Factors Influencing the Results of Double-Valve Surgery in Patients with Fulminant Endocarditis: The Importance of Valve Selection
DOI:
https://doi.org/10.1532/HSF98.20041075Abstract
Background: Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome.
Patients: Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age ( ± SD) was 53 ± 14.2 years; there were 37 men and 16 women.
Methods: The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion.
Results: All patients with destructive endocarditic double-valve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis.
Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 ± 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 ± 10.4 mm Hg and 12 ± 5.7 mm Hg, respectively, for the homografts and 24 ± 8.4 mm Hg and 15 ± 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular outflow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation.
Conclusions: The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.
References
Abolhoda A, Yu S, Oyarzun JR, et al. 1996. No-React detoxification process: a superior anticalcification method for bioprostheses. Ann Thorac Surg 62:1724-30.nArnett EN, Roberts WC. 1976. Valve ring abscess in active infective endocarditis. Circulation 54:140-5.nBaumgartner FJ, Omari BO, Robertson JM, Nelson JR, Pandya A, Miliken JC. 2000. Annular abscess in surgical endocarditis: anatomic, clinical and operative features. Ann Thorac Surg 70:442-7.nBlumberg EA, Karalis DA, Chandrasekaran K, et al. 1995. Endocarditis associated paravalvular abscess: do clinical parameters predict presence of abscess? Chest 107:898-903.nCarrel TP, Berdat P, Engleberger L, et al. 2003. Aortic root replacement with a new stentless aortic valve xenograft conduit: preliminary hemodynamic and clinical results. J Heart Valve Dis 12:752-7.nDanchin N, Cherrier F. 1999. Comparison of long-term outcome in patients with or without aortic ring abscess treated surgically for aortic valve infective endocarditis. Heart 81:177-81.nDavid TE, Feindel CM, Armstrong S, Sun Z. 1996. Long-term results of operation for paravalvular abscess. Ann Thorac Surg 62:48-53.nDearani JA, Orszulak TA, Schaff HV, Daly RC, Anderson BJ, Danielson GK. 1997. Results of allograft aortic valve replacement for complex endocarditis. J Thorac Cardiovasc Surg 113:287-91.nDelay D, Pellerin M, Carrier M, et al. 2000. Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis. Ann Thorac Surg 70:1219-23.nErgin MA, Raissi S, Follis F, Lansman SL, Griepp RB. 1989. Annular destruction in acute bacterial endocarditis. J Thorac Cardiovasc Surg 97:755-63.nHetzer R, Deyerling W, Borst HG. 1984. Herzklappenchirurgie beiaktiver infektiöser Endokarditis. In: Infektiöser Endokarditis. Klinik, Diagnostik und Therapie. Darmstadt, Germany: Steinkopff-Verlag. p 148-76.nKirklin JK, Kirklin JW, Pacifico AD. 1988. Aortic valve endocarditis with aortic root abscess cavity: surgical treatment with aortic valve homograft. Ann Thorac Surg 45;674-7.nKnosalla C, Weng Y, Yankah AC, et al. 2000. Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess: 13 year results. Eur Heart J 21:490-7.nMaisch B. 1989. Klinik der infektiösen Endokarditis. Internist (Berl) 30:483-91.nNetzer RO, Zollinger E, Seiler C, Cerny A. 2000. Infective endocarditis: clinical spectrum, presentation and outcome. An analysis of 212 cases< 1980-1995. Heart 84:25-30.nSheldon WH, Golden A. 1951. Abscesses of the valve rings of the heart: a frequent but not well recognized complication of acute bacterial endocarditis. Circulation 4:1-12.nSiniawski H, Lehmkuhl H, Weng Y, et al. 2003. Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess. Ann Thorac Surg 75:803-8.n
