A structured approach to native mitral valve infective endocarditis: Is repair better than replacement?

Abstract

OBJECTIVES Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients. METHODS Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and ‘patch’ repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed. RESULTS In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504–2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002–6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52). CONCLUSIONS Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.

Feasibility and outcome of mitral valve repair in patients with infective endocarditis

“…The repair rate in our study was similar to that reported in the review of Feringa et al, but clearly lower than the feasibility reported by Defauw et al of 66% [21] or by de Kerchove et al of 80% [22]; on the other hand, we registered a lower in-hospital mortality (4%) than the latter two, who reported 15.4% and 16%, respectively. We favored safety, at the price of a lower rate of complex repair procedures, with similar long-term survival rate.…”

“…Similar to the degenerative MR experience, valve repair recently became the procedure of choice in IE, as confirmed by several studies [18][19][20][21][22]. Patients who undergo mitral valve repair need significantly fewer reinterventions during the early post-operative period and long-term follow-up and have less long-term IE relapses and cerebrovascular events.…”

“…The feasibility of mitral valve repair in patients with infective endocarditis is still a matter of debate, since it seems to vary significantly among different centers [11][12][13][14][15][16][17][18][19][20][21][22]. Although most studies agree about the benefits of repair, any single experience adds strength to recommend this strategy.…”

“…Reconstructive surgery in inflammatory tissue may be hard, and the feasibility of repairing infected mitral valves for acute IE has been reported to vary considerably [11][12][13][14][15][16][17][18]. In a systematic review of 24 studies on this issue, Feringa et al [3] observed that valve repair was possible in approximately 39% of patients presenting with mitral valve IE, but some recent experiences report a higher feasibility rate, even over 80% [19][20][21].…”

Rupture of Both Left-Sided Valves Following Endocarditis Causing One Trouble After Another: A Case Report

“…Acute severe regurgitations which lead to heart failure should be managed by surgical intervention as soon as possible [ 11 ]. In patients with active infective endocarditis, valve repair seems to be a better option than replacement [ 12 ] as valve replacement is associated with the risk of future episodes of endocarditis [ 13 ]. However, our patient was not in active infection and underwent both mitral and aortic valves replacement.…”