Surgical treatment of valve endocarditis in high-risk patients and predictors of long-term outcomes

Abstract

Infective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97–100%), 96% (95% CI 92–100%), 85.9% (95% CI 76–97%), and 74% (95% CI 60–91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

Percutaneous transeptal mitral valve endocarditis debulking with AngioVac aspiration system

“…Reasons for nonsurgical treatment included; poor prognosis (33.7%), death before surgery (23.3%), stroke (22.7%), sepsis (21%) and hemodynamic instability (19.8%) 2 . In another retrospective study of 123 patients operated for IE, a 27% in‐hospital mortality was found in patients who had undergone prior aortic valve replacement ( p = 0.01), operated on active phase of IE versus after acute phase (16% vs. 0%, p = 0.02), and increased cross clamp time significantly affected survival rate (mean cross‐clamp time 135 ± 65 min in dead vs. 76 ± 32 min in surviving patients; p = 0.0005) when followed for mean of 57.94 ± 30.9 months 3 . While these high‐risk cohort of patients in the acute phase of IE are not offered valve surgery due to high surgical mortality risk, without surgery, they have a significantly high in‐hospital morbidity and mortality and are often placed on palliative care measures.…”

“…when followed for mean of 57.94 ± 30.9 months. 3 While these highrisk cohort of patients in the acute phase of IE are not offered valve surgery due to high surgical mortality risk, without surgery, they have a significantly high in-hospital morbidity and mortality and are often placed on palliative care measures. Thus, a percutaneous approach for mitral valve (MV) IE debulking may be an alternative therapeutic option if able to be performed in a predictable manner.…”

Endocarditis: Cardiac Surgery Treatment/A Thrilling Challenge in Cardiac Surgery

“…Habib et al In the EURO-ENDO registry, from 1 January 2016 to 31 March 2018, centers were asked to include consecutive patients aged greater than 18 years who presented with IE during a 1-year period [21]. A total of 156 centers from 40 countries included 3116 cases of IE, representing an average of 20.19 patients per center per year offers a unique opportunity to assess the current characteristics of IE in Europe [22]. It allows us to consider clinical presentation, microbiology, complications, management, and prognosis.…”

Native valve, prosthetic valve, and cardiac device-related infective endocarditis: A review and update on current innovative diagnostic and therapeutic strategies

“…Surgery can be required however also cannot be a treatment option due to patient refusal, high surgical risk, neurological complications, or death before surgery (Ortiz-Bautista et al, 2017;Habib et al, 2019). In-hospital mortality following surgery was highest for PVE (up to 27%) when compared to NVE (16%) and CDRIE (8-15%) (Ortiz-Bautista et al, 2017;Habib et al, 2019;Nasso et al, 2021).…”

“…Additionally, fungal endocarditis can occur up to 3 years following surgery ( Shokohi et al, 2014 ). The post-surgical 30-day mortality for PVE is 14–20% and at 1-year 22–36% ( Pyo et al, 2021 ; Weber et al, 2021 ), with 27% in-hospital mortality in patients with a prior aortic valve replacement ( Nasso et al, 2021 ). For both NVE and PVE, the type of prosthesis (biological or mechanical) chosen is not associated with mortality while (longer) aortic cross-clamp times are a significant mortality predictor ( Nasso et al, 2021 ).…”