Prosthetic Infective Endocarditis Research Articles

Successful treatment of healthcare-associated Mycobacterium chimaera prosthetic infective endocarditis: the first Spanish case report.

BackgroundSince 2011, several cases of health care-related disseminated Mycobacterium chimaera infection outbreaks have been reported subsequent to cardiac surgery. Diagnosis is difficult and the prognosis is extremely poor despite long-term antibiotic treatment and surgery.Case summaryWe report a Spanish case of M. chimaera infective endocarditis (IE) with disseminated infection. The patient was treated with long-term antibiotic therapy, valve replacement, and the novel use of interferon-gamma as adjuvant therapy. In addition, [18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) was used in combination with computed tomography (CT) to facilitate the diagnosis as well as to determine the duration of antibiotics and success of treatment.DiscussionDiagnosing M. chimaera IE is difficult and requires a high index of clinical suspicion. Controlling the infection is even more difficult. Interferon-g used adjuvant to surgery and antibiotic therapy could be useful in achieving this goal. Given that the appropriate duration of antibiotics is unknown, FDG PET/CT could also be a valuable tool for determining when antibiotic therapy can be withdrawn.

4775Diagnostic value of Positron emission tomography (PET/CT) in native and prosthetic infective endocarditis

4775Diagnostic value of Positron emission tomography (PET/CT) in native and prosthetic infective endocarditis

Absceso paravalvular en la endocarditis bacteriana: influencia en el pronóstico postoperatorio

ObjectiveParavalvular abscess (PAb) increases mortality, complexity and complications associated with infectious endocarditis (IE) surgery. We analysed the impact of PAb in different clinical presentations of IE. MethodsRetrospective, observational study that included all patients undergoing heart surgery because of EI between 2002 and 2015 in one center. Clinical follow-up was performed after discharge. Results169 patients were operated, and there was a PAb present in the 33% of them. Abscess was associated with increased perioperative mortality (30.9% vs. 23.4%)) and permanent pacemaker implantation (15.2% vs. 9.3%).PAb was significantly more frequent in aortic (50.0%) than in mitral (20.3%) surgery, as well as in native (44.4%) versus prosthetic (26.2%) IE.The presence of abscess significantly increased surgical mortality in aortic IE (21,4% vs. 3.6%; P=.043), with no significant differences in mitral IE (25,5% vs. 25%; P=.97). It was also associated with higher but no significantly increased mortality in native endocarditis (29.6% vs. 19.7%), with similar results in prosthetic IE (32,1% vs. 31,4%).After a median follow-up of 51 months after discharge, survival (70.6% with PAb vs. 75.7% without PAb) and re-infection (13.3% vs. 10,2%) were similar among patients with and without PAb. ConclusionThe presence of PAb was associated with poor prognosis in IE, especially in aortic and native valve involvement. When indicated, early surgery could be beneficial in these patients to prevent abscess formation. After discharge patients had a similar long-term prognosis.

術前に上腸間膜動脈塞栓症を合併した大動脈弁位人工弁感染性心内膜炎の1例

症例は75歳男性．73歳時に大動脈弁狭窄症と上行大動脈瘤に対して大動脈弁置換術（生体弁）および上行大動脈置換術を施行した．1週間前からの発熱を主訴に来院し，血液培養にてStreptococcus bovisが検出され，心エコーで人工弁尖に小さな疣贅を認めた．抗生物質治療をすぐに開始したが，上腸間膜動脈塞栓症を発症した．絶飲食管理で症状が消失したため，腸管手術はせずに経過観察することになった．この時点で人工弁尖の疣贅は消失したため，抗生物質治療を継続した．しかし，その後再び人工弁尖に疣贅が出現した．塞栓症再発予防目的に緊急大動脈弁再置換術を行った．術後食事開始とともに腸管壊死を発症し，広範囲腸管切除を要した．術前に上腸間膜動脈塞栓症を発症した場合，周術期の腸管壊死を予防するため，積極的な腸間膜動脈への血行再建を検討する必要がある．

Mid-term durability of the Trifecta bioprosthesis for aortic valve replacement

ObjectiveTo clarify the mid-term durability of the Trifecta bioprosthesis for aortic valve replacement (AVR). MethodsWe retrospectively analyzed the prospectively collected data of 824 consecutive implants of the Trifecta valve at a single institution. A 100% complete follow-up was available (average duration, 2.2 ± 1.3 years; range, 0.03-6.9 years; 1747.6 patient-years). Echocardiography data at discharge were recorded prospectively. ResultsOperative mortality was 3.8%; 2.7% in patients receiving isolated AVR. There were 5 valve-related early reoperations, including 1 for infective prosthetic endocarditis and 4 for nonstructural valve dysfunction. The global rate of severe patient–prosthesis mismatch was 1.26%. Overall 5-year survival was 74.9%, and freedom from valve-related death was 97.8%. The majority of deaths attributed to the valve were due to unknown causes. We observed 6 SVD events at 3.4 ± 1.6 years after surgery. At 5 years, the actuarial freedom from SVD was 98% ± 0.9% (n = 6), freedom from reintervention for SVD was 98% ± 0.9% (n = 5, including 2 transcatheter valve-in-valve), and freedom from open reoperation for SVD was 98.9% ± 0.6%. The 5-year freedom from prosthetic endocarditis was 97.7% ± 0.7% (n = 12, 6 requiring reoperation). There was 1 case of late NSVD (5-year freedom, 99.8% ± 0.2%). Freedom from hemorrhagic events was 98.6% ± 0.5% (86% occurring in patients on anticoagulants); there were no thromboembolic events at follow-up. ConclusionsThe Trifecta bioprosthesis is a reliable device for AVR. We confirm excellent immediate hemodynamic properties and a very low rate of patient–prosthesis mismatch. The absolute number of SVD cases observed remains limited; nevertheless, their timing, pathological characteristics, and clinical presentation mandate continued follow-up.

Comparison of prognoses of Staphylococcus aureus left-sided prosthetic endocarditis and prosthetic endocarditis caused by other pathogens

Staphylococcus aureus prosthetic valve endocarditis (SAPIE) is a serious disease. Our objective was to study the clinical, echocardiographic and prognostic characteristics of left-sided SAPIE, and to compare these characteristics with those of left-sided non-S.aureus prosthetic infective endocarditis (NSAPIE) (i.e. left-sided prosthetic infective endocarditis caused by another germ). This was a retrospective analysis of 35 cases of SAPIE among 247 cases of left-sided prosthetic valve endocarditis hospitalized at two university hospitals (Amiens and Marseille, France). SAPIE accounted for 14.1% of the cases of left-sided prosthetic valve endocarditis. SAPIE complications included heart failure (in 42.8% of cases), acute renal failure (in 51.4%), sepsis (in 51.4%), neurological events (in 31.4%), systemic embolic event (in 34.2%) and abscess (in 60.0%). In-hospital mortality occurred in 48.5% of SAPIE cases compared with 16% of NSAPIE cases. A comparison of the SAPIE and NSAPIE groups showed a significant difference in terms of 4-year survival (31.8±7.3% vs 60.1±4.1%; P=0.001). Severe sepsis was the only prognostic factor associated with in-hospital mortality (odds ratio 5.7; P=0.03) and long-term mortality (odds ratio 3.7; P=0.01) in cases of SAPIE. Sepsis-induced multiple organ dysfunction syndrome was the main cause of in-hospital mortality (70.5%). SAPIE is a very serious disease, with elevated in-hospital mortality resulting from sepsis-induced multiple organ dysfunction syndrome. Emergency surgery is recommended in these cases, when possible, before the occurrence of complications, especially severe sepsis.

Surgical treatment of infective prosthetic endocarditis of ascending aorta with aorto-pulmonary fistula and ascending aortic giant aneurysm after previous Bentall-DeBono procedure

Surgical treatment of infective prosthetic endocarditis of ascending aorta with aorto-pulmonary fistula and ascending aortic giant aneurysm after previous Bentall-DeBono procedure

Abstract 9865: A Validated, Simplified Risk Model for Predicting 6-Month Mortality in Infective Endocarditis

Introduction: Infective endocarditis (IE) is a disease with high in-hospital and longer term mortality. Hypothesis: A validated risk model of prognostic variables may improve clinical risk stratification. Methods: Using a large, multinational, prospective registry of definite IE (International Collaboration on Endocarditis-Prospective Cohort Study, 2000-2006, n=4066), a model to predict 6-month survival was developed by Cox proportional hazard modeling with inverse probability weighting for surgery treatment and internally validated by bootstrapping method. This model was externally validated in an independent prospective registry (ICE-PLUS, 2008-2012, n=1582). Results: Six-month mortality was 964/4066 (23.7%) in ICE-PCS and 346/1582 (21.9%) in ICE-PLUS cohorts. Surgery during the index hospitalization was performed in 49.5% and 56.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left-sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6-month mortality, and surgery was associated with a lower risk of mortality (Harrell’s C statistic=0.715). In the validation model, these variables had similar hazard ratios (Harrell’s C statistic=0.682), with a similar, independent benefit of surgery (HR=0.74 [95% CI, 0.62-0.89]). Both models differentiated quintiles of risk for 6-month mortality. A simplified risk model was developed by weight-adjustment of these variables. Conclusions: Six-month mortality after IE is approximately 25% and predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality. A simplified risk model may be used to identify specific risk sub-groups in IE.

Nontuberculous Mycobacteria: An Underestimated Cause of Bioprosthetic Valve Infective Endocarditis.

Background. Atypical mycobacteria, or nontuberculous mycobacteria (NTM), have been barely reported as infective endocarditis (IE) agents. Methods. From January 2010 to December 2013, cardiac valve samples sent to our laboratory as cases of blood culture-negative suspected IE were analyzed by 16S rDNA polymerase chain reaction (PCR). When positive for NTM, hsp PCR allowed species identification. Demographic, clinical, echocardiographic, histopathological, and Ziehl-Neelsen staining data were then collected. Results. Over the study period, 6 of 370 cardiac valves (belonging to 5 patients in 3 hospitals) were positive for Mycobacterium chelonae (n = 5) and Mycobacterium lentiflavum (n = 1) exclusively on bioprosthetic material. The 5 patients presented to the hospital for heart failure without fever 7.1-18.9 months (median 13.1 months) after biological prosthetic valve implantation. Echocardiography revealed paravalvular regurgitation due to prosthesis dehiscence in all patients. Histopathological examination of the explanted material revealed inflammatory infiltrates in all specimens, 3 of which were associated with giant cells. Gram staining and conventional cultures remained negative, whereas Ziehl-Neelsen staining showed acid-fast bacilli in all patients. Allergic etiology was ruled out by antiporcine immunoglobulin E dosages. These 5 cases occurred exclusively on porcine bioprosthetic material, revealing a statistically significant association between bioprosthetic valves and NTM IE (P < .001). Conclusions. The body of evidence confirmed the diagnosis of prosthetic IE. The statistically significant association between bioprosthetic valves and NTM IE encourages systematic Ziehl-Neelsen staining of explanted bioprosthetic valves in case of early bioprosthesis dysfunction, even without an obvious sign of IE. In addition, we strongly question the cardiac bioprosthesis conditioning process after animal sacrifice.

Valve disease in pregnancy

Maternal cardiac disease is a major cause of non-obstetric morbidity and accounts for 10–25% of maternal mortality. Valvular heart disease may result from congenital abnormalities or acquired lesions, some of which may involve more than one valve. Maternal and fetal risks in pregnant patients with valve disease vary according to the type and severity of the valve lesion along with resulting abnormalities of functional capacity, left ventricular function, and pulmonary artery pressure. Certain high-risk conditions are considered contraindications to pregnancy, while others may be successfully managed with observation, medications, and, in refractory cases, surgical intervention. Communication between the patient׳s obstetrician, maternal–fetal medicine specialist, obstetrical anesthesiologist, and cardiologist is critical in managing a pregnancy with underlying maternal cardiac disease. The management of the various types of valve diseases in pregnancy will be reviewed here, along with a discussion of related complications including mechanical prosthetic valves and infective endocarditis.

Trends in the profile of infective endocarditis at a university hospital in Tunis

Infective endocarditis (IE) is a serious disease for which diagnosis and treatment continue to develop. Purpose of work. To analyze trends in its epidemiologic, clinical, and microbiologic characteristics, as well as its treatment and outcome. Retrospective review of data of 135 patients admitted to our adult cardiology department from January 1981 through December 2011. IE was diagnosed according to the modified Duke Criteria. We defined 2 groups of patients according to their date of admission: group A (n = 55), patients admitted before 1995, and group B (n = 80), patients admitted in and after 1995. The entire population was predominantly male, and their mean age was 38.5 ± 16 years, 36 years in group A and 44 years in group B. IE affected mainly native valves (90% group A, 74% group B; p<0.05). Prosthetic IE was more frequent in group B (20% vs 10%, p<0.05), and the portal of entry identified more often (59% vs 22%; p = 0.03). Blood cultures were negative in 78% of patients in group A vs 57.5% in group B (p = 0.04). The principal causative microorganism was streptococcus before 1995 and staphylococcus after 1995, but this difference was not significant. Heart failure was more frequent in group A (p = 0.05). Embolic events affected 27% of the patients in group A vs 32.5% in group B (p = 0.05). The rate of surgery (51% in group A vs 62.5% in group B) did not differ significantly. The in-hospital mortality rate was 53% in group A vs 11% in group B (p<0.001); operative mortality was also higher in group A (p<0.001). Our work shows changes in the epidemiologic characteristics of IE that parallel changes in demographic and risk factors. The progress of diagnosis and surgery explains the better prognosis for this pathology today.

Determinants of Cerebral Lesions in Endocarditis on Systematic Cerebral Magnetic Resonance Imaging

Cerebral lesions are frequent complications of infective endocarditis (IE) and have a prognostic impact. Cerebral MRI identifies lesions in a high number of patients. However, their determinants have not been identified. The aim of the study was to define the determinants of cerebral lesions in patients with IE undergoing systematic cerebral MRI. Determinants of ischemic lesions and of microbleeds were prospectively analyzed in 120 patients with left-sided IE, using systematic cerebral MRI. Median age was 60 years (interquartile range 51-72); IE occurred on a prosthetic valve in 37 patients (30.8%) and was due to Streptococci in 47 patients and Staphylococci in 36; 15 (12.5%) had neurological symptoms. MRI detected ischemic lesions in 64 patients (53.3%; territorial lesions in 32 and small lesions in 57) and microbleeds in 72 (60.0%). In multivariate analysis, ischemic lesions were associated with vegetation length (odds ratio 1.10/mm; 95% confidence interval 1.03-1.16; P=0.003) and Staphylococcus aureus IE (odds ratio 2.65; 95% confidence interval 1.01-6.96; P=0.05). A vegetation length >4 mm identified ischemic lesions with a sensitivity of 74.6% and a specificity of 51.5%. Microbleeds were associated with prosthetic IE (odds ratio 8.01; 95% confidence interval 2.58-24.90; P=0.0003) and not with prior anticoagulant therapy (P=0.67). Systematic cerebral MRI frequently detects ischemic lesions and microbleeds during acute IE. The high sensitivity of MRI shows that each millimeter increase in vegetation length is associated with a 10% increase in the rate of ischemic lesions. Conversely, microbleeds are associated only with prosthetic IE in this study. http://www.clinicaltrials.gov. Unique identifier: NCT00144885.

THE TENDENCIES OF SURGICAL TREATMENT OF INFECTIVE ENDOCARDITIS DURING THE PERIOD OF 2007-2009 YEARS IN VILNIUS UNIVERSITY HOSPITAL SANTARIŠKIŲ KLINIKOS

This article describes the tendencies of surgical treatment of the patients, admitted to Vilnius University Hospital Santariškių Klinikos due to infectious endocarditis, during the period of 2007-2009 years. Objective. To assess the factors influencing the timing of surgery. To determine if timing of surgery impacts an outcome of infective endocarditis. Design and methods: Demographic, clinical, transthoracic/ transesophagal echocardiographic, microbiological, operation protocol data were analyzed. During the research patients were defined into two different groups by timing of surgical treatment. Surgery performed during the first 7 days after an admission to hospital was named as an emergent/ urgent (n=50), later surgery – as an elective (n=50). Finally, 100 patients with Duke Criteria based diagnosis entered the research. Results. There was a relation between the timing of surgery and etiologic factors of infective endocarditis evaluated, p = 0,034. Patients with diagnosis of prosthetic infective endocarditis received an elective surgical treatment usually - 9 (90%), p = 0,008. Refracteric lung edema required an urgent surgical treatment - 9 (82%), p = 0,050. If intracardiac complications were present, surgical treatment was usually delayed - 20 (70%) cases, p=0,008. The length of vegetations (more than 15 mm) did not influence on timing of surgery. The timing of surgical treatment due to infective endocarditis had no influence on the mortality rates, which were the same - 14% - in both groups.

Severe Mitral Regurgitation Caused by Perivalvular Abnormal Communication of the Mitral Valve Due to Blunt Chest Trauma

Perivalvular leaks are usually caused by suture interruption in prosthetic valves or infective endocarditis. Traumatic mitral annular dehiscence is a very uncommon event. We present a rare case of severe mitral regurgitation secondary to perivalvular abnormal communication in a 35-year-old man with a history of blunt chest trauma. He presented with symptoms of cough and chest tightness for 3months. Preoperative two-dimensional and real time three-dimensional transesophageal echocardiography clearly showed the position and size of the perivalvular abnormal communication and the incident damage of the left ventricular wall. The patient finally underwent successful surgical repair.

Multimodality Imaging of Mitral Perivalvular Abscess with Annular Fistula and Preserved Leaflet Function

A devastating complication of both native and prosthetic valvular infective endocarditis can involve periannular extension, which is associated with increased perioperative mortality and long-term adverse outcomes. Cardiac imaging, both noninvasive and invasive, is essential to accurately identify the extent and complexity of these infections to perform effective surgical interventional strategies. We present the case of a 62-year-old woman who was found to have a perivalvular mitral valve abscess with an annular fistula without evidence of mitral valve leaflet involvement on histopathology, diagnosed by 3-dimensional transesophageal echocardiography, computed tomography, and left ventriculography.

Invited Commentary

Jassar and colleagues [1Jassar A.S. Bavaria J.E. Szeto W.Y. et al.Graft selection for aortic root replacement in complex active endocarditis: does it matter?.Ann Thorac Surg. 2012; 93: 480-488Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar] have examined the effect of prosthetic valve choice in patients requiring aortic root replacement operations for active endocarditis. The authors retrospectively reviewed 134 patients operated on over a 10-year period, dividing them into those receiving a mechanical valved conduit, a nonhomograft biologic valved conduit, or a homograft. They conclude that choice of valved conduit does not have any demonstrable effects on perioperative or long-term outcomes in this high-risk patient population. The authors are to be commended for trying to answer an important question that frequently arises in clinical practice: what is the best surgical option for patients presenting with destructive aortic root endocarditis? Although the principles of endocarditis surgery are frequently stated in the literature as straightforward pronouncements, including aggressive debridement of all infected material, reconstruction or replacement of debrided vital structures, and targeted antibiotic therapy, the reality is much more complex when surgeons are faced with trying to reconstruct aggressively resected tissue planes. Given the surgical challenges involved in destructive aortic root endocarditis and the lack of clearcut evidence of valve choice superiority, the most prudent advice may be for surgeons to stick with what they know best and to implant the valved conduit with which they have the most experience. Having said this, homografts may be the superior choice for several reasons: One reason is the increased reconstructive options that homografts provide, particularly with regards to reconstruction of the intervalvular body and the anterior leaflet of the mitral valve. Another reason is the superior tissue handling and hemostasis characteristics of homografts. Patients with advanced aortic root endocarditis frequently have several causes for coagulopathy, such as sepsis, reoperation, and long cardiopulmonary bypass times. Suture holes through a homograft are much more hemostatic than those through a porcine root, which can be very important in coagulopathic patients. Lastly and most importantly, the issue of nonsuperiority of homografts has not been adequately proven. Most studies that have argued this point in the literature have been woefully underpowered to make such conclusions. Although Jassar and colleagues [1Jassar A.S. Bavaria J.E. Szeto W.Y. et al.Graft selection for aortic root replacement in complex active endocarditis: does it matter?.Ann Thorac Surg. 2012; 93: 480-488Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar] did not demonstrate beneficial outcomes for patients who received homografts, their small sample size of 36 homografts and incomplete follow-up (80%) make interpretation of their results problematic. In addition, other centers have demonstrated much better freedom from reinfection rates for homograft patients. In the largest series to date, Musci and colleagues [2Musci M. Weng Y. Hübler M. et al.Homograft aortic root replacement in native or prosthetic active infective endocarditis: twenty-year single-center experience.J Thorac Cardiovasc Surg. 2010; 139: 665-673Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar] found that among 221 homograft patients, more than 92% were free from reoperation for reinfection 10 years after homograft implantation for endocarditis. For all of the above reasons, I remain a strong proponent of homograft root replacement for patients with advanced infective destruction of the aortic root. The disadvantages of homografts are well known and include increased technical complexity of implantation, costs, availability, and challenging reoperations due to calcification. The latter problem may become less of an issue in the future with increased usage of transcatheter aortic valve implantation. It should also be noted that if a patient with destructive aortic valve endocarditis survives long enough to require a reoperation for structural valve deterioration without recurrent endocarditis, then this should probably be regarded as a major success. Graft Selection for Aortic Root Replacement in Complex Active Endocarditis: Does It Matter?The Annals of Thoracic SurgeryVol. 93Issue 2PreviewEndocarditis affecting the aortic valve, with abscess formation and root destruction, remains a challenge to treat. Aortic root homografts have been advocated because of a perceived lower risk of infective complications than with other root replacement grafts. However, the theoretical advantage of homografts has not been re-evaluated in the modern era. This report is based on an examination of our results for all aortic root replacements in complex, active endocarditis affecting the aortic valve. Full-Text PDF

Active infective prosthetic endocarditis after percutaneous edge-to-edge mitral valve repair

A 57-year-old man with ischaemic cardiomyopathy was admitted to our institution with fever. The patient had undergone percutaneous mitral valve repair abroad 2 weeks before admission. Transthoracic and transoesophageal echocardiography (TTE/TEE) were performed, showing a mobile lesion (red arrows) originating from the implanted MitraClip mitral valve repair system (*). Staphylococcus aureus was detected in all six serial blood cultures. Therefore, the diagnosis of infective endocarditis was definite. Antibiotic therapy (Vancomycin, Gentamicin, …

Native valve endocarditis due to Micrococcus luteus: a case report and review of the literature

IntroductionMicrococcus luteus endocarditis is a rare case of infective endocarditis. A total of 17 cases of infective endocarditis due to M luteus have been reported in the literature to date, all involving prosthetic valves. To the best of our knowledge, we describe the first case of native aortic valve M luteus endocarditis in an immunosuppressed patient in this report.Case reportA 74-year-old Greek-Cypriot woman was admitted to our Internal Medicine Clinic due to fever and malaise and the diagnosis of aortic valve M luteus endocarditis was made. She was immunosuppressed due to methotrexate and steroid treatment. Our patient was unsuccessfully treated with vancomycin, gentamicin and rifampicin for four weeks. The aortic valve was replaced and she was discharged in good condition.ConclusionsProsthetic infective endocarditis due to M luteus is rare. To the best of our knowledge, we report the first case in the literature involving a native valve.

Infective Endocarditis: The European Viewpoint

Infective endocarditis (IE) is a difficult and complex disease. In recent years epidemiology and microbiology have changed. In developed countries IE is now affecting older patients and patients with no previously known valve disease. Prosthetic IE (prosthetic valve endocarditis [PVE]) and endocarditis in patients with pacemakers and other devices (cardiac device related infective endocarditis [CDRIE]) are becoming more frequent. The number of Staphylococcus aureus IE is increasing related to the number of endocarditis that occurs because of health care associated procedures, especially in diabetics or patients on chronic hemodialysis. The change in the underlying population and the increase in the number of cases caused by very virulent organism explain why the disease still carries a poor prognosis and a high mortality. The variety of clinical manifestations and complications, as well as the serious prognosis, makes it mandatory that IE patients need to be treated in experienced hospitals with a collaborative approach between different specialists, involving cardiologists, infectious disease specialists, microbiologists, surgeons, and frequently others, including neurologists and radiologists. Only an early diagnosis followed by risk stratification and a prompt institution of the correct antibiotic treatment as well as an appropriate and timed surgical indication may improve mortality figures. The recent European Guidelines try to provide clear and simple recommendations, obtained by expert consensus after thorough review of the available literature to all specialists involved in clinical decision-making of this difficult and changing disease.

Homograft aortic root replacement in native or prosthetic active infective endocarditis: Twenty-year single-center experience

We compared early and long-term results of cryopreserved homograft aortic root replacement in native valve endocarditis or prosthetic valve endocarditis associated with periannular abscess. Between May 1986 and December 2007, 1163 patients with endocarditis were operated upon. Of these, 221 patients (n = 185 men, median age 55 years) had homograft aortic root replacement due to 99 cases of native valve endocarditis (45%) and 122 of prosthetic valve endocarditis (55%). Perinannular abscess developed in 189 patients (86%), and aortoventricular dehiscence in 120 (63.5%) of them. Perioperative characteristics, probability of survival, freedom from recurrence, and reoperation were analyzed. Follow-up (mean 5.2 +/- 0.4 years, maximum 18.4 years) was completed in 96.8% with a total of 1127 patient-years. Overall native valve endocarditis survival at 30 days and 1, 5, and 10 years was 83.8% +/- 3.7%, 76.6% +/- 4.3%, 66.5% +/- 4.9%, and 47.3% +/- 5.6%, respectively, significantly better than for patients with prosthetic valve endocarditis, who had a greater tendency toward abscess formation (P = .029). Thirty-one patients (14.0%) required reoperation either for structural valve deterioration (n = 19, 8.6%), with a greater tendency in patients aged <40 years, or for recurrent endocarditis of the homograft (n = 12, 5.4%). One-year reoperation mortality rate was 16.1% (n = 5). Homograft aortic root replacement in active infective endocarditis with periannular abscess formation shows satisfactory early and long-term results with significantly better survival in native valve endocarditis than prosthetic valve endocarditis. It is associated with a low recurrence rate, although the risk of structural valve deterioration increases over time, especially in young patients, and reoperation remains a challenge. In our institution, the homograft remains the preferred valve substitute in active infective endocarditis with periannular abscess formation.