Active Native Valve Endocarditis: Determinants of Operative Death and Late Mortality

doi:10.1016/S0003-4975(97)00117-3

The Annals of Thoracic Surgery

Volume 63, Issue 6, June 1997, Pages 1737-1741

https://doi.org/10.1016/S0003-4975(97)00117-3 Get rights and content

Abstract

Background. In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993.

Methods. There were 201 male and 46 female patients (mean age, 45.4 ± 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (χ² test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival.

Results. Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% ± 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% ± 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found.

Conclusions. Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.

(Ann Thorac Surg 1997;63:1737–41)

Section snippets

Patients and Methods

From January 1979 to December 1993, we operated on 247 patients for active NVE. There were 201 male and 46 female patients. Mean age was 45.4 ± 5.6 years (range, 8 to 79 years). Forty-seven patients were 60 years old and older. There were 3 drug addicts. The aortic valve was involved in 163 patients (65.6%), the mitral valve in 36 patients (14.6%), both mitral and aortic valves in 44 patients (17.8%), and the tricuspid valve alone in 4 patients (1.6%).

Endocarditis was labeled active if the

Operative Mortality

The operative mortality was 7.6% (n = 19). Twelve patients died of hemodynamic failure, 2 of neurologic complications, 2 of pulmonary infection, and 3 of mixed causes. Univariate and multivariate analyses (Table 2, Table 3) showed that increased age, cardiogenic shock at the time of the operation, greater cardiothoracic ratio, and insidious illness were the predominant risk factors.

Follow-up

Fifteen patients were lost to follow-up. Among 213 survivors, there were 43 late deaths:

Hemodynamic failure	7

Comment

These data confirm that NVE operative mortality is now near 10%, as reported by many teams [1, 2]. Risk factors are shown in Table 2 and Table 3.

We find no statistical difference in operative mortality according to the microorganism; operative mortality has been reported higher with staphylococci [[5]], but our subgroup is perhaps too small to show this result. The length of antibiotic therapy before the operation appears to have no influence on operative mortality, as in Jubair and associates’

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There is limited data on the outcomes of children who undergo surgery for aortic valve infective endocarditis (IE), and the optimal surgical approach remains controversial. We investigated the long-term outcomes of surgery for aortic valve IE in children, with a particular focus on the Ross procedure. A retrospective review of all children who underwent surgery for aortic valve IE was performed at a single institution. Between 1989 and 2020, 41 children underwent surgery for aortic valve IE, of whom 16 (39.0%) underwent valve repair, 13 (31.7%) underwent the Ross procedure, 9 (21.9%) underwent a homograft root replacement, and 3 (7.3%) underwent a mechanical valve replacement. Median age was 10.1 years (interquartile range, 5.4–14.1). The majority of children (82.9%, 34/41) had underlying congenital heart disease, while 39.0% (16/41) had previous heart surgery. Operative mortality was 0.0% (0/16) for repair, 15.4% (2/13) for the Ross procedure, 33.3% (3/9) for homograft root replacement, and 33.3% (1/3) for mechanical replacement. Survival at 10 years was 87.5% for repair, 74.1% for Ross, and 66.7% for homograft (P > 0.05). Freedom from reoperation at 10 years was 30.8% for repair, 63.0% for Ross, and 26.3% for homograft (P = 0.15 for Ross vs repair, P = 0.002 for Ross vs homograft). Children undergoing surgery for aortic valve IE have acceptable long-term survival, although the need for long-term reintervention is significant. The Ross procedure appears to be the optimal choice when repair is not feasible.
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2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines
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This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.
A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline.
Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality
2020, Annales de Cardiologie et d'Angeiologie
La moitié des patients atteints d’endocardite infectieuse (EI) bénéficient d’un traitement chirurgical. Malgré des recommandations claires sur les indications et les délais opératoires, la décision reste difficile et doit prendre en compte plusieurs facteurs.
On a réalisé une étude rétrospective au sein de l’hôpital Foch. Tous les patients opérés entre 2005 et 2018 pour une EI certaine ont été inclus. Les caractéristiques des patients, les indications et les délais opératoires, ainsi que la mortalité intra hospitalière, ont été notés. Le suivi des patients a été assuré par appel téléphonique.
Cinquante-deux patients étaient opérés pour une EI entre 2005 et 2018. Les indications opératoires les plus fréquentes étaient la présence d’une fuite massive symptomatique, l’absence du contrôle de l’infection par le traitement médical et la présence de grosses végétations emboligènes. Le délai opératoire moyen était de 13,2 jours avec 56,5 % des patients opérés dans les 10 premiers jours. Les complications postopératoires les plus fréquentes étaient une insuffisance rénale aiguë dans 57,7 % des cas dont 9,6 % nécessitant la dialyse, un état de choc dans 50 % des cas, les troubles de rythme dans 40,4 % des cas, infectieuses dans 19,2 % des cas, troubles conductifs dans 25 % des cas dont 17,3 % nécessitant l’implantation d’un pace maker. La mortalité intrahospitalière était de 7,7 % et la durée moyenne d’hospitalisation était de 35 jours. La survie à un an et à 5 ans était de 95 % et de 85 %, respectivement.
Les indications et les délais opératoires étaient conformes aux différentes recommandations. La mortalité intrahospitalière et au long cours était plutôt faible.
In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors.
A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls.
Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively.
The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.
A predictive model for early mortality after surgical treatment of heart valve or prosthesis infective endocarditis. The EndoSCORE
2017, International Journal of Cardiology
Citation Excerpt :
Surgical treatment of heart valve and prosthesis infective endocarditis (IE) is account for 25–50% of cases in active IE and 20–40% in treated IE [1–4].
The aim of this large retrospective study was to provide a logistic risk model along an additive score to predict early mortality after surgical treatment of patients with heart valve or prosthesis infective endocarditis (IE).
From 2000 to 2015, 2715 patients with native valve endocarditis (NVE) or prosthesis valve endocarditis (PVE) were operated on in 26 Italian Cardiac Surgery Centers. The relationship between early mortality and covariates was evaluated with logistic mixed effect models. Fixed effects are parameters associated with the entire population or with certain repeatable levels of experimental factors, while random effects are associated with individual experimental units (centers).
Early mortality was 11.0% (298/2715); At mixed effect logistic regression the following variables were found associated with early mortality: age class, female gender, LVEF, preoperative shock, COPD, creatinine value above 2 mg/dl, presence of abscess, number of treated valve/prosthesis (with respect to one treated valve/prosthesis) and the isolation of Staphylococcus aureus, Fungus spp., Pseudomonas Aeruginosa and other micro-organisms, while Streptococcus spp., Enterococcus spp. and other Staphylococci did not affect early mortality, as well as no micro-organisms isolation. LVEF was found linearly associated with outcomes while non-linear association between mortality and age was tested and the best model was found with a categorization into four classes (AUC = 0.851).
The following study provides a logistic risk model to predict early mortality in patients with heart valve or prosthesis infective endocarditis undergoing surgical treatment, called “The EndoSCORE”.

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Original ArticlesActive Native Valve Endocarditis: Determinants of Operative Death and Late Mortality

Abstract

Section snippets

Patients and Methods

Operative Mortality

Follow-up

Comment

Am J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Acute bacterial endocarditisoptimizing surgical results

Circulation

Aortic valve endocarditis. Determinants of early survival and late morbidity

Circulation

Original Articles
Active Native Valve Endocarditis: Determinants of Operative Death and Late Mortality