Long-term Outcomes of Surgery for Invasive Valvular Endocarditis Involving the Aortomitral Fibrosa

Abstract

Background. Reconstruction of the intervalvular fibrosa (IVF) for invasive double-valve infective endocarditis (IE) is a technically challenging operation. This study presents the long-term outcomes of two surgical techniques for IVF reconstruction.Methods. From 1988 to 2017, 138 patients with invasive double-valve IE underwent surgical reconstruction of the IVF, along with double-valve replacement (Commando procedure, n [ 86) or aortic valve replacement with mitral valve repair (hemi-Commando procedure, n [ 52). Mean follow-up was 41 ± 5.9 months.Results. Reoperation was required in 82% of patients, and 34% underwent emergency surgery. Pathologic features included positive blood cultures (90%), prosthetic valve IE (75%), aortic root abscess (78%), mitral annular abscess (24%), and intracardiac fistula (12%). There were 28 hospital deaths: 21 (24%) in the Commando group and 7 (14%) in the hemi-Commando group (P [ .12). Overall survival at 1, 5, and 10 years was 67%, 48%, and 37%, respectively. Coronary artery disease, native valve IE, and causative organism (Staphylococcus aureus, coagulasenegative Staphylococcus, and viridans streptococci) were risk factors for late mortality. Freedom from reoperation at 1, 5, and 8 years was 87%, 74%, and 55%, respectively. Freedom from recurrent IE at 1, 5, and 8 years was 90%, 78%, and 67%, respectively.Conclusions. Although it is technically demanding, surgery for invasive IE involving IVF, which provides the only chance for cure, can be performed with reasonable clinical outcomes. In cases of IE invading the IVF and limited to the anterior mitral valve leaflet, a hemi-Commando procedure that includes mitral valve repair has improved early outcomes.

Magnetic resonance imaging in a patient with temporary external pacemaker

“…With the imaging results of the brain MRI and cardiac CT, cardiac surgery evaluated the patient and estimated an approximately 40% operative mortality risk and determined that surgical intervention could not be safely offered. 6 After discussions with palliative care, the patient’s family decided to transition to comfort-oriented care. The patient subsequently died on hospital day 14.…”

Contemporary Surgery in Infective Endocarditis

“…The so-called "commando" or "hemi-commando" operations could be an option ( Figure 1A-D). Elgharably et al reported one-year survival of 91% and a 3-year survival of 82% when the hemi-commando procedure was performed, with recent additional information on the reconstruction of the aortomitral fibrosa in general with different techniques (27)(28)(29) . Moreover, such operations Review Article require long cardiopulmonary bypass, ischemic and overall operative times, which increase further the risk of postoperative complications.…”

Fibrous skeleton reconstruction for invasive aortic and mitral valve endocarditis

“…(B) The exposure following debridement of all infected tissue, removal of the aortic and mitral valves, and removal of the intervalvular fibrosa. Image courtesy of Navia et al4 Used with permission.…”

“…The first step in the reconstruction, showing the mitral prosthesis sewn along the posterior two-thirds of the annulus. Image courtesy of Navia et al4 Used with permission.…”

“…Placement of the patch: the aortic valve is placed and sewn onto the patch. Image courtesy of Navia et al4 Used with permission.…”