Reoperation For Prosthetic Valve Endocarditis Research Articles

Recent outcomes of surgical redo aortic valve replacement in prosthetic valve failure.

As redo surgical aortic valve replacement(AVR) is relatively high risk, valve-in-valve transcatheter AVR has emerged as an alternative for failed prostheses. However, the majority of studies are outdated. This study assessed the current clinical outcomes of redo AVR. This study enrolled 324 patients who underwent redo AVR due to prosthetic valve failure from 2010 to 2021 in four tertiary centers. The primary outcome was operative mortality. The secondary outcomes were overall survival, cardiac death, and aortic valve-related events. Logistic regression analysis, clustered Cox proportional hazards models, and competing risk analysis were used to evaluate the independent risk factors. Redo AVR was performed in 242 patients without endocarditis and 82 patients with endocarditis. Overall operative mortality was 4.6% (15 deaths). Excluding patients with endocarditis, the operative mortality of redo AVR decreased to 2.5%. Multivariate analyses demonstrated that endocarditis (HR 3.990, P=0.014), longer cardiopulmonary bypass time (HR 1.006, P=0.037) and lower left ventricular ejection fraction (LVEF) (HR 0.956, P=0.034) were risk factors of operative mortality. Endocarditis and lower LVEF were independent predictors of overall survival. The relatively high risk of redo AVR was due to reoperation for prosthetic valve endocarditis. The outcomes of redo AVR for non-endocarditis are excellent. Our findings suggest that patients without endocarditis, especially with acceptable LVEF, can be treated safely with redo AVR.

Long-term valve performance of St Jude Medical Epic porcine bioprosthesis in aortic position.

The aim of this study was to review long-term clinical outcomes and valve performance after Epic Supra valve implantation in aortic position. From 2011 to 2022, 44 patients (mean age 75 ± 8years) underwent surgical aortic valve replacement (SAVR) with an Epic Supra valve at our hospital. Survival, incidence of late complications, and echocardiographic date were retrospectively analyzed. During a mean follow-up period of 6.2 ± 3.5years, the overall survival rate was 91 ± 4% at 2 and 88 ± 5% at 5years, while rates of freedom from major adverse cardiovascular and cerebrovascular events (MACCE) were 86 ± 5% and 83 ± 6%, respectively. There was one case of reoperation for prosthetic valve endocarditis at 6years after the initial surgery. Echocardiographic examinations showed 5-year rates of freedom from severe structural valve deterioration (SVD) and moderate SVD of 100 and 92%, respectively. There was no significant increase in mean pressure gradient or decrease in left ventricular ejection fraction from 1week after surgery to the late follow-up period. Long-term clinical results and durability of the Epic Supra valve in aortic position were satisfactory.

Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Hundred plus Minimally Access Cardiac Surgery: Our Experience

Background: Minimally invasive procedures lead to less scarring resulting in better cosmetic outcomes. This has resulted in increased patient interest in such procedures and this has motivated surgeons to pursue newer and improved techniques for Minimally invasive cardiac surgery (MICS). Obviously, with the advent of MICS the techniques to achieve it also needed to be changed and upgraded which includes access for cannulation for cardiopulmonary bypass (CPB). Right internal jugular vein percutaneous cannulation, together with the direct surgical cannulation of femoral vessels with minithoracotomy/ministernotomy proves to be a safe and effective tool in patients with body weight of above 20 kg for minimally access cardiac surgery. We use this technique for Atrial septal defect (ASD) closure, aortic valve replacement (AVR), redo Tricuspid valve replacement (TVR) and mitral valve replacement (MVR). Here, we describe our experience with minimally invasive approach using total peripheral cannulation and an anterior mini-thoracotomy (6 cm or less) incision for ASD closure, AVR, TVR and MVR. Methods: The preoperative variables, intraoperative data and postoperative outcomes of patients undergoing minimally invasive ASD closure, AVR, TVR and MVR with total peripheral cannulation were collected and analyzed. Results: Between May 2014 to May 2019 we performed minimally invasive closure of atrial septal defects, AVR, TVR and MVR with total peripheral cannulation in 103 patients. There were 64 females and 39 males Mean age was 25 years (range 8 - 58 years), Spectrum of procedures include ASD closure in 81 patients (78.6%), AVR via minithoracotomy in 13 patients (12.6%) and AVR via ministernotomy in 3 patients (2.9%), redo TVR in 5 (4.8%), MVR in 1 patient (0.97%). Average cardiopulmonary bypass (CPB) time was 46 minutes (range 22 - 78 min) and average aortic cross-clamp time (AoX) 26 min (range 12 - 45 min) in ASD closure group. In AVR group average CPB time was 91 min (range 72 - 120 min) and AoX time 76.5 min (range 65 - 109 min). In TVR group average CPB time 54 min (range 45 - 67 min) on beating heart. Only one MVR done in this period and CPB time was 82 min and AoX time was 65 min. The mean length of stay in intensive care unit was 1.8 days in ASD closure, 2 days in AVR group when in TVR group 3.5 days, and hospital stay was 3 days in ASD closure group, 4 days in AVR group and 7 days in TVR group. The only one patient who underwent MVR died in 12th post operative day from sepsis. There was one late mortality in AVR group after reoperation for prosthetic valve endocarditis at 3 months from first operation. Conclusion: ASD closure, AVR, TVR and MVR with mini invasive approach is safe with very few manageable preoperative complications and good patient satisfaction.

Contemporary outcomes of composite aortic root replacement in elderly patients.

We investigated the clinical and haemodynamic outcomes in elderly patients undergoing composite aortic root replacement. Between 2005 and 2017, 135 patients underwent aortic root surgery at our hospital. Of these 135 patients, 47 patients aged ≥65 years were included in this study. Pathologies included aneurysms in 31, chronic aortic dissection in 6, acute aortic dissection in 4 and other causes in 6 patients. A bioprosthesis was used in 27 and a mechanical valve in 20 patients. The mean age was 71.0 ± 4.3 years. The mean follow-up period was 61 ± 35 months. Follow-up echocardiographic data (average 48 months after surgery) were collected in 35 patients (74%). The in-hospital mortality rate was 2.1% (1 patient). Seven late deaths occurred during follow-up. The 1-, 5- and 8-year overall survival was 93.6%, 82.9% and 82.9%, respectively. Infective endocarditis, Marfan syndrome and diabetes were independent predictors of poorer survival. During the follow-up, thromboembolism occurred in 1 patient, major bleeding events in 5 patients, or proximal reoperation for prosthetic valve endocarditis in 1 patient. The type of valve, mechanical or biological valve, did not affect late mortality and morbidity. Follow-up echocardiography revealed significantly improved left ventricular ejection fraction compared with that at discharge. Composite aortic root replacement provided satisfactory midterm outcomes in patients aged ≥65 years. Further studies with a longer follow-up are warranted to evaluate late valve-related events.

Surgical management of infective endocarditis with cerebrovascular complications

To investigate the result of surgical treatment of active infective endocarditis in patients with recent cerebrovascular events, and to evaluate the optimal indication and timing of surgical intervention. The clinical data of 26 patients with cerebrovascular complications before surgery Between December 2007 and December 2013 were analyzed retrospectively. There were 17 male and 9 female patients, aged (42±14) years. Types of disease included single aortic valvular disease (n=8), single mitral valvular disease (n=12), multiple valvular disease (n=5), and aortic valvular disease with ventricular septal defect (n=1). Type of cerebrovascular complication included cerebral infarction (n=25) and cerebral hemorrhage (n=1). Thirty-one valves were involved in 26 patients, mechanical prosthetic valve replacement (n=25), bioprosthetic valve replacement (n=4), and mitral valve repair (n=2). The interval between onset of cerebrovascular event and surgical intervention was less than 14 days (n=3), 14 to 21 days (n=13), over 21 days (n=10), and the mean was (20±4) days. There were 33 vegetations found intraoperatively. The mean size of vegetations was (10±4) mm and 19 were found in mitral valve. Two patients died in hospital. One case relapsed after 1 year and underwent reoperation for prosthetic valve endocarditis. The remaining patients recovered with cardiac function of New York Heart Association class I to II after the period of 3 months to 5 years follow-up. Appropriate surgery may effectively improve the outcome of IE patients with cerebrovascular complications. The surgical indications and risks of further neurologic deterioration after cardiac surgery should be assessed comprehensively before surgical intervention.

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis

Composite Freestyle Stentless Xenograft With Dacron Graft Extension for Ascending Aortic Replacement

The present study was undertaken to evaluate clinical, hemodynamic, and morphologic results of composite stentless xenograft with polyethylene terephthalate fiber (Dacron; DuPont, Wilmington, DE) graft extension for combined replacement of the aortic valve, root, and ascending aorta. Between 1997 and 2008, 55 consecutive patients (33 men, 71 +/- 11 years) underwent ascending aortic replacement using Medtronic Freestyle with Dacron graft extension (DuPont). Indications included aneurysm (n = 31, 56%), dissection (n = 16, 29%), and endocarditis (n = 8, 15%). Associated procedures were performed in 25 patients (46%). Preoperative logistic EuroSCORE averaged 34% +/- 28%. Mean cardiopulmonary bypass and aortic cross-clamp times were 244 +/- 134 minutes and 162 +/- 69 minutes, respectively. Clinical follow-up was 100% complete and averaged 2 +/- 3 years. Early mortality was 0% (n = 0) in patients with a preoperative EuroSCORE of less than 20 (n = 26, mean expected mortality, 13% +/- 5%) and 31% (n = 9) in those with preoperative logistic EuroSCORE of at least 20 (n = 29, mean expected mortality, 52% +/- 28%). One- and 3-year survival rates were 83% +/- 5% and 78% +/- 7%, respectively. No major thromboembolic or spontaneous bleeding events were recorded. One patient (2%) required late reoperation for prosthetic valve endocarditis. Echocardiographic follow-up showed no valve dysfunction and low mean transvalvular gradients (7 +/- 5 mm Hg). A 64-channel computed tomographic scan was performed in 33 patients at 32.4 +/- 34 months and revealed two small pseudoaneurysms in a single patient. Composite Freestyle with Dacron graft extension appears to be a safe option for bioprosthetic replacement of the aortic root and tubular ascending aorta. However, long-term results using this composite graft will have to be determined.

Predictors of recurrence and reoperation for prosthetic valve endocarditis after valve replacement surgery for native valve endocarditis

Surgical treatment of native valve endocarditis remains challenging, especially in cases with paravalvular destruction. Basic principles include complete debridement and reconstruction. This study is designed to evaluate the outcomes of surgical reconstruction of complex annular endocarditis using standard techniques and materials, including autologous and bovine pericardium. From 1975 to 2000, 358 cases (357 patients, mean age 49 +/- 16 years, range 18-88 years) of native valve endocarditis were surgically managed. Bioprosthetic valves were implanted in 189 cases, and mechanical prostheses were implanted in 169 cases. A total of 78 cases of paravalvular destruction were identified: 62 annular abscesses, 8 fistulas, and 8 combined abscesses/fistulas. These were managed with 46 pericardial patches and 32 isolated suture reconstructions after radical debridement and prosthetic valve replacement. The overall early mortality was 8.4% (n = 30). The mortality with paravalvular destruction was 17.9%, and the mortality with simple leaflet infection was 5.7% (P = .001). The unadjusted survival at 20 years was 26.4% +/- 4.9% for bioprosthetic valves and 56.5% +/- 8.1% for mechanical prostheses (P = .007). The freedom from recurrent prosthetic valve endocarditis was 78.9% +/- 4.4% at 15 years. The freedom from reoperation for recurrent prosthetic valve endocarditis was 85.8% +/- 4.2% at 15 years. The freedom from reoperation after reconstruction for paravalvular destruction was 88.2% +/- 6.9% at 15 years. The freedom from mortality for recurrent prosthetic valve endocarditis was 92.7% +/- 3.4% at 15 years. The independent predictors of reoperation were age (hazard ratio 0.930, P = .005) and intravenous drug use/human immunodeficiency virus plus surgical technique (hazard ratio 12.8, P = .003 for patch reconstruction plus valve and hazard ratio 3.6, P = .038 for valve replacement only). Prosthesis type was not predictive when separated from intravenous drug use/human immunodeficiency virus (hazard ratio 3.268, P = .088). Paravalvular destruction is associated with a higher operative mortality. Native valve endocarditis can be managed with reasonable long-term survival and low rates of reinfection with radical debridement and pericardial reconstruction with bioprostheses and mechanical prostheses. The type of prosthesis implanted does not influence long-term outcome. Patients with a history of intravenous drug use and human immunodeficiency virus are at increased risk for recurrent infection and reoperation.

Early and late outcomes after reoperation for prosthetic valve endocarditis.

Prosthetic valve endocarditis remains a challenging complication after heart valve replacement. To identify predictive risk factors, we have reviewed 30 patients who underwent surgery for prosthetic valve endocarditis between March 1986 and May 1999. There were 15 men and 15 women (mean age 51 years). Prosthetic valve endocarditis was classified as early (< or = 1 year after operation) in 10 cases, and as late in the other 20 cases. The most common indication for surgery was moderate to severe congestive heart failure due to prosthetic valve dysfunction in 21 (70%) patients. The average follow-up period was 6.5 years, with a range of 0.3 to 14.1 years. The most common microorganism was Staphylococcus epidermidis in both patients with early (50%) and late prosthetic valve endocarditis (25%). The in-hospital mortality was 13.3% (4/30). There were six late deaths. The actuarial survival at 5 years was 78% and 66% at 10 years. An early onset of prosthetic valve endocarditis was the only significant determinant of both in-hospital mortality (p = 0.005) and overall mortality (p = 0.021). Emergency surgery had a statistically significant relationship with in-hospital mortality (p = 0.045). No significant influence on mortality after reoperation for prosthetic valve endocarditis was found in age, sex, valve position, antecedent native valve endocarditis, or in the type of pathological findings (ring abscess, valve dehiscence, and vegetation). Early onset of prosthetic valve endocarditis and emergency surgery were important risk factors for mortality due to prosthetic valve endocarditis.

Prosthetic Valve Endocarditis: Surgical Procedures and Clinical Outcome

Over a period of 10 years, 25 patients underwent reoperation for prosthetic valve endocarditis. The basic procedure for surgical treatment differed depending on the presence or absence of annular ring abscess. Standard valve replacement was employed in 15 patients without annular ring abscess (three aortic, eleven mitral and one tricuspid). The ten other patients who had had partial destruction of the annulus underwent complex surgical treatment (six aortic, three mitral and one aortic and mitral). Complex operative techniques consisted of three different procedures, depending on the anatomical lesion in each patient. Aortic valve replacement was performed by subannular implantation with horizontal Dacron felt-supported mattress sutures through the ventricular septum, ventricular outflow wall muscles and base of the anterior mitral leaflet. A prosthesis with a polytetrafluoroethylene flange was used for mitral valve replacement to permit double suturing of the prosthesis and firm anchoring. Double valve replacement (mitral, aortic) with destruction of the fibrous skeleton was carried out using a composite graft consisting of a triangular-shaped Dacron patch and two Björk—Shiley valves. There were four operative deaths (16%; three who underwent standard valve replacement and one who had complex surgical treatment). In no case could the cause of death be related to the surgical procedure. These patients had had haemodynamic decompensation before operation and required urgent reoperation. Preoperative New York Heart Association functional class IV ( P&lt; 0.05) and operative urgency ( P&lt; 0.05) had a significant correlation with mortality. On the basis of these results, operative mortality can be improved if conditions leading to myocardial damage are prevented and proper reconstruction conducted.

Reoperation for prosthetic valve endocarditis in the third trimester of pregnancy

A pregnant 29-year-old woman underwent emergency aortic valve re-replacement for prosthetic valve endocarditis. Cesarean section was performed with the chest open ready for cannulation. Fears of uterine hemorrhage during systemic heparinization for cardiopulmonary bypass were unfounded, and both mother and the 28-week-gestation newborn recovered uneventfully.

Durability and Low Thrombogenicity of the St. Jude Medical Valve at 5-Year Follow-up

Between November, 1978, and December, 1983, 736 patients had valve replacement with the St. Jude Medical valve prosthesis. There were 478 patients with aortic valve replacement (AVR), 188 with mitral valve replacement (MVR), 63 with double valve replacement, and 7 with tricuspid valve replacement (they were not included in this study). The mean age at the time of operation was 46.7 years for patients having AVR and 48.6 years for those having MVR and AVR + MVR. Follow-up totaled 1,116 patient-years (range, 4 to 82 months). Early (30-day) mortality was lowest for isolated MVR (2.3%) and AVR (3.7%), and increased with reoperation or when associated procedures were combined with valve replacement. Patients undergoing reoperation or having associated procedures made up 49% of the AVR and 54% of the MVR groups. All patients were advised of the need for long-term anticoagulation with warfarin sodium. Nine patients (7 with AVR, 1 with MVR, 1 with AVR + MVR) had suspected or confirmed episodes of systemic thromboembolism, a linearized incidence of 0.99% per patient-year for AVR, 0.36% per patient-year for MVR, and 0.98% per patient-year for AVR + MVR. Eight patients with AVR underwent reoperation for prosthetic valve endocarditis (5 of the 8 patients had endocarditis prior to initial valve replacement). There were no instances of structural valve failure. There were 37 late deaths. Actuarial survival at 5 years (excluding early mortality, 95% confidence limits) was 89.8% for AVR, 84.8% for MVR, and 95.2% for AVR + MVR. At 5-year follow-up the St. Jude Medical prosthetic valve has a low incidence of valve-related complications, which makes it a suitable choice in patients requiring valve replacement.