Long-Term Outcomes in Valve Replacement Surgery for Infective Endocarditis

doi:10.1016/j.athoracsur.2006.07.037

The Annals of Thoracic Surgery

Volume 83, Issue 1, January 2007, Pages 30-35

Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

https://doi.org/10.1016/j.athoracsur.2006.07.037 Get rights and content

Background

Infective endocarditis is associated with a high rate of long-term mortality. Patients with a history of intravenous drug use (IVDU) are at increased risk for infective endocarditis. However, few studies have reported results of surgical treatment on this population. We present 19.5 years of experience with surgically treated patients with infective endocarditis.

Methods

A retrospective study of all cardiac surgeries with a diagnosis of infective endocarditis at a single institution from 1986 to 2005 was performed. Logistic stepwise regression with an end point of operative mortality was done. Variables were age, gender, race, history of drug use, previous valve surgery, and previous valve replacement. Perioperative and outcome variables were compared between IVDU and non-IVDU populations.

Results

The IVDU population required surgery at a younger age (39 ± 9 years versus 54 ± 15 years; p < 0.001). Overall operative mortality was 12% (41/346). The perioperative complication rate was similar for both groups. When adjusted for age, the two groups had similar long-term survival (p = 0.78). Kaplan-Meier estimator showed that survival at 10 and 15 years was 66% and 54% for IVDU and 56% and 42% for non-IVDU (number at risk, 19, 11, and 61, 28, respectively; p = 0.137). Reoperation for recurrent infective endocarditis was necessary in 9 (17%) of 52 of the IVDU group versus 14 (5%) of 270 of the non-IVDU group (p = 0.03).

Conclusions

Patients with a history of IVDU required reoperation for recurrent infective endocarditis at a significantly higher rate than the non-IVDU patients. Long-term survival was similar between the younger IVDU population and the older non-IVDU population. Anticipated life span is one of many factors when considering prosthetic valve choice in this population.

Section snippets

Patients and Methods

This study was approved by the Institutional Review Board in December 2002, which waived the requirement for patient consent. Between January 31, 1986, and June 9, 2005, 322 patients (213 men, 109 women) underwent 346 consecutive valve replacement operations for infective endocarditis at Barnes Jewish Hospital in St. Louis, Missouri. Hospital records for all 322 patients, including admission notes, operative reports, discharge summaries, and patient-physician correspondence were reviewed

Results

Of the 322 patients that underwent 346 surgeries during the nearly 19.5-year period, 52 were identified as IVDUs who underwent 62 valve operations. Patient demographics are summarized in Table 1. The mean age of the total patient population was 51 ± 15 years (range, 22 to 83 years). The IVDU group age was 39 ± 9 years (range, 22 to 67 years), which was significantly lower than the non-IVDU group of 54 ± 15 years (range, 22 to 83 years, p < 0.001). Mean follow-up of patient chart records was 1.8

Comment

IVDU use has emerged as a prevalent cause of infective endocarditis. During the past 20 years, nearly one fifth of the patients who underwent valve operations for infective endocarditis at Barnes Jewish hospital had a history of IVDU. In this study, right-sided valve involvement was significantly higher in the IVDU population than the non-IVDU population. This supports the previously published association between IVDU and infection of the right-sided heart valves [10, 11, 12]. Ako and

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The Evolving Trends in Infective Endocarditis and Determinants of Mortality: a 10-year Experience From a Tertiary Care Epicenter
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The epidemiology of infective endocarditis (IE) continues to evolve in areas affected by the opioid epidemic. Understanding the demographics of the disease allows us to better tailor therapy towards this at-risk population. This was an observational study of adults (age ≥ 18) admitted to the University of Kentucky hospital with IE between January 2009 and December 2018. 1,255 patients were included in the final analysis. The mean age was 42 years, 45% were female and injection drug use was seen in 66% of patients. On multivariable analysis, higher Charlson comorbidity indices, left sided, and multivalve involvement were associated with increased mortality, whereas surgical intervention demonstrated a trend towards lower mortality. Our results highlight the alarming increase in injection drug use related IE and the high mortality rates despite therapeutic advances. Patients with left sided IE, multivalve involvement and a higher Charlson comorbidity index had decreased survival.
Does Perivalvular Involvement Affect the Long-Term Surgical Outcomes of Primary Left-Sided Endocarditis?
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Nevertheless, we emphasize that the presence of a critical preoperative state rather than the extent of the destruction is the major risk factor for early mortality. In line with previous reports,7,11,12,14,15 we found cumulative survival rates of 49% and 43% at 10 and 15 years, respectively. Yet, despite the need for extensive debridement and reconstruction, the long-term mortality was not significantly different in complex versus simple diseases.
Surgical treatment of infective endocarditis (IE) remains challenging, especially in cases of perivalvular destruction and poor clinical presentation. We evaluated the outcomes of surgery for simple (isolated leaflet involvement) versus complex (perivalvular involvement) primary left-sided native valve endocarditis. From 2005 to 2019, a total of 128 consecutive patients (age 57.7 ± 14.2 years) with IE were surgically managed. Study end points were operative and late mortality and freedom from recurrent infection and reoperation for recurrent endocarditis. Patients were categorized as having simple IE (n = 91) versus complex IE (n = 37) based on the preoperative imaging and/or intraoperative findings. Valves involved were aortic in 39% (n = 50), mitral in 46% (n = 59), or both (11%, n = 14). The operative mortality was 11.7% (n = 15), and 9 of them (60%) presented with shock or multiorgan failure. A critical preoperative state was the only independent risk factor for early mortality (odds ratio 7.43, p <0.01). The overall survival was 81.9%, 74.8%, 58%, and 52% at 1, 5, 10, and 15 years, respectively. Long-term survival was similar between simple and complex groups (p = 0.29). Chronic renal failure was the only independent risk factor for late mortality (hazard ratio 2.44, p = 0.02). Freedom from re-endocarditis was 95.2%. None of the patients underwent reoperation because of recurrent endocarditis. Mitral valve repair was performed in 30.7% of all cases with mitral valve involvement. None of them had significant mitral regurgitation or recurrent endocarditis on follow-up. In conclusion, surgery for IE in the setting of complex perivalvular involvement is associated with a low rate of recurrent endocarditis or reoperation and comparable long-term survival to patients with isolated leaflet involvement. Mitral valve repair was feasible and durable in a significant proportion of patients even in the presence of endocarditis.
Poor long-term outcomes of intravenous drug users with infectious endocarditis
2022, JTCVS Open
The optimal management of active endocarditis in intravenous (IV) drug users is still lacking.
From the years 1997 to 2017, 536 patients with active infectious endocarditis were surgically treated, including 83 (15%) with IV drug use (IVDU) and 453 (85%) without IV drug use (non-IVDU). Initial data were obtained from the Society of Thoracic Surgeons database and supplemented with chart review and national death index data.
The IVDU group was significantly younger (43 vs 56 years old) than the non-IVDU group and had greater rates of psychiatric disorders, drug use, and tricuspid valve endocarditis (28% vs 8.6%). Hypertension, dyslipidemia, and diabetes mellitus were significantly more common in the non-IVDU group. Perioperative complications and operative mortality (7.2% vs 7.9%) were similar. IVDU was not a significant risk factor for operative mortality. Kaplan–Meier survival was significantly lower in the IVDU group (5-year survival, 46% vs 67%). Significant risk factors for long-time mortality included IV drug use (hazard ratio [HR], 1.92), age ≥65 years (HR, 1.78), congestive heart failure (HR, 1.87), and enterococcus endocarditis (HR, 1.54). The 5-year rate of reoperation was similar between IVDU and non-IVDU groups (2.4% vs 2.7%).
IVDU is a significant risk factor for long-term mortality. A multidisciplinary approach was preferred for IVDU patients to treat both endocarditis and substance use disorder and improve long-term survival.
PET imaging in cardiovascular infections
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Cardiovascular (CVS) infections are associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient's management, as early treatment improves the prognosis. Hardly they are diagnosed on the basis of a single symptom, sign or diagnostic test, being a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data and imaging data necessary in many cases. The application of multimodality imaging, including molecular imaging techniques has improved the sensitivity to detect infections involving heart valves and vessels and implanted cardiovascular devices while also allowing for early detection of septic emboli and metastatic infections before these become clinically apparent. In this chapter, we describe the role of WBC SPECT/CT and [¹⁸F] FDG PET/CT in most clinically relevant CVS infections including dedicated imaging acquisition protocols, specific imaging reading and interpretations criteria, emphasizing the need of a specific reference framework within a Cardiovascular Multidisciplinary Team Approach to select the best test or combination of tests for each specific clinical situation.
Postoperative care of the critically ill endocarditis patient
2022, Infective Endocarditis: A Multidisciplinary Approach
Patients with infective endocarditis who undergo surgery face many postoperative challenges both general to cardiac surgery and specific to endocarditis. The combination of vasoplegia, sepsis, and cardiogenic shock is frequently present and demands active hemodynamic monitoring and targeted fluid management. Preoperative risk factors including arrhythmias, embolic stroke, and active infection increase the risk of postoperative complications. Postoperative management of anticoagulation, antimicrobial therapy, arrhythmias, and pain management are essential for reducing morbidity and mortality in this patient population that had recently undergone major operative stress in the setting of active infection. And when complications do occur, including stroke, renal, and respiratory failure, prompt recognition and management can prevent further adverse outcomes in this critically ill population. This chapter discusses the considerations, recommendations, and management of endocarditis patients following surgery, and the postoperative conditions and complications that threaten their successful recovery.
Predictors of long-term mortality in left-sided infective endocarditis: an historical cohort study in 414 patients
2021, European Journal of Internal Medicine
Citation Excerpt :
In-hospital mortality of IE ranges between 16% and 22%, whilst 6 month mortality rises up to 30%, with 1-year mortality exceeding this number [2]. Long-term survival ranges in different studies from 60% to 80% at 10 years [3-5]. Several studies identified predictors of in-hospital prognosis, including older age, S. aureus infection, large vegetations, embolic complications and stroke, prosthetic valve IE and paravalvular complications [6-8].
: Very limited data are available on the long-term outcome of infective endocarditis (IE) and its determinants. The aim of this study was to identify the predictors of long-term mortality in patients affected by left sided IE (LSIE).
: This was an historical retrospective observational study on prospectively collected data from patients with LSIE hospitalized in our Unit (January 2000-December 2017). Multiple variables relevant to history, physical examination, laboratory tests, echocardiography, comorbidities, complications and outcome were analysed by Cox regression to identify predictors of long-term mortality.
: 414 patients were included, and followed up for a median of 39 months [IQR 11-74]. Median age was 59 years [range 3-89], and most patients were male. Over 50% showed at least one comorbidity. Hyperglycaemia, increased creatinine and an indication for surgery predicted in-hospital mortality, while a prior myocardial infarction, chronic kidney disease (CKD) on hemodialysis and a larger vegetation were independent predictors of 1-year mortality. At multivariate analysis, peripheral arterial disease (p= 0.017), hyperglycemia on admission (p=0.013) and a higher BMI (p=0.009) were independent predictors of long-term mortality in 1-year survivors. At multivariable Cox proportional hazard regression, peripheral arterial disease (p=0.002), hyperglycemia (p=0.041) and CKD on hemodialysis (p=0.025) confirmed to be independently associated with an increased risk of long-term mortality in the overall 414 patient cohort.
: Cardiovascular and metabolic risk signals, specifically peripheral arterial disease and hyperglicemia, affect long-term mortality of LSIE. An active and long-term follow up seems warranted in IE survivors showing these conditions at outset.

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Original articleCardiovascularLong-Term Outcomes in Valve Replacement Surgery for Infective Endocarditis

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Temporal trends in infective endocarditis: a population-based study in Olmsted County, Minnesota

JAMA

Infective endocarditis

Lancet

Drug Abuse Warning Network (DAWN), 2003: interim national estimates of drug-related emergency department visits

Infective endocarditis and cardiac surgery in intravenous drug abusers and HIV-1 infected patients

Cardiol Clin

Infective endocarditis: determinants of long term outcome

Heart

Prosthetic valve endocarditis: early and late outcome following medical or surgical treatment

Heart

Long-term outcome of infective endocarditis: the impact of early surgical intervention

Clin Infect Dis

Superiority of surgical versus medical treatment in patients with Staphylococcus aureus infective endocarditis

Int J Cardiol

Acute bacterial endocarditisOptimizing surgical results

Circulation

Infective endocarditis in the injection drug user

Infect Dis Clin North Am

Right-side endocarditis in injection drug users: review of proposed mechanisms of pathogenesis

Clin Infect Dis

Right-sided endocarditis in intravenous drug usersPrognostic features in 102 episodes

Ann Intern Med

Changing spectrum of infective endocarditis: review of 194 episodes over 20 years

Circ J

Original article
Cardiovascular
Long-Term Outcomes in Valve Replacement Surgery for Infective Endocarditis