Annular Abscess Research Articles

Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess

Background The valve substitute of choice in active infective aortic valve endocarditis complicated by annulus abscess in our institution is the cryopreserved homograft. To avoid implantation of any prosthetic material, the Shelhigh No-React stentless valves and conduits may be considered an alternative when no suitable homograft is available. Methods Between March 1986 and January 2001, 452 homografts were implanted in the aortic position. From January 2000 to August 2001, 75 Shelhigh No-React prostheses were implanted at our institution. In 25 consecutive patients (study group) with aortic annulus abscess, urgent aortic valve replacement with the Shelhigh SuperStentless and Stentless Aortic Valve Conduit was undertaken. Patients (16 male, 9 female; age, 49 ± 19 years) were studied with follow-up until March 2002. The control group comprised 68 consecutive historical patients (46 male, 22 female; age, 53 ± 14.4 years) with similar disease treated between January 1997 and December 1999 in whom an aortic homograft was implanted. This group was also followed up until March 2002. Demographic data and preoperative characteristics of the patients were without significant differences. Patients were studied by echocardiography. Results Sixty-day mortality was 16% (11 patients) in the control group compared with 12% (3 patients) in the study group. Recurrent infection occurred in 4% in both groups. The instantaneous and mean Doppler gradients yielded no significant differences (19.4 ± 10.4 mm Hg and 11.8 ± 5.7 mm Hg versus 18.2 ± 8.7 mm Hg and 10.9 ± 5.3 mm Hg, respectively). The mean effective orifice area calculated from Doppler flow velocity for the stentless valve was 2.3 ± 0.6 cm 2. Preoperative evaluation of left ventricular dimensions and global left ventricular systolic function did not vary significantly between the two groups. However, postoperatively evaluated left ventricular end-diastolic diameter dimensions in the study group were significantly smaller than those in the control group (47.6 ± 7.9 mm versus 56 ± 9.5 mm; p = 0.05). Ejection fraction was similar in both groups (56.2% ± 12.8% for the study [Shelhigh] and 52.6% ± 16.8% for the control [homograft] group). Conclusions Our experience with both the Shelhigh No-React SuperStentless and Stentless Aortic Valve Conduit in patients with native or prosthetic aortic valve endocarditis appears to demonstrate good results, similar to those of cryopreserved homografts. Ease of implantation and favorable effective orifice area and pressure gradients, as well as the No-React anticalcification treatment, are promising factors.

Repair of spontaneous rupture of the posterior wall of the left ventricle after mitral valve replacement

One of the most serious complications in cardiac surgery is the occurrence of a rupture of the posterior wall of the left ventricle after mitral valve replacement. This is a challenging and often humbling experience to the cardiac surgeon, carrying a significant morbidity and mortality. The original reports of this complication were documented in the late 60s and early 70s. 1-3 Since then, multiple reports of isolated cases or short series have appeared in the literature, describing the events and proposing different technical approaches to prevent and correct the problem. The etiologic factors have become well recognized, and preventive measures, including new developments and technical approaches to mitral valve surgery, have reduced markedly the incidence of this problem and virtually eliminated the potential occurrence of certain types of left ventricular rupture. Three specific types of rupture are described (Fig 1) and they have been classified according to their anatomic location. 2,4 TYPE I A Type I rupture is located at the atrioventricular groove. This remains the most common site and can be seen in the following circumstances: ● Heavily calcified mitral valve annulus requiring considerable dissection and debridement of calcium sediment from the atrioventricular groove. ● Cases of bacterial endocarditis with mitral valve annular abscess, requiring extensive debridement at the time of mitral valve replacement.5 ● Resection of the posterior leaflet with placement of subannular sutures for valvular replacement, with consequent local trauma, hematoma, and rupture. ● Improper inspection of the left ventricular posterior wall after mitral valve replacement, by lifting the heart from the pericardial cavity, erroneously using the atrioventricular groove as a fulcrum.

Mitral valve replacement in patients with mitral annulus abscess

R of the mitral valve in the presence of an abscess of the mitral annulus presents a major challenge to the surgeon. The patients involved are frequently very ill as a result of uncontrolled infection as well as hemodynamic compromise because of valve dysfunction. They frequently have severe coagulation derangements before surgery. It is not surprising that surgery in these patients is associated with a relatively high mortality and complication rate. However, a carefully planned surgical approach offers these patients the best chance of survival. There are two fundamental principles that a surgeon must adhere to in treating these patients. The first one is that all of the infected valvular and perivalvular material must be removed before a new prosthesis is secured in place. Failure to do this will invariably result in reinfection of the new valve prosthesis as well as the surrounding annulus. Once all the infected material is removed, the surgical team should change their gown and gloves. All instruments used to remove the infected material are discarded, and new sterile towels placed around the open wound. Complete removal of all of the infection, especially the infected annular tissue, will often leave insufficient annulus to which a new valve can be secured. This leads to the second principle, which is to carefully reconstruct the annulus before sewing in a new valve. Simply attempting to secure a new valve into a partially destroyed annulus will either result in immediate and usually fatal atrial ventricular disassociation or to early valve dehiscence. The following outlines the surgical steps that we recommend for management of the infected mitral annulus. The simplest repair applies to the case where only one part, usually the posterior part, of the annulus is involved. A more complex repair, which is really an extension of the simplest repair, is required if the entire circumferential annulus is infected, as is often the case with a previously inserted infected prosthetic valve. Finally, if the infection is so extensive so that not only is the mitral annulus destroyed but also part of the aortic annulus and the central fibrous body, an extensive and complex reconstruction is required. We will review the surgery for the first two conditions. Further details regarding the most complex reconstruction are outlined in previously published articles.1,2

Treatment of destructive aortic valve endocarditis with the freestyle aortic root bioprosthesis

Background Successful treatment of destructive aortic valve endocarditis with annular abscess formation requires extensive surgical debridement and reconstruction of the left ventricular outflow tract and aortic root. Homograft aortic roots are the conduits of choice, but because they are not available in all cases, alternative conduits are needed. Methods Owing to its features, which are comparable to those of homografts, the Freestyle aortic root xenograft was used in 10 consecutive patients aged between 32 and 77 years. All patients had extensive abscess formation, 5 presented with prosthetic valve endocarditis, 2 had additional mitral valve endocarditis requiring partial leaflet resection and reconstruction, 1 patient had an additional fistula into the right atrium, and 1 required coronary bypass. One patient developed a septic ventricular septal defect and fistula into the right atrium with tricuspid valve endocarditis. Results None of the patients required reoperation for bleeding. Two (20%) patients died in the postoperative period, 1 due to multiorgan failure, and 1 due to preexisting invasive pulmonary aspergillosis. At autopsy, neither had evidence of intrapericardial hematoma or suture dehiscence. One patient died 13 months postoperatively without clinical signs of valve dysfunction or recurrent endocarditis. All other patients are well at 12 to 42 months after surgery. Clinical examination and echocardiography at the most recent follow-up showed no signs of valve dysfunction, recurrent fistulation, or endocarditis. Conclusions The Freestyle aortic root appears to be an acceptable alternative to homografts in the treatment of severe endocarditis. Long-term valve durability in younger patients, however, remains to be determined.

Multivariate analysis of risk factors for hospital mortality in valvular reoperations for prosthetic valve dysfunction.

The purpose of the study was to analyze risk factors for hospital mortality in patients undergoing valvular reoperations for prosthetic valve dysfunction. We performed a prospective analysis of 146 patients who underwent valvular reoperations for prosthetic valve dysfunction between July 1995 and June 1999 at the Heart Institute of the University of São Paulo Medical School. Multivariate statistical analysis with logistic regression was used to analyze preoperative and intraoperative variables to determine risk factors for hospital mortality. The overall hospital mortality was 10.9% (16 patients). Univariate analysis showed that the following variables were associated with higher mortality rates: advanced New York Heart Association (NYHA) functional class, increased creatinine level, prolonged extracorporeal circulation time and treatment of annular abscess. Logistic multivariate analysis identified advanced NYHA functional class and a creatinine level higher than 1.5 mg/dl as independent predictors of hospital mortality. Advanced NYHA functional class and higher creatinine levels were independent predictors of hospital mortality in patients submitted for valvular reoperations for prosthetic valve dysfunction.

ENHANCING STRATEGIES TO TREAT MRSA INFECTION IN CARDIOVASCULAR SURGERY

PURPOSE OF STUDY: Consequences of infections including mediastinitis, annular abscess and prosthetic graft infection can he serious and associated with longer hospital stay, higher mortality. Particularly, methicillin-resistant staphylococcus aureus (MRSA) is hard to handle. The aim of this study was to develop the controlled release system of vancomycin (VM) with biodegradable polymers for adjuvant topical treatment of MRSA infection. METHODS USED: Co-polymers of D, L-lactic acid and ε-caprolactone was mixed with VM aqueous solution (dosage of 0.9 mg). In Study-1, drug release test was performed for 14 days. In Study-2, after implantation of the film into the back subcutis of rats, the drug concentration was detected around the implanted site. Study-) was conducted to evaluate how much the film inhibits MRSA infection (106CFU/ abscess) by use of microcarrier heads as abscess-promoting agents in rats. SUMMARIZE RESULTS: Study-1 revealed that the controlled release of VM was achieved from the copolymer film over 14 days. In Study-2, the film exhibited the drug release for 7 days in vivo. In Study-3, the film suppressed MRSA proliferation more than subcutaneous injection of free VM after implantation (Day3 4.05±0.59 v.s. 4.55±0.27, Day14 5.09±0.47 V.S. 6.33 ± 0.61 log of CFU/ abscess, P < 0.05). In conclusion, the biodegradable copolymer achieved the controlled release of vancomycin in an effective dose both in vitro and in vivo. The drug-copolymer composite may be a promising tool to treat MRSA infections.

Functional tricuspid regurgitation secondary to aortic annular abscess: An unusual presentation of infective endocarditis

An unusual case of aortic annular abscess is presented, in which the patient presented with features of gross tricuspid regurgitation. There was no direct involvement of the tricuspid valve. Tricuspid regurgitation disappeared following surgical repair of the annular abscess. The present case also illustrates the utility of trans-oesophageal echocardiography in establishing the diagnosis and planning surgical intervention.

Acute type A aortic dissection associated with an aortic annular abscess

We describe a 66-year-old woman who underwent open heart surgery because of congestive heart failure. During operation, we found a Stanford type A dissection and an aortic ring abscess, which had burst into the aortic lumen. No other entries were found. Pathological examination showed excessive neutrophil infiltration in the aortic root. We strongly suspect that the abscess produced the intimal tear to cause the aortic dissection.

Redo aortic root replacement: experience with 31 patients

Background. Aortic root re-replacement is being performed with increased frequency. Limited information is available regarding the surgical approaches and clinical outcomes of this reoperation.Methods. Between May 1980 and May 1999, 31 patients (mean age, 45 ± 15 years) underwent redo composite replacement of the aortic valve and ascending aorta. Indications for reoperation were prosthetic valve endocarditis in 12 patients (39%), failed biological valve in 17 (55%), and false aneurysm in 2 (6%). At reoperation, mechanical valves were implanted in 24 patients and biologic valves in 7. All patients with endocarditis had annular abscess and required reconstruction of the left ventricular outflow tract before implantation of a new valved conduit. Mechanical valves were used in 24 patients, aortic homograft in 4, and bioprosthetic valves in 3. The coronary button technique was used to reimplant the coronary arteries whenever possible. Extension of one or both coronary arteries with a short segment of saphenous vein or a synthetic graft was used in 16 patients (52%). The aortic arch was replaced in 7 patients (23%).Results. There was one operative death (3%) because of rupture of an abdominal aortic aneurysm. The mean follow-up was 47 ± 46 months and was 100% complete. There were five late deaths (16%), three of which were cardiac related. The actuarial survival was 71% ± 12% at 5 years. Three patients experienced recurrent prosthetic valve endocarditis 4 months to 8 years after operation. The 8-year freedom from endocarditis for patients operated on for endocarditis was 82% ± 11% compared with 100% for those operated on for other reasons (p = 0.1). At the last follow-up, 21 of 25 survivors (84%) were in New York Heart Association functional classes I or II, and 4 were in class III.Conclusions. Redo aortic root replacement can be performed with good early and late results. Patients operated on for prosthetic root endocarditis may have an increased risk of recurrent late endocarditis.

Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features

Background. The aim of this study was to determine patterns of anatomic, clinical, and operative features in surgical endocarditis (SE) with annular abscess (AA). Methods. The study consisted of a retrospective analysis of SE cases with AA between 1981 and 1997. Results. A total of 41 cases with AA were found in 106 consecutive SE cases. There was a higher incidence of AA in aortic (37 of 71 [52%]) ( p < 0.01) compared to mitral (6 of 42 [14.3%]) or tricuspid (0 of 12) infections. However, the mitral abscesses had a greater tendency toward fistula or pseudoaneurysm formation (4 of 6 [67%]) than other valve abscess cavities (7 of 46 [15%]) ( p < 0.01). Severe heart failure ( p < 0.01), heart block ( p < 0.05), and fistula/pseudoaneurysm ( p < 0.001), were more often found in SE with AA than without. There were 46 separate aortic AA in 37 instances of aortic valve SE. Of these, 31 of 46 (67%) were less than 1 cm (group 1), 10 of 46 (22%) were large but confined to a given cusp annulus (group 2), 4 of 46 (8.6%) were large between multiple cusps (group 3), and 1 of 46 (2.2%) was circumferential (group 4). There were four instances of aortoventricular discontinuity. Group 1 abscesses were repaired by local closure without a patch significantly more often than the other groups. The mortality of SE with AA was significantly greater for larger AA (groups 3 and 4, 3 of 5 [60%]) than for smaller AA (groups 1 and 2, 0 of 36) ( p < 0.001). There were six separate mitral AA in six instances of mitral SE, five requiring patch repair. The 30-day operative mortality for AA cases was 3 of 41 (7.3%) compared to 2 of 65 (3.1%) without AA. All AA mortalities involved large AA in the aortic valve position. Of 35 mechanical valves placed for AA, only one required subsequent removal for prosthetic endocarditis. Conclusions. Annular abscesses are most frequent in aortic AA, but fistulas/pseudoaneurysms are more frequent in mitral AA. Small to moderate aortic AA can be managed by local closure without an increased mortality compared to SE without AA. Patients with large aortic AA have a higher operative mortality. Mechanical prostheses are safe and effective for the majority of patients with AA.

Surgery for active culture-positive endocarditis: determinants of early and late outcome

Background. The purpose of this study was to describe a single unit experience in the surgical treatment of active culture-positive endocarditis and identify determinants of early and late outcome.Patients and Methods. One hundred eighteen consecutive patients with positive blood culture up to 3 weeks before operation (or positive valve culture) and macroscopic evidence of lesions typical for endocarditis, undergoing operation between January 1973 and December 1996 in Southampton, were evaluated. The aortic valve was infected in 53 (48.9%), the mitral in 46 (39%), both aortic and mitral in 12 (10.1%), the tricuspid in 4 (3.9%), and the pulmonary valve in 3 (2.5%). Native valve endocarditis was present in 83 (70.3%) and prosthetic valve endocarditis in 35 (29.7%). Streptococci and staphylococci were the most common pathogens. Mean follow-up was 5.6 years (range, 0 to 25 years).Results. Operative mortality was 7.6% (9 patients). Endocarditis recurred in 8 (6.7%). A reoperation was required in 12 (10.2%). There was 24 late deaths, 17 of them cardiac. Actuarial freedom from recurrent endocarditis, reoperation, late cardiac death, and long-term survival at 10 years were 85.9%, 87.2%, 85.2%, and 73.1%, respectively. On multiple regression analysis the following were independent adverse predictors: pulmonary edema (p = 0.007) and impaired left ventricular function (p = 0.02) for operative mortality; prosthetic valve endocarditis (p = 0.01) for recurrent infection; myocardial invasion by the infection (p = 0.01) and reoperation (p = 0.04) for late cardiac death; and coagulase-negative staphylococcus (p = 0.02), annular abscess (p = 0.02), and longer intensive care unit stay (p = 0.02) for long-term survival.Conclusions. Operation for active culture-positive endocarditis carries an acceptable mortality. Freedom from recurrent infection, reoperation, and long-term survival are satisfactory. In our data, patients’ hemodynamic status at operation was the major determinant of operative mortality. Prosthetic valve endocarditis, coagulase-negative staphylococcus, and annular or myocardial infectious invasion were the critical adverse determinants of late outcome.

Long term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone?

OBJECTIVETo identify predictors for the safe use of antibiotic treatment without reoperation in patients with prosthetic valve endocarditis.SETTINGRetrospective study in a tertiary care centre.SUBJECTS AND DESIGNAll 49 episodes of definite...

The freestyle stentless bioprosthesis for prosthetic valve endocarditis

We report a case of methicillin-resistant Staphylococcus aureus-induced prosthetic valve endocarditis, which was successfully treated with aortic valve replacement using the Freestyle stentless bioprosthesis. The total root and stentless design of this bioprosthesis allows for more radical removal of infected tissue and easier treatment for annular abscess, while requiring less prosthetic materials than a conventional prosthesis. This bioprosthesis thus seems to be a valuable option for active endocarditis.

Allograft Aortic Root Replacement in Prosthetic Aortic Valve Endocarditis: A Review of 32 Patients

Background. This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction.Methods. From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 ± 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 ± 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 ± 11.8 days.Results. There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 ± 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%)Conclusions. Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.(Ann Thorac Surg 1997;63:1644–9)

Results of allograft aortic valve replacement for complex endocarditis

Methods: Between November 1985 and July 1995, 36 patients underwent allograft aortic valve replacement for endocarditis. The mean age of the 29 men and seven women was 53 years (range 25 to 79 years). Previous procedures included mechanical ( n = 9), bioprosthetic ( n = 5), and allograft ( n = 2) aortic valve replacement, aortic valvotomy ( n = 1), and orthotopic heart transplantation ( n = 1). Infecting organisms were Staphylococcus and Streptococcus species in 69% of patients and fungi in 6%. Intraoperative findings demonstrated valvular vegetations ( n = 25), annular abscesses ( n = 25), and cusp destruction ( n = 13). Complex reconstruction of the aortic anulus was required in 25 patients, and associated procedures included mitral valve repair ( n = 2), mitral valve replacement ( n = 3), coronary artery bypass grafting ( n = 8), repair of ventricular septal defect ( n =4), left ventricular aneurysmectomy ( n = 1), and repair of atrial septal defect ( n = 1). Allograft valve insertion was performed by the scalloped technique in seven, intraaortic cylinder technique in 19, and allograft aortic root replacement in 10. Results: Follow-up was 100% complete at a mean of 2.6 ± 2.8 years after valve replacement. Operative mortality was 13.8%. Complications included low cardiac output ( n = 10), bleeding ( n = 2), myocardial infarction ( n = 1), stroke ( n = 1), renal insufficiency ( n = 2), respiratory insufficiency ( n = 3), and heart block ( n = 8). Late echocardiogram (mean 2.6 ± 1.8 years) demonstrated grade III/IV aortic regurgitation in five patients. There were seven late deaths (five cardiac, not valve-related; two noncardiac). No patient has had recurrence of endocarditis. Actuarial survival at 5 years was 53.1% ± 11.5%. Univariate analysis demonstrated prosthetic valve endocarditis to adversely affect late survival ( p = 0.04). Cumulative risk of reoperation at 5 years was 8.0% ± 5.6%. Conclusion: Allograft aortic valve replacement facilitated reconstruction of complex aortic valve endocarditis with a low reoperation rate and no recurrent endocarditis in this series.

Surgical treatment of infective endocarditis complicated by annular infection and cerebral infarction.

The surgical treatment of nine patients with infective endocarditis (IE) complicated by annular infection and five with IE complicated by cerebral infarction is described herein. In those with annular infection, after thorough débridement of the infected tissues, valve replacement was performed at the original position in five, at the supraannular position in three, and one underwent a translocation procedure. Aortic valve replacement was able to be performed at the original position in two patients by closing the defect at the aortic annulus with a patch after through débridement. The five patients who underwent original valve position replacement recovered well. Of the three who underwent supraannular position replacement, two died of septicemia after a redo operation, and one received pacemaker implantation. The patient undergoing the translocation procedure died of intestinal infarction. In the five patients who suffered cerebral infarction due to embolus of the vegetation, valve replacement was performed between 40 h and 5 months after its onset. Although one patient died of the rapid progression of brain damage, the other four are alive and well, including two who developed mycotic cerebral aneurysm in the infarcted areas. In conclusion, early surgery for IE is mandatory irrespective of active infection, due to the high mortality and morbidity associated with serious sequelae such as annular abscess or cerebral infarction.

Surgical treatment of Brucella endocarditis

Between April 1987 and October 1992, six cases of Brucella endocarditis were operated on in the authors' hospital for valve replacement. They were five men and one woman with a mean(s.d.) age of 52(15) years (range 30–71 years). Three patients were in New York Heart Association (NYHA) class III and three in class IV. Two patients had previous history of rheumatic fever, one was a drug abuser, two had peripheral embolism and one constrictive pericarditis. Most were living in rural areas. Echocardiographic diagnoses were: severe aortic regurgitation in two patients, mixed disease in two and double valve involvement in two. Valve vegetations were demonstrated in two patients, valve calcification in two and annulus abscess in two others. Serological tests were positive in all patients. All patients had valve replacements and three were operated on as emergencies. Surgical findings were: valve vegetations in two patients, cusp perforation in two, annulus abscess in two and prosthetic leak in two. Mean(s.d) cardiopulmonary bypass time was 123(77) min with a mean ischaemic time of 79(43) min. All patients were given specific antibiotic treatment after surgery. There was no intraoperative mortality and the 5-year survival rate was 100%. Early reoperations were needed in three patients, two because of prosthetic leakage causing severe regurgitation and one for tamponade. The results suggests that Brucella endocarditis is rare, but still occurs in Mediterranean areas. Surgical replacement is needed in spite of antibiotic treatment and recurrences with prosthetic leaks are usual.

Surgical Treatment of Brucella Endocarditis

Between April 1987 and October 1992, six cases of Brucella endocarditis were operated on in the authors' hospital for valve replacement. They were five men and one woman with a mean(s.d.) age of 52(15) years (range 30–71 years). Three patients were in New York Heart Association (NYHA) class III and three in class IV. Two patients had previous history of rheumatic fever, one was a drug abuser, two had peripheral embolism and one constrictive pericarditis. Most were living in rural areas. Echocardiographic diagnoses were: severe aortic regurgitation in two patients, mixed disease in two and double valve involvement in two. Valve vegetations were demonstrated in two patients, valve calcification in two and annulus abscess in two others. Serological tests were positive in all patients. All patients had valve replacements and three were operated on as emergencies. Surgical findings were: valve vegetations in two patients, cusp perforation in two, annulus abscess in two and prosthetic leak in two. Mean(s.d.) cardiopulmonary bypass time was 123(77) min with a mean ischaemic time of 79(43) min. All patients were given specific antibiotic treatment after surgery. There was no intraoperative mortality and the 5-year survival rate was 100%. Early reoperations were needed in three patients, two because of prosthetic leakage causing severe regurgitation and one for tamponade. The results suggests that Brucella endocarditis is rare, but still occurs in Mediterranean areas. Surgical replacement is needed in spite of antibiotic treatment and recurrences with prosthetic leaks are usual.

Reconstruction of the mitral anulus: A ten-year experience

Reconstruction of the mitral anulus was done in 93 patients because of extensive calcification in 24, infective endocarditis with annular abscess in 27, damaged anulus as a result of previous valve replacement in 36, and rupture of the posterior wall of the left ventricle after mitral valve replacement in 6. The reconstruction was done with fresh autologous pericardium in 30 patients, glutaraldehyde-fixed bovine pericardium in 56, and Dacron graft in 7. An appropriately tailored patch was sutured to the endocardium of the left ventricle or to fibrous skeleton of the heart, or to both. Sixty patients had had previous operation; most patients were in New York Heart Association functional class IV and 15 were in shock. The mitral valve was repaired in 10 patients and replaced in 83. Other procedures were aortic valve replacement in 40, tricuspid valve repair in 25, coronary artery bypass in 12, and replacement of the ascending aorta in 2. Eight patients died in the perioperative period. Postoperative complications were common. Patients were followed up from 12 to 96 months, with a mean of 30 months. There have been 18 late deaths, mostly cardiac. The actuarial survival at 5 years was 68% ± 6%. A total of 8 patients have required reoperation: 4 because of endocarditis, 2 because of bioprosthetic valve failure, and 2 because of patch dehiscence. The freedom from reoperation was 80% ± 8% at 5 years. The freedom from patch dehiscence was 95% ±4% at 5 years. Reconstruction of the mitral anulus has been an extremely useful operative technique for patients with complex mitral valve disease. (J THORAC CARDIOVASC SURG 1995;110:1323-32)

Early and Late Survival After Surgical Treatment of Culture-Positive Active Endocarditis

To describe a 30-year experience with surgically treated culture-positive active endocarditis. We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991. The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62% of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71% and 60%, respectively. Univariate determinants of an adverse long-term survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively. Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.