4/33 patients, 12.1%) compared with mechanical MVR (9/29 patients, 31.0%), which approached (p = 0.067) but did not reach statistical significance, probably because of small patient numbers.

There was also a trend toward lower complications-related mortality with SVP than without, at 30% versus 50% (NS), 9% versus 17% (NS), and 5% versus 30%, (p = 0.058) in the uncontrolled active, partially treated, and healed groups, respectively. This is consistent with previous studies, which have demonstrated the importance of SVP for maintenance of left ventricular function [9] and its association with improved outcome [1–3]. Patient numbers in this study were too small for meaningful comparison between repair and MVR with SVP, or multivariate analysis of potential risk factors.

Beyond the first 10 months of follow-up, there were no complications-related deaths in the uncontrolled active group, 2 in the partially treated group, and 2 in the healed group. This apparent late difference with continued attrition associated with the latter two groups may be spurious. It is not statistically significant because of diminishing numbers of patients and the low event rate in late follow-up. In addition, these deaths were necessarily classified as complications-related although they may have been unrelated or inevitable. One was caused by a stroke in a patient with mechanical MVR without SVP but occurred within a month of serious bleeding from a malignant gastric ulcer and consequent problems with anticoagulation. One was caused by bronchopneumonia after hip fracture following a transient ischemic attack. This patient may not have died were it not for his frailty at age 79 years. He also had other risk factors for cerebrovascular disease in the form of atrial fibrillation and atherosclerosis with proven coronary artery disease. Two patients died of myocardial failure, both of whom had poor left ventricular function perioperatively, which failed to recover. There were also more patients with significantly impaired left ventricular function at baseline in the partially treated and healed groups, an important risk factor for late postoperative death caused by myocardial failure even if the subvalvular apparatus is preserved [3].

Conservation of macroscopically uninfected mitral valve tissue does not predispose significantly to postoperative endocarditis. Outcome is good with valve repair and MVR with SVP. In view of the importance of SVP in maintenance of left ventricular function, a conservative operation, preferably repair, should be performed whenever feasible for infective endocarditis requiring surgical intervention.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank our cardiac technicians, Mrs Catherine Fuller and Mr Christopher Wisbey, and our secretary, Mrs Julie Stephenson.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

1. Krayenbuehl H.P. Surgery for mitral regurgitation. Repair versus valve replacement. Eur Heart J 1986;7:638-643.[Free Full Text]
2. Yun K.L., Miller D.C. Mitral valve repair versus replacement. Cardiol Clin 1991;9:315-327.[Medline]
3. Lee E.M., Shapiro L.M., Wells F.C. The importance of subvalvular preservation and early operation in mitral valve surgery. Circulation 1996;94:2117-2123.[Abstract/Free Full Text]
4. Galloway A.C., Colvin S.B., Baumann G., et al. Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78(Suppl 1):97-105.
5. Lessana A., Carbone C., Romano M., et al. Mitral valve repair: results and the decision-making process in reconstruction. Report of 275 cases. J Thorac Cardiovasc Surg 1990;99:622-630.[Abstract]
6. David T.E., Armstrong S., Zhao S., Daniel L. Late results of mitral valve repair for mitral regurgitation due to degenerative disease. Ann Thorac Surg 1993;56:7-14.[Abstract/Free Full Text]
7. Duran C.M.G., Gometza B., De Vol E.B. Valve repair in rheumatic mitral disease. Circulation 1991;84(Suppl 3):125-132.
8. Rankin J.S., Feneley M.P., Hickey M.S., et al. A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation. J Thorac Cardiovasc Surg 1988;95:165-177.[Abstract]
9. Okita Y., Miki S., Ueda Y., Tahata T., Sakai T., Matsuyama K. Comparative evaluation of left ventricular performance after mitral valve repair or valve replacement with or without chordal preservation. J Heart Valve Dis 1993;2:159-166.[Medline]
10. Carpentier A. Cardiac valve surgery—the "French correction". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
11. Pons-Llado G., Carreras-Costa F., Ballester-Rodes M., Auge-Sampera J.M., Crexells-Figueras C., Oriol-Palou A. Doppler patterns of left atrial flow in mitral regurgitation. Am J Cardiol 1986;57:806-810.[Medline]
12. Dreyfus G., Serraf A., Jebara V.A., et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990;49:706-713.[Abstract/Free Full Text]
13. Hendren W.G., Morris A.S., Rosenkranz E.R., et al. Mitral valve repair for bacterial endocarditis. J Thorac Cardiovasc Surg 1992;103:124-129.[Abstract]
14. Pagani F.D., Monaghan H.L., Deeb G.M., Bolling S.F. Mitral valve reconstruction for active and healed endocarditis. Circulation 1996;94(Suppl 2):133-138.
15. Larbalestier R.I., Kinchla N.M., Aranki S.F., Couper G.S., Collins J.J., Jr, Cohn L.H. Acute bacterial endocarditis. Optimizing surgical results. Circulation 1992;86(Suppl 2):68-74.
16. Nelson R.J., Harley D.P., French W.J., Bayer A.S. Favorable 10 year experience with valve procedures for active endocarditis. J Thorac Cardiovasc Surg 1984;87:493-502.[Abstract]
17. Verheul H.A., van den Brink R.B., van Vreeland T., Moulijn A.C., Duren D.R., Dunning A.J. Effects of changes in management of active infective endocarditis on outcome in a 25 year period. Am J Cardiol 1993;72:682-687.[Medline]
18. D’Agostino R.S., Miller D.C., Stinson E.B., Mitchell R.S., Oyer P.E. Valve replacement in patients with native valve endocarditis: what really determines operative outcome?. Ann Thorac Surg 1985;40:429-438.[Abstract/Free Full Text]
19. Wilcox B.R., Murray G.F., Starek P.J.K. The long-term outlook for valve replacement in active endocarditis. J Thorac Cardiovasc Surg 1984;87:493-502.
20. Deloche A., Jebara V.A., Relland J.Y., et al. Valve repair with Carpentier techniques. The second decade. J Thorac Cardiovasc Surg 1990;99:990-1002.[Abstract]

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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): Evelyn M. Lee Leonard M. Shapiro Francis C. Wells Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, E. M. Articles by Wells, F. C. Search for Related Content PubMed PubMed Citation Articles by Lee, E. M. Articles by Wells, F. C.