Surgical Outcomes and Complications

Excellent surgical results can be achieved in situations where infection has been brought under control, IE is confined to a native valve, valve damage is amenable to repair or simple replacement, and the patient is relatively young without comorbidities. Table 8.3 summarizes factors that negatively affect morbidity and/or mortality after surgical management of IE.

Both short- and long-term results are less favorable following surgery for PVE as compared

Right — coronary artery

Non-coronary sinus

Figure 8.4. Various locations and extents of infection on the aortic valve. A: Lesion limited to the right coronary cusp,sparing the annulus.The lesion has eroded the cusp, resulting in a tear in the cusp. B: Lesion involving the right coronary cusp and extending to the annulus. C: A diseased noncoronary sinus with extension of the lesion to the annulus and the anterior mitral leaflet.

Figure 8.4. Various locations and extents of infection on the aortic valve. A: Lesion limited to the right coronary cusp,sparing the annulus.The lesion has eroded the cusp, resulting in a tear in the cusp. B: Lesion involving the right coronary cusp and extending to the annulus. C: A diseased noncoronary sinus with extension of the lesion to the annulus and the anterior mitral leaflet.

Tga Switch Operation

Figure 8.5. A: An aortic homograft without the aortomitral curtain. B: The defect left from the removal of the aortic root and the diseased aortomitral curtain. C: A pericardial patch is first used to repair the defect at the aortomitral location. D: The aortic homograft is then anchored in place with part of the homograft sutured onto the pericardial patch.

Figure 8.5. A: An aortic homograft without the aortomitral curtain. B: The defect left from the removal of the aortic root and the diseased aortomitral curtain. C: A pericardial patch is first used to repair the defect at the aortomitral location. D: The aortic homograft is then anchored in place with part of the homograft sutured onto the pericardial patch.

Infective Endocarditis 101

Figure 8.6. Homografts can be used in the reconstruction of extensively diseased aortic root. A: An aortic homograft with the accompanying aortomitral curtain. B: The aortomitral curtain of the aortic homograft can be used to repair the defect caused by the removal of aortic root lesions extending to the aortomitral location.

Figure 8.6. Homografts can be used in the reconstruction of extensively diseased aortic root. A: An aortic homograft with the accompanying aortomitral curtain. B: The aortomitral curtain of the aortic homograft can be used to repair the defect caused by the removal of aortic root lesions extending to the aortomitral location.

Table 8.3. Factors Adversely Affecting Surgical Outcomes (Mortality and Morbidity)

PVE (versus NVE) Intracardiac abscess Left-sided (versus right-sided) IE Aortic (versus mitral) IE

Extensive disease/destruction, multiple valve involvement Staphylococcal or culture-negative infection Advanced age

Increasing cardiopulmonary bypass and aortic cross-clamp time Valve replacement versus repair (affects morbidity only) Delay in surgery in face of worsening cardiac function Early PVE (associated with higher rate of late death) Emergent /urgent surgery due to progressive heart failure Poor LV function (whether or not due to IE) Postoperative sepsis (most commonly pneumonia) Postoperative renal failure Liver failure

Table B.4. Hospital (or 30-Day) Mortality in NVE and PVE

Study

NVE (%)

PVE(%)

P-value

Murashitaetal.,2004 [28]a

15.5

33.3

0.0123

Romano et al., 2004 [29]

6.6

24.2

<0.0001

d'Udekem etal.,1997 [5]

4

13

0.062

Wilhelm et al., 2004b [23]

3.2

Amrani etal.,1995c [30]

8.5

Akowuah etal.,2003d [31]

24

a Numbers in brackets [ ] indicate reference numbers.

b Native mitral valve endocarditis.

c Native aortic valve endocarditis.

d Aortic and/or mitral PVE.

to NVE (Tables 8.4 and 8.5). The reasons for relatively poor outcomes in PVE are higher rates of staphylococcal infection and perivalvular abscess, the presence of less healthy perivalvular tissue, risks of reoperation, and a generally older population compared to NVE patients. Multiple valve disease is associated with more extensive tissue destruction, longer duration of operation, and less favorable results (Table 8.5).

The infecting microorganism directly affects mortality and morbidity. Staphylococcal infections, especially those caused by Staphylococcus aureus, as well as culture-negative IE are associated with poor outcomes (Tables 8.6 and 8.7). Staphylococcus aureus infections cause more extensive destruction, more frequent abscess formation, and greater hemodynamic derangement.

Valve repair procedures, especially in the mitral position, are associated with significantly lower postoperative morbidity than valve replacement. However, there is no significant difference between repair and replacement procedures in terms of mortality (Table 8.8).

The first postoperative year is of crucial importance, as most of the adverse events occur during this period. Patients who have an eventfree first postoperative year are likely to have a favorable long-term survival. Table 8.9 summarizes surgical complications. Recurrent IE is a serious postoperative complication and is associated with poor prognosis, especially when it occurs in the replaced prosthetic (versus repaired native) valves. Early recurrent IE is usually due to residual infected tissue, and the recurrence risk can be minimized by complete debridement of the infected tissue and proper surgical technique. Late recurrent IE is more frequent in patients who have abscess at the

Table 8.5. Survival in NVE and PVE

Survival in NVE (%)

Study

1-year

5-year

10-year

15-year

20-year

P-value

Romano etal.,2004 [29]a

91

82

67.5

48.8

0.0016 (vs. PVE)

Wilhelm etal.,2004 [23]

93

81

61

Amrani etal.,1995 [30]

Non-complex operationsb

93.5

93.5

0.042

Complex operationsc

79.9

76.1

Moon etal.,2001[32]

54

44

<0.003 (vs. PVE)

Survival in PVE (%)

1-year

5-year

10-year

15-year

20-year

P-value

Romano etal.,2004 [29]

79.7

64.2

33.5

33.5

0.0016 (vs. NVE)

Moon etal.,2001[32]

41

16

<0.003 (vs.NVE)

Akowuah etal.,2003 [31]

58

a Numbers in brackets [ ] indicate reference numbers.

b Single aortic valve replacement.

c Aortic valve replacement plus another valve procedure.

Table 8.6. Effect of Infecting Microorganism on Survival

Study

Infecting Microorganism

Early Postoperative Mortality (%)

P-value

Murashita etal.,2004 [28]a

Amrani etal.,1995 [30] d'Udekem et al., 1996 [8]

Staphylococcus aureus, Staphylococcus epidermidis, or culture-negative

Other pathogens

Staphylococcus aureus

Other pathogens

Staphylococci

Other pathogens

8.5 0 22 3

0.158 0.020

Survival (%)

1-year

5-year 10-year

P-value

Wilhelm etal.,2004 [23]

Staphylococcus aureus Other pathogens

76.5 98.9

65 44 84.9 67

0.008

a Numbers in brackets [ ] indicate reference numbers.

time of the initial operation [9]. Recurrent IE rates are given in Table 8.10.

There is no significant difference in either short- or long-term survival between mechani cal and bioprosthetic valves. A recent study suggests superiority of mechanical valves in the mitral position in terms of mortality for patients 51-70 years of age [33]. However, further studies are required to support this finding. Due to the need for lifetime anticoagulation in mechanical valves, this group has a higher risk of hemorrhage. Reoperation, on the other hand, is more common in bioprosthetic valves due to propensity for degeneration over time. Bioprostheses are also associated with a higher rate of recurrent endocarditis [33-35]. Table 8.11 gives a brief comparison of mechanical versus biopros-thetic valves.

Table 8.7. Effect of Infecting Microorganisms on Event-Free Survival

(Murashita etal.,2004 [28])

Three-Year Freedom

Infecting Microorganism

from Events (%)

Staphylococcus aureus

55.6

Culture-negative

47.6

Streptococcus

100

Table 8.8. Valve Replacement Versus Repair

Operative/In-Hospital Mortality

Study

Mortality with Repair (%)

Mortality with Replacement (%)

P-value

Wilhelm etal.,2004 [23]a

1.7

4

0.67

Mihaljevic etal.,2004 [24]

0

13

0.14

Survival (%)

1-year

5-year

10-year

P-value

Wilhelm etal.,2004 [23]

Valve replacement

96.5

92.5

79

0.1

Valve repair

98

95.4

95.4

Mihaljevic etal.,2004 [24]

Valve replacement

78

73

Not significant

Valve repair

85

85

Morbidity

Variable

Valve Replacement

Valve Repair

P-value

Wilhelm etal.,2004 [23]

Perioperative Morbidity

(<30 days after surgery)

62%

5%

< 0.001

Mihaljevic etal.,2004 [24]

Median of Hospital Stay

21 days

9.5 days

<0.01

a Numbers in brackets [ ] indicate reference numbers.

Table 8.9. Postoperative Complications

Early Complications

Late Complications

Failure of repair procedure

Deterioration of repair

Prosthetic dehiscence with/

Prosthetic dehiscence with/

without significant paravalvular

without significant

leakage

paravalvular leakage

Sepsis (most commonly pneumonia)

Anticoagulation-related events

(in mechanical valves)

Renal failure

Hemorrhage

Recurrent IE, including PVE

Need for reoperation

Bioprosthesis degeneration

Atrioventricular block and/or

arrhythmia (with/without need

for permanent pacemaker)

Recurrent IE, including PVE

Table 8.10. Risk of Recurrence of Infective Endocarditis Following Surgical

Intervention for Endocarditis

Type of IE

Rate of Recurrent IE (%)

Study

in the Study

At 5 years

At 10 years

d'Udekem et al.,

1997 [8]a

NVE and PVE

9

21

Mihaljevic et al.,

2004 [24]

NVE

5.7b

Akowuah et al.,

2003 [31]

PVE

40

a Numbers in brackets [ ] indicate reference numbers.

b All reinfections occurred within 5 months of surgery.

Table 8.11. Comparison of Outcomes in Mechanical and Bioprosthetic Valves

Table 8.11. Comparison of Outcomes in Mechanical and Bioprosthetic Valves

Operative Mortality: No significant difference Bleeding: More frequent in mechanical valves (Associated with anticoagulation)

Reoperation: Higher rate with bioprostheses in younger (< 60 years)

patients (Degeneration) Recurrent Endocarditis: More frequent in bioprostheses Long-Term Survival: No significant difference

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