Abstract:Background
Contemporary data on mitral valve (MV) surgery in patients with infective endocarditis (IE) are limited.
Methods
The National Inpatient Sample was queried to identify patients with IE who underwent MV surgery between 2003 and 2016. We assessed (a) temporal trends in the incidence of MV surgery for IE, (b) morbidity, mortality, and cost of MV repair vs replacement, and (c) predictors of in‐hospital mortality.
Results
The proportion of MV operations involving patients with IE increased from 5.4% in 20… Show more
“…The current study presents a 15-year experience in a high-volume single-centre comparing the long-term outcomes of MVr and MVR in native valve endocarditis. As a specialist centre, we found that MVr was feasible in 46% of patients, higher than numerous contemporary studies [9,10,16,17]. Patients unsuitable for MVr were more likely to be higher risk (higher logistic EuroSCORE, non-elective, active IE).…”
Section: Discussionmentioning
confidence: 64%
“…Despite these clear recommendations, MVr rates have lagged. The National Inpatient Sample in the USA report a repair rate of 25% [9] and the Taiwan National Health Insurance program report a repair rate of 21% [10]. This could be due to concerns over the durability of MVr and recurrence of IE especially in active endocarditis and in non-elective surgery.…”
Objective
To describe the long-term outcomes of mitral valve repair (MVr) versus mitral valve replacement (MVR) in patients with native valve infective endocarditis (IE) at a centre with high-repair rates.
Methods
We conducted a retrospective single-centre cohort study. From 2005 to 2021, 183 patients with active or healed native valve IE were included. The primary outcome was long-term mortality. Patient status was last confirmed 31 March 2021. Secondary outcomes were post-operative MR, MV reoperation, length of post-operative intensive care stay and total hospital stay.
Results
85 patients (46.4%) underwent MVr and 98 (53.6%) underwent MVR. Follow-up was 98.9% complete. Mean follow-up time was 5.3 years with 17% of patients reaching a follow-up time of over 10 years. There were 47 deaths (25.7%) within the follow-up period. MVR patients were more likely to have higher logistic EuroSCORE, active IE and were less likely to have elective surgery. In multivariate Cox proportional hazards analysis, there was no significant difference in long-term mortality between MVr and MVR groups (hazard ratio 1.09, 95% confidence interval [0.59–2.00]). In Kaplan–Meier analysis, MVR patients had a higher all-cause mortality although there was no significant difference at the endpoint. Propensity score matching analysis showed a significantly higher mortality in the replacement group instead (p = 0.002), Subgroup analysis revealed there remained no significant difference in mortality even in patients with active IE (P-interaction = 0.859) or non-elective surgery (P-interaction = 0.122). MV reoperation (odds ratio 1.00 [0.24–4.12]), post-operative intensive care stay (p = 0.9650) and total hospital stay (p = 0.9144) were comparable.
Conclusions
Our data demonstrates repair was at least non-inferior to replacement in IE, supporting more aggressive use of repair. There is no reason the general principle of why repair is superior to replacement should not hold in IE, with enough operator expertise. Other experienced units should be encouraged to increase repair rates as feasible in line with current guidelines.
“…The current study presents a 15-year experience in a high-volume single-centre comparing the long-term outcomes of MVr and MVR in native valve endocarditis. As a specialist centre, we found that MVr was feasible in 46% of patients, higher than numerous contemporary studies [9,10,16,17]. Patients unsuitable for MVr were more likely to be higher risk (higher logistic EuroSCORE, non-elective, active IE).…”
Section: Discussionmentioning
confidence: 64%
“…Despite these clear recommendations, MVr rates have lagged. The National Inpatient Sample in the USA report a repair rate of 25% [9] and the Taiwan National Health Insurance program report a repair rate of 21% [10]. This could be due to concerns over the durability of MVr and recurrence of IE especially in active endocarditis and in non-elective surgery.…”
Objective
To describe the long-term outcomes of mitral valve repair (MVr) versus mitral valve replacement (MVR) in patients with native valve infective endocarditis (IE) at a centre with high-repair rates.
Methods
We conducted a retrospective single-centre cohort study. From 2005 to 2021, 183 patients with active or healed native valve IE were included. The primary outcome was long-term mortality. Patient status was last confirmed 31 March 2021. Secondary outcomes were post-operative MR, MV reoperation, length of post-operative intensive care stay and total hospital stay.
Results
85 patients (46.4%) underwent MVr and 98 (53.6%) underwent MVR. Follow-up was 98.9% complete. Mean follow-up time was 5.3 years with 17% of patients reaching a follow-up time of over 10 years. There were 47 deaths (25.7%) within the follow-up period. MVR patients were more likely to have higher logistic EuroSCORE, active IE and were less likely to have elective surgery. In multivariate Cox proportional hazards analysis, there was no significant difference in long-term mortality between MVr and MVR groups (hazard ratio 1.09, 95% confidence interval [0.59–2.00]). In Kaplan–Meier analysis, MVR patients had a higher all-cause mortality although there was no significant difference at the endpoint. Propensity score matching analysis showed a significantly higher mortality in the replacement group instead (p = 0.002), Subgroup analysis revealed there remained no significant difference in mortality even in patients with active IE (P-interaction = 0.859) or non-elective surgery (P-interaction = 0.122). MV reoperation (odds ratio 1.00 [0.24–4.12]), post-operative intensive care stay (p = 0.9650) and total hospital stay (p = 0.9144) were comparable.
Conclusions
Our data demonstrates repair was at least non-inferior to replacement in IE, supporting more aggressive use of repair. There is no reason the general principle of why repair is superior to replacement should not hold in IE, with enough operator expertise. Other experienced units should be encouraged to increase repair rates as feasible in line with current guidelines.
“…Despite these potential limitations, a major strength of our study is that rather than relying solely on ICD codes as multiple prior studies have done [6,9,20,29,30], we validated IE and drug use diagnoses with other clinical indicators through a detailed chart review. Use of ICD code combinations for identification of DU-IE are not specific and frequently fail to identify DU-IE cases correctly [31].…”
Introduction
Life-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years.
Materials and methods
This retrospective, observational study, incorporating manual review of electronic medical records, included all patients aged 18–90 years who had their first admission for IE in any of the four university-affiliated referral hospitals in WV during 2014–2018. IE was identified using ICD-10-CM codes and confirmed by chart review. Demographics, clinical characteristics, and healthcare utilization were compared between patients with DU-IE and non-DU-IE using Chi-square/Fisher’s exact test or Wilcoxon rank sum test. Multivariable logistic regression analysis was conducted with discharge against medical advice/in-hospital mortality vs. discharge alive as the outcome variable and drug use as the predictor variable.
Results
Overall 780 unique patients had confirmed first IE admission, with a six-fold increase during study period (p = .004). Most patients (70.9%) had used drugs before hospital admission, primarily by injection. Compared to patients with non-DU-IE, patients with DU-IE were significantly younger (median age: 33.9 vs. 64.1 years; p < .001); were hospitalized longer (median: 25.5 vs. 15 days; p < .001); had a higher proportion of methicillin-resistant Staphylococcus aureus (MRSA) isolates (42.7% vs. 29.9%; p < .001), psychiatric disorders (51.2% vs. 17.3%; p < .001), cardiac surgeries (42.9% vs. 26.6%; p < .001), and discharges against medical advice (19.9% vs. 1.4%; p < .001). Multivariable regression analysis showed drug use was an independent predictor of the combined outcome of discharge against medical advice/in-hospital mortality (OR: 2.99; 95% CI: 1.67–5.64).
Discussion and conclusion
This multisite study reveals a 681% increase in IE admissions in WV over five years primarily attributable to injection drug use, underscoring the urgent need for both prevention efforts and specialized strategies to improve outcomes.
“…In the last decade, the number of patients with IE undergoing MV surgery has increased significantly as well as the number of mitral valve repair [18] . However, the percentage of repair vs. replacement showed high variability in different centers.…”
Infective endocarditis is still a challenging clinical condition undergoing continuous epidemiologic changes, involving both the population at risk and the microbiological etiology. Antibiotic treatment alone is not effective in presence of structural abnormalities of native valves, leading to heart failure and/or to high embolic risk. Moreover, some patients despite being treated with antibiotics, their valve leaflets may undergo profound degenerative changes responsible for significant hemodynamic abnormalities. The resulting valve disease may lead to a decreased life expectancy. In these patients, surgery was the only independent factor associated with long-term survival. Valve repair in the last two decades has demonstrated to be a valuable alternative to valve replacement in mitral valve 0 endocarditis. Mitral valve repair was associated with decreased hospital and long-term mortality, recurrent endocarditis and overall need for reoperation in comparison to valve replacement. Furthermore, repair limits the risks related to prolonged anticoagulation. However, these results suffer from several limitations: results of repair are dependent on the experience of surgical team, valve damage is usually less extended in patients undergoing repair as well clinical and hemodynamic impairment are more severe in patients undergoing replacement. Therefore, although repair should be preferred when technically feasible caution must be paid to assess its absolute superiority in comparison to valve replacement.
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