Ann Thorac Surg 1996;61:1130
© 1996 The Society of Thoracic Surgeons
Discussion
Discussion
See also page 1125.
DR NORMAN J. SNOW (Cleveland, OH): You have not mentioned the use of transesophageal echocardiography in this disease. In this day, when echocardiographers visualize the pedunculated mass or vegetation on the valve, they are encouraging us to operate right away. And in a very small number of patients, fewer than 6, we have operated within 24 to 48 hours of a stroke, if the patients do not have a hemorrhagic stroke, with basically the same results and with no worsening of neurologic deficit. How do you persuade your medical colleagues to allow you to wait for 22 days to do this operation?
DR GILLINOV: This was a retrospective study, and 22 days was the mean interval between the neurologic event and operation. Seven patients had their operation within 1 week of the neurologic event. The importance of vegetations seen on echocardiography remains controversial in the echocardiography and cardiology literature. It is virtually impossible to predict which vegetations will embolize and lead to stroke. There are data that vegetations on the mitral valve greater than 10 mm in size significantly increase the risk of suffering an embolic event, and in these patients we would be inclined to operate more urgently. But in a patient who is stable and who does not have mobile or pedunculated lesions by echocardiography, we do try to wait at least 10 to 15 days before operating.
DR SAFUH ATTAR (Baltimore, MD): What type of valve was used? Did you use anticoagulation postoperatively? In addition, were there any cases of recurrent endocarditis and, if so, did they require reoperation? What was the result?
DR GILLINOV: In this series, 17 patients received mechanical valves, 16 had bioprosthetic valves, and 1 had an aortic root homograft placed for extensive destruction of the root. The choice of valves was dictated in large part by the fact that nearly half of these patients were intravenous drug abusers and would not be candidates to receive a mechanical valve. In most cases, people who would be compliant, who did not have a bleeding diathesis, and who had not had a cerebral hemorrhage would receive a St. Jude valve, because of data from the Texas Heart Institute suggesting a reduced incidence of recurrent endocarditis.
As far as follow-up goes, unfortunately, because so many of these patients were intravenous drug abusers, they were hard to locate for follow-up. We do know of 2 cases of recurrent endocarditis after the study; 1 patient underwent re-replacement of the valve and did well, and the other died.
Related Article
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Valve Replacement in Patients With Endocarditis and Acute Neurologic Deficit
- A. Marc Gillinov, Rinoo V. Shah, William E. Curtis, R. Scott Stuart, Duke E. Cameron, William A. Baumgartner, and Peter S. Greene
Ann. Thorac. Surg. 1996 61: 1125-1129.
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[Full Text]
