Infective endocarditis is one of the severest valvar diseases, commonly affecting the mitral valve. Currently, valvuloplasty and replacement are the main surgical options for mitral infective endocarditis. However, the complexity of the infectious lesions has caused a raging debate on which surgical approach offers more benefits. With the development of surgical treatment for endocarditis, mitral valvuloplasty may be a superior solution. It can preserve the integrity of the valve structure, avoiding complications caused by replacement. However, there is a lack of evidence from randomized clinical trials and other evidence-based medical supports. Furthermore, issues regarding the timing of surgery, repair methods, and material choices for mitral valvuloplasty in these patients have not been standardized. Therefore, this article summarizes existing literature to assist clinicians in making appropriate treatment decisions.
Objective To investigate clinical diagnosis，timing of surgery and perioperative therapeutic strategies for blood culture-negative infective endocarditis （IE）. Methods Clinical data of 240 IE patients who were admitted tWuhan Asia Heart Hospital between July 2008 and July 2012 were retrospectively analyzed. According to their blood cultureresults，all the patients were divided into blood culture-negative group and blood culture-positive group. In the blood culture-negative group，there were 158 patients including 88 male and 70 female patients with their age of 51.3±10.1 years. In the blood culture-positive group，there were 82 patients including 45 male and 37 female patients with their age of 48.9±9.8 years. All the patients underwent surgical treatment，and the surgical procedures included complete vegetations excision，debridement of infected valves，removal of necrotic tissue around the annulus，and concomitant heart valve replacement or intracardiac repair. Postoperatively，all the patients received routine monitoring in ICU，cardiac glycosides，diuretics，other symptomatic treatment and adequate dosages of antibiotics for 4-6 weeks. Results Four patients died postoperatively in this study including 1 patient for low cardiac output syndrome and 3 patients for multiple organ dysfunction syndrome，1 patient in the blood culture-positive group and 3 patients in the blood culture-negative group respectively. There was no statistical difference in surgical mortality between the 2 groups （χ2=0.15，P=0.70）. All the other patients were discharged successfully and followed up for 6 to 36 months with the median follow-up time of 22 months. During follow-up, 2 patients died including 1 patient for cerebral infarction 2 years after surgery and another patient for cerebral hemorrhage 3 yearsafter surgery. Conclusion Patients with blood culture-negative IE should receive adequate dosage and duration of broad-spectrum antibiotics to control the infection rapidly, and aggressive surgical therapy to decrease in-hospital mortality and improve their quality of life and prognosis.
ObjectiveTo analyze the clinical efficacy of valve surgeries for infective endocarditis and the affecting factors, and compare the early- and long-term postoperative outcomes of different surgery approaches. MethodsThe patients with infective endocarditis who underwent valve replacement/valvuloplasty in our hospital from 2010 to 2022 were retrospectively collected. The clinical data of the patients were analyzed. ResultsA total of 343 patients were enrolled, including 197 patients with mechanical valve replacement, 62 patients with bioprosthetic valve replacement, and 84 patients with valvuloplasty. There were 238 males and 105 females with an average age of (44.2±14.8) years. Single-valve endocarditis was present in 200 (58.3%) patients, and multivalve involvement was present in 143 (41.7%) patients. Sixty (17.5%) patients had suffered thrombosis before surgery, including cerebral embolisms in 32 patients. The mean follow-up time was (60.6±43.8) months. Early mortality within one month after the surgery occurred in 17 (5.0%) patients, while later mortality occurred in 19 (5.5%) patients. Eight (2.3%) patients underwent postoperative dialysis, 13 (3.8%) patients suffered postoperative stroke, 6 patients underwent reoperation, and 3 patients suffered recurrence of infective endocarditis. Smoking (P=0.002), preoperative embolisms (P=0.001), duration of surgery (P=0.001), and postoperative dialysis (P=0.001) were risk factors for early mortality, and left ventricular ejection fraction ≥60% (P=0.022) was protective factor for early mortality. New York Heart Association classification Ⅲ-Ⅳ (P=0.010) and ≥3 valve procedures (P=0.028) were risk factors for late mortality. The rate of composite endpoint events was significantly lower in the valvuloplasty group than that in the valve replacement group. ConclusionFor patients with infective endocarditis, smoking and preoperative embolisms are associated with high postoperative mortality, multiple-valve surgery is associated with a poorer prognosis, and valvuloplasty has advantages over valve replacement and should be attempted in the surgical management of patients with infective endocarditis.
ObjectiveTo investigate clinical outcomes of mitral valvuloplasty (MVP)for the treatment of infective endocarditis (IE)and mitral regurgitation (MR). MethodsFrom March 2002 to January 2012, 33 patients with IE and MR underwent MVP in Fu Wai Hospital. There were 23 male and 10 female patients with their age of 10-67 (35.7±17.8)years. Thirteen patients had previous cardiac anomalies. Preoperatively, there were 5 patients with mild MR, 15 patients with moderate MR and 13 patients with severe MR. There were 5 patients in New York Heart Association (NYHA)functional classⅠ, 23 patients in classⅡ, 4 patients in classⅢ and 1 patient in classⅣ. All the patients received MVP including 14 patients received MVP in active phase of IE. Concomitantly, 6 patients received aortic valve replacement, 5 patients received tricuspid valvuloplasty, 1 patient received coronary artery bypass grafting, 1 patient received resection of left atrial myxoma and 1 patient received repair of aortic sinus aneurysm. Surgical procedures included pericardial patch closure of leaflet perforation in 5 patients, leaflet excision and suturing in 17 patients, double-orifice method in 3 patients, chordae transfer and artificial chordae implantation in 5 patients, and annuloplastic ring implantation in 15 patients. ResultsOne patient died of acute myocardial infarction 7 days after the operation. All other 32 patients were successfully discharged. Echocardiography before discharge showed left ventricular end-diastolic diameter (LVEDD, 48.9±7.6 mm)and left atrial diameter (LAD, 31.7±7.4 mm)were significantly smaller than preoperative values (P=0.000). Thirty-two patients were followed up for 6-125 (73.0±38.6)months. There was no death, IE recurrence, bleeding or thromboembolism during follow-up. One patient received mitral valve replacement for mitral stenosis 3 years after discharge. There were 25 patients in NYHA func-tional classⅠ, 5 patients in classⅡand 2 patients in classⅢ. There were 4 patients with mild MR, 1 patient with moderate MR, and 26 patients had no MR. One patient had faster mitral inflow at diastolic phase (1.7 m/s). One patient had moderate aortic regurgitation. LVEDD and LAD during follow-up were not statistically different from those before discharge. Left ventricular ejection fraction during follow-up was significantly higher than that before discharge (60.9%±6.6% vs. 57.5%±6.7%, P=0.043). ConclusionMVP is a reliable surgical procedure for patients with IE and MR, and can significantly reduce left atrial and left ventricular diameter and improve cardiac function postoperatively.
Infective endocarditis (IE) is a disease with severe complications and high mortality. It is heterogeneous in etiology, clinical manifestations, and course. At the same time, there are many disputes on the clinical practice of antibiotic treatment, surgical indications and timing. In this review, we discuss the epidemiology, diagnosis, treatment, and prevention of IE, especially the latest advances in surgical treatment after the release of European Society of Cardiology and American Heart Association guidelines in 2015.
ObjectiveTo systematically review the short term and long term efficacy of early surgery for infective endocarditis (IE) patients. MethodsWe searched PubMed, EMbase, The Cochrane Library, CBM, WanFang Data and CNKI databases for cohort studies concerning the efficacy of early surgery for IE patients from inception to October 2014. Two reviewers independently screened literature, extracted data and assessed the risk bias of included studies. Then meta-analysis was performed by using RevMan 5.3 software. ResultsSixteen cohort studies including 8 141 patients were included. The results of meta-analysis showed that early surgery could reduce the short term mortality (OR=0.57, 95%CI 0.42 to 0.77, P=0.000 4) and long term mortality (OR=0.57, 95%CI 0.43 to 0.77, P=0.000 7) in IE patients. Subgroup analysis showed that early surgery could significantly reduce the short term mortality and long term mortality in patients with native valve endocarditis (NVE). ConclusionEarly surgery can reduce IE patients' short term mortality and long term mortality. Due to the limited quality and quantity of the included studies, more large-scale high-quality studies are needed to verify the above conclusion.
ObjectiveTo study the relationship between the timing of surgery and one-year outcome in patients with infective endocarditis. MethodsWe retrospectively analyzed the clinical data of 97 patients suffered from leftside native valve infective endocarditis with neoplasm, admitted in Shanghai First People's Hospital between January 2000 and December 2011. There were 65 males and 32 females with mean age of 55.2±16.3 years (ranged 29 to 75 years). They were divided into two groups according to whether the surgery was performed within a week after diagnosis. The in-hospital mortality and one-year mortality, embolism and re-infection were calculated and compared between the two groups. ResultsThere was no significant difference in the in-hospital mortality between the early surgery group and the conventional surgery group (1.9% versus 6.7%, P=0.241). While there was a significant difference in the rate of inhospital embolism related complications (1.9% versus 13.3%, P=0.030) between the two groups. There was no significant difference in one-year mortality between the two groups (1.9% versus 8.9%, P=0.122). The incidence rate of embolism related complication was 5.8% in the early surgery group and 20.0% in the conventional surgery group with a statistical difference (P=0.034). There was one patient with recurrent cerebral infarction among the 11 patients of cerebral infarction in the early surgery group,while 6 recurrent patients in the 9 patients with cerebral infarction in the conventional surgery group (9.1% versus 66.7%, P<0.005). ConclusionsEarly surgery in patients with left-side native valve infective endocarditis can't reduce the in-hospital mortality and one-year mortality but does decrease embolic events significantly. Early surgery is feasible in the patients with cerebral infarction.
The patient underwent prostatectomy before two months. After the operation, he suffered from intermittent fever, chest tightness, and suffocation. Combined with the history, symptoms, signs, laboratory examination, echocardiography, imaging examination (CT), and the positive blood culture for Enterococcus faecalis, the admitting diagnosis was aortic stenosis and insufficiency, mitral insufficiency, cardiac function grade Ⅲ (New York Heart Association grade), infective endocarditis, and aneurysm of aortic sinus. After 4-week antimicrobial drug treatment, the patient was in a stable condition with normal body temperature, multiple negative blood cultures, and normal laboratory-related examinations. After careful and sufficient preparation, transcatheter aortic valve replacement operation was performed in the hybrid operating room with 32 mm Venus-A valve. The operation was successful and the patient was discharged on the seventh day after operation. He continued to be treated with antimicrobial drugs for 4 weeks after surgery, and his temperature was normal. He had no chest tightness, asthma, or other symptoms. One, three, and six months after operation, blood tests and erythrocyte sedimentation rate were normal, electrocardiogram showed sinus rhythm, and echocardiography showed a maximum aortic valve pressure difference of 7 mm Hg (1 mm Hg=0.133 kPa), no perivalvular leak and no pericardial effusion.
Objective To improve the surgical results of infective endocarditis, the results and methods of aortic root replacement in patients with severe aortic valve infective or prosthetic valve endocarditis were summarized. Methods From Sept.1995 to June 2008, there were 11 patients with severe aortic valve endocarditis treated surgically, included 6 active endocarditis and 5 healed endocarditis. Preoperative arterial blood bacterial culture were positive in 6 patients. Preoperative echocardiography showed all patients had various degree of aortic regurgitation or paraprosthetic leakage, left ventricular endsystolic diameter(LVESD) was 6.0±0.7cm, LVESD was equal or greater than 5.5cm in 7 patients, left ventricular ejection fraction (LVEF) was 47.8%±11.2％, and LVEF was equal or less than 50% in 8 patients. After careful debridement, composite conduit (9 patients) or cryopreserved allograft (2 patients) was used to replace the aortic root. Concomitant procedures were coronary artery bypass grafting in 4 patients, mitral annuloplasty in 3 patients, and ventricular septal defect repair in 1 patient. Results There was one patient died of postoperative cardiac arrest, one patient had Ⅲ° atrioventricular block and pacemaker implanted. Ten patients were followed up, followup time were from 3 months to 13.2 years. During the followup period, one patient had recurrence of endocarditis and died, others survived uneventually. Conclusion Aortic root replacement must be considered in following patients: endocarditis combined with root aneurysm or sinus aneurysm, infectious disease involved in sinus wall or nearby coronary ostia, annulus impairment and severe destructive annulus after debridement. The key points of the surgery are debriding the infectious tissue completely, preventing aortic root bleeding. Although the root replacement is relatively complex, the surgical results could be improved after complete debridement of infectious tissue.
Objective To investigate the clinical efficacy of minimally invasive mitral valvuloplasty (MVP) in the treatment of infective endocarditis (IE) with mitral regurgitation (MR). Methods A retrospective analysis was conducted on the clinical data of patients who underwent MVP for IE with MR in the Department of Cardiovascular Surgery at Zhongshan Hospital, Fudan University from January 2016 to December 2020. Patients were divided into two groups based on the surgical incision: those with a right mini-thoracotomy were classified as a minimally invasive surgery (MIS) group, and those with a median sternotomy were classified as a median sternotomy (MS) group. All patients had isolated mitral valve involvement. Perioperative data were analyzed, and mid- to long-term outcomes were compared between the two groups. Results A total of 86 patients were included, with 40 in the MIS group (22 males and 18 females, with a mean age of 39±15 years ranging from 8 to 71 years) and 46 in the MS group (27 males and 19 females, with a mean age of 49±16 years ranging from 14 to 71 years). The patients in the MIS group were relatively younger (P=0.004) with better preoperative cardiac function (P=0.004). There was no statistical difference in preoperative fever, gender, or comorbidities between the two groups (P>0.05). The MIS group had shorter postoperative ventilation times, less postoperative 24-hour drainage, less blood transfusion, and shorter total hospital stays compared to the MS group (P=0.001, 0.018, 0.005, 0.005). There was no statistical difference in cardiopulmonary bypass times or ICU stays between the two groups (P>0.05). The perioperative complication rates and mortality rates were not significantly different between the two groups (P>0.05). Follow-up was conducted for 11-92 months, with a mean duration of 49±19 months and an overall follow-up rate of 91.6%. During the follow-up, 3 patients in each group required reoperation for mitral valve issues, with no statistical difference in incidence (7.5% vs. 6.5%, P=0.691). There were no warfarin-related complications, recurrences, or deaths in either group during follow-up. Multivariate regression analysis identified age, preoperative cardiac function, and surgeon experience as influencing factors for the choice of surgical approach. Conclusion Minimally invasive MVP for IE with MR is relatively safe in the perioperative period and shows significant efficacy, with clear mid- to long-term outcomes. It is recommended for younger patients with better preoperative cardiac function and when performed by surgeons with extensive experience in mitral valvuloplasty.