Surgery For Endocarditis Research Articles

Impact of early surgery in non-complicated left-sided native-valve infective endocarditis with large vegetations

The impact of early surgery for patients with left-sided native-valve infective endocarditis (LS-NV-IE) with a large vegetation (between 10 and 30 mm), free of embolic events and of other complication, has not yet been established. We aimed to describe the characteristics of these patients and to assess the impact of early surgery (≤ 7 days) in terms of 6-month outcomes. Among 1340 patients diagnosed with LS-NV-IE, 174 patients with a vegetation between 10 and 30 mm and without class I or IIa indication for surgery (according to European guidelines) were included. The primary endpoint combined death and endocarditis complications (recurrence of endocarditis, heart failure requiring hospitalization, or clinical embolic event) at 6-months. Patients( n = 42) who underwent early surgery were younger ( P = 0.019) and more likely to have a vegetation length > 15 mm (66.7%vs.47.7%) and highly mobile vegetations (59.5%vs.39.4%), than patients managed conservatively. The 6-month event-free survival was 98 ± 2% in the early surgery group and 86 ± 3% in the conservative group ( P = 0.037), even after propensity matching ( P = 0.003). On multivariable analysis, early surgery was associated with better outcome [Adjusted HR(95%CI) = 0.16(0.04–0.97); P = 0.046] ( Fig. 1 ). Early surgery for patients with LS-NV-IE and vegetation between 10 and 30 mm, free of embolic events and of other IE complication, is associated with a lower rate of events at 6 months.

Pediatric Cylinder Tricuspid Valve Replacement: A Case Report

Cylinder tricuspid valve replacement was performed on a 6.5-year-old child who suffered from massive valve insufficiency following previous emergency surgery for tricuspid endocarditis and pulmonary embolism. The material used for the realization of the customized graft was photofixed decellularized heterologous pericardium. The postoperative course and the short-term follow-up have been satisfactory and encourage the use of the technique in similar situations even in the pediatric age.

Quantile-Specific Heritability of Mean Platelet Volume, Leukocyte Count, and Other Blood Cell Phenotypes

Introduction: “Quantile-dependent expressivity” occurs when the effect size of a genetic variant depends upon whether the phenotype (e.g., mean platelet volume, MPV) is high or low relative to its distribution. Methods: Offspring-parent regression slopes (β_OP) were estimated by quantile regression, from which quantile-specific heritabilities (h²) were calculated (h² = 2β_OP/[1 + r_spouse]) for blood cell phenotypes in 3,929 parent-offspring pairs from the Framingham Heart Study. Results: Quantile-specific h² (±SE) increased with increasing percentiles of the offspring’s age- and sex-adjusted MPV distribution (p_linear = 0.0001): 0.48 ± 0.09 at the 10th, 0.53 ± 0.04 at the 25th, 0.70 ± 0.06 at the 50th, 0.74 ± 0.06 at the 75th, and 0.90 ± 0.12 at the 90th percentile. Quantile-specific h² also increased with increasing percentiles of the offspring’s white blood cell (WBC, p_linear = 0.002), monocyte (p_linear = 0.01), and eosinophil distributions (p_linear = 0.0005). In contrast, heritibilities of red blood cell (RBC) count, hematocrit (HCT), and hemoglobin (HGB) showed little evidence of quantile dependence. Quantile-dependent expressivity is consistent with gene-environment interactions reported by others, including (1) greater increases in WBC and PLT concentrations in subjects who are glutathione-S-transferase Mu1 (GSTM1) null homozygotes than GSTM1 sufficient when exposed to endotoxin; (2) significantly higher WBC count in AA homozygotes than carriers of the G-allele of the glutathione S-transferase P1 (GSTP1) rs1695 polymorphism at low but not high benzene exposure in shoe factory workers; (3) higher WBC counts in TT homozygotes than C-allele carriers of the interleukin-1β (IL1B) c.315C>T polymorphism after undergoing surgery for infective endocarditis but not before surgery. Discussion/Conclusion: Quantile-dependent expressivity may explain several purported gene-environment interactions involving blood cell phenotypes.

Early Mortality Predictors in İnfective Endocarditis Patients: A Single-Center Surgical Experience.

Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis. In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared. Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all). The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Simple scoring system to predict in hospital mortality after surgery for infective endocarditis at the Ibn Rochd university hospital in Casablanca, Morocco

Aspecific scoring systems are used to predict the risk of death postsurgery in patients with infective endocarditis (IE). The purpose of the present study was both to analyze the risk factors for in-hospital death, which complicates surgery for IE, and to create a mortality risk score based on the results of this analysis. Outcomes of 361 consecutive patients (mean age, 59.1 ± 15.4 years) who had undergone surgery at the IBN ROCHD University Hospital in Casablanca, Morocco, and a risk factor analysis (multivariable logistic regression) for in-hospital death was performed. The discriminatory power of a new predictive scoring system was assessed with the receiver operating characteristic curve analysis. Score validation procedures were carried out. Fifty-six (15.5%) patients died postsurgery. BMI > 27 kg/m 2 (odds ratio [OR], 1.79; P = 0.049), estimated glomerular filtration rate < 50 mL/min (OR, 3.52; P < 0.0001), New York Heart Association class IV (OR, 2.11; P = 0.024), systolic pulmonary artery pressure >55 mm Hg (OR, 1.78; P = 0.032), and critical state (OR, 2.37; P = 0.017) were independent predictors of in-hospital death. A scoring system was devised to predict in-hospital death postsurgery for IE (area under the receiver operating characteristic curve, 0.780; 95% CI, 0.734–0.822). The score performed better than 5 of 6 scoring systems for in-hospital death after cardiac surgery that were considered. A simple scoring system based on risk factors for in-hospital death was specifically created to predict mortality risk postsurgery in patients with IE.

Reassessment of Vegetation Size as a Sole Indication for Surgery in Left-Sided Infective Endocarditis

Guidelines recommend surgery for left-sided infective endocarditis (LSIE) that is associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome. A total of 726 patients with definitive LSIE were included in our analysis. The mean age was 64.9years, and 61% were male. Multivariate analysis of all patients was performed to determine whether vegetation size is related to death in LSIE. Then patients were divided into two groups according to vegetation size: group A (>10mm, n=420) and group B (≤10mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. The impact of surgery on mortality in group A patients without heart failure or uncontrolled local infection (n=139) was assessed. Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure, and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B; P=.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%; P=.678), stroke (22% vs 17.0%, P=.091), systemic embolism (39% vs 32%; P=.074), perivalvular complication (28% vs 28%; P=.865), and septic shock (15% vs 13%; P=.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection, mortality was similar with and without surgery (n=139; n=70 with surgery and n=69 without surgery; mortality, 18.6% vs 11.6%, respectively; P=.251). Large vegetations identify patients with poor outcomes in the context of LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

Outcomes of surgically treated infective endocarditis in a Western Australian population

BackgroundInfective endocarditis is a disease that carries high morbidity and mortality. The primary endpoint of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary endpoint of this study is to assess the incidence of post-operative stroke, renal failure, complete heart block and recurrence.MethodsBetween the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital, Western Australia. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record. A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital morbidity and mortality.ResultsA total of 89 patients underwent surgery for infective endocarditis from 2015 to 2019, affecting a total of 101 valves. The mean age of patients was 53.7 ± 16.5. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 h of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass time and cross clamp time. Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 11 patients developed a complete heart block post operatively (12%) and endocarditis recurred in 10 patients (11%).ConclusionProlonged cardiopulmonary bypass times were significantly associated with mortality. This study is novel to report a lower mortality rate than previously quoted in the literature. We also report our findings of organisms, preoperative embolic phenomena and surgery in a Western Australian population. We recommend that all patients with endocarditis are discussed in multidisciplinary forum.

MRI versus CT in the detection of brain lesions in patients with infective endocarditis before or after cardiac surgery

PurposeImaging of brain involvement in infective endocarditis can drive the clinical management of this serious condition. MRI is very sensitive, but CT is more readily available. In this retrospective study, we compared the detection rates of CT and MRI.MethodsAfter Ethics Committee approval, we retrospectively reviewed a series of 20 patients (13 males, median age 64 years) who underwent both CT and MRI either before or after cardiac surgery for definite infective endocarditis. Plain CT and MRI were evaluated for acute ischemic lesions, both punctuate and large, intraparenchymal hemorrhages, cerebral microbleeds, subarachnoid hemorrhages, abscesses, microabscesses, and meningitis. Qualitative assessment and McNemar test were performed. The value of contrast-enhanced scans (MRI, n = 14; CT, n = 9) and cognitive status were also assessed.ResultsA total of 166 lesions were identified on either technique: 137 (83%) on MRI only, 4 (2%) on CT only, and 25 (15%) on both techniques (p < 0.001). For these last 25 lesions, concordance on lesion type was only 16/25 (64%). MRI detected more microbleeds and ischemic lesions, while the 4 CT-only findings were false positives. Contrast-enhanced scans identified 68 enhancing lesions, mainly abscesses and microabscesses, and allowed a better characterization for 61/117 lesions (52%) with MRI, and for 11/81 (14%) with CT. Follow-up identified mild cognitive impairment in 6/13 and dementia in 3/13 patients.ConclusionWhile CT rapidly excludes large hemorrhages in patients with infective endocarditis, MRI accurately distinguishes the whole spectrum of brain lesions, including small ischemic lesions, microbleeds, and microabscesses.

Sex Differences in the Utilization and Outcomes of Cardiac Valve Replacement Surgery for Infective Endocarditis: Insights From the National Inpatient Sample.

BackgroundThe data on the differential impact of sex on the utilization and outcomes of valve replacement surgery for infective endocarditis are limited to single‐center and small sample size patient population.Methods and ResultsWe utilized the National Inpatient Sample database to identify patients with a discharge diagnosis of infective endocarditis from 2004 to 2015 to assess differences in the characteristics and clinical outcomes of patients hospitalized with infective endocarditis stratified by sex. We also evaluated trends in utilization of cardiac valve replacement and individual valve replacement surgeries in women versus men over a 12‐year period, and compared in‐hospital mortality after surgical treatment in women versus men. A total of 81 942 patients were hospitalized with a primary diagnosis of infective endocarditis from January 2004 to September 2015, of whom 44.31% were women. Women were less likely to undergo overall cardiac valve replacement (6.92% versus 12.12%), aortic valve replacement (3.32% versus 8.46%), mitral valve replacement (4.60% versus 5.57%), and combined aortic and mitral valve replacement (0.85% versus 1.81%) but had similar in‐hospital mortality rates. From 2004 to 2015, the overall rates of cardiac valve replacement increased from 11.76% to 13.96% in men and 6.34% to 9.26% in women and in‐hospital mortality declined in both men and women. Among the patients undergoing valve replacement surgery, in‐hospital mortality was higher in women (9.94% versus 6.99%, P<0.001).ConclusionsDespite increased utilization of valve surgery for infective endocarditis in both men and women and improving trends in mortality, we showed that there exists a treatment bias with underutilization of valve surgeries for infective endocarditis in women and demonstrated that in‐hospital mortality was higher in women undergoing valve surgery in comparison to men.

Impact of concomitant replacement of the ascending aorta in patients undergoing aortic valve replacement on operative morbidity and mortality.

The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.

CASE OF GONOCOCCAL ENDOCARDITIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gonococcal endocarditis is rare occurrence since the advent of antibiotics. The aortic valve is the most commonly affected. Complications such as valvular abscess require evaluation by cardio-thoracic surgery. CASE PRESENTATION: A 26-year-old African American man with past medical history significant for paroxysmal atrial fibrillation and heart failure with preserved ejection fraction presented as a transfer from an outside hospital to be evaluated by cardiothoracic surgery for aortic valve replacement. He had a recent hospitalization and had blood cultures which revealed Neisseria gonorrhea. His subsequent blood cultures were negative. He received a dose of Azithromycin. He was also treated with Ceftriaxone. Ceftriaxone was changed to Meropenem which he was continued on. He was found to have significant troponin elevation during the recent hospitalization which was thought to be secondary to myocarditis. At the outside hospital during this hospitalization, he developed acute hypoxic respiratory failure and required mechanical ventilation. Cardiac catheterization showed severely elevated filling pressures and severely reduced cardiac output. A coronary angiogram showed worsening of left circumflex artery compression with concern for a hematoma causing compression of the artery. Transthoracic echo showed a grossly normal aortic valve but an adjacent circumferential echo lucent structure suggestive of an abscess or aneurysm. Aortic abscess was confirmed with transesophageal echocardiogram. Cardiothoracic surgery performed an aortic valve replacement. He was found to have pericarditis due to the gonococcal cardiac abscess which prevented successful bypass to the LAD or left circumflex. He was managed in the intensive care unit with inotropic support. Infectious Disease recommended treatment with IV Ceftriaxone for 6 weeks from his operation with transition to oral Cefotaxime. The tip of his central line grew Candida Albicans and he was started on Fluconazole to complete a 3-week course. Subsequent blood cultures remained negative. He also remained off vasopressors and oxygenation requirements were starting to improve. General surgery was consulted for placement of tracheostomy and PEG tube. The patient was then transferred to a specialty hospital. DISCUSSION: Disseminiated gonococcal infection may result in a valvular abscess. Complicatons like valvular abscess can be detected early with transesophageal echocardiography. Clinical deterioraton from valvular destruction is an indcation for early valve replacement. CONCLUSIONS: Our patient is a young sexually active African American man who required surgical intervention for gonococcal endocarditis. This case demonstrates the significance of early diagnosis of valvular abscess with trans esophageal echocardiography and evaluation by cardiothoracic surgery for a rare disease which has an alarming rate of mortality. REFERENCE #1: Prendergast BD, Tornos P. Surgery for infective endocarditis: who and when? Circulation. 2010;121(9):1141-52. https://doi.org/10.1161/CIRCULATIONAHA.108.773598. PMid: [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Kristina Akopyan, source=Web Response

Association Between Volume and Outcomes of Infective Endocarditis Surgery: A Nationwide Cohort Study

BackgroundTo determine the relationship between hospital surgical volume and mortality risk and valve repair rate in infective endocarditis (IE) surgery. MethodsUsing the Taiwan National Health Insurance Research Database, 3873 patients were identified who underwent surgery between 2000 and 2013. The cumulative hospital volume of valve surgery for IE was calculated, and patients were divided into 4 subgroups according to the quartile. Outcomes were mortality and valve repair rate and the cut point of referral excellence. ResultsThe distribution of IE surgery has been shifting to lower-volume hospitals over the years. The global disease severity (Charlson Comorbidity Index score) of patients was greater in the lowest-volume hospital than in the highest-volume hospital (2.4 vs 2.0). The crude in-hospital mortality rate was 15.8% and 9.4% for the lowest- and highest-volume hospitals, respectively, with a significant difference (adjusted odds ratio: 1.86, 95% confidence interval: 1.22-2.85) after adjustment of baseline characteristics including the Charlson Comorbidity Index score. The mitral valve repair rate increased with the increase in cumulative volume. During a mean follow-up period of 4.4 years, 324 (41.9%) and 254 (30.9%) patients died in the lowest- and highest-volume subgroups, respectively, and the difference was significant (adjusted hazard ratio: 1.59, 95% confidence interval: 1.21-2.10). ConclusionsA higher cumulative volume of IE surgery is associated with a lower risk of mortality and a higher likelihood of successful mitral valve repair. Therefore, interfacility transfer to a high-volume hospital may improve outcomes of IE surgery.

Disorders of the Blood Coagulation System in Patients with Infectious Endocarditis

Infectious endocarditis is a disease which is still hard to diagnose and treat. The success of the proposed ther-apy depends not only on the surgical correction of the heart disease, but also on effective perioperative management of this group of patients. In most cases, patients have a long history of drug treatment and compromised status of all organs and systems. Coagulation disorders in patients with infectious endocarditis are one of the main links which lead to the patient’s death, despite advances in therapeutic and surgical treatment. Since the development of infectious endocarditis is based on thrombo-inflammatory lesions of the endocardium as a result of the interaction of microorganisms and modifiers of the blood coagulation system, the appointment of effective anticoagulant therapy in the postoperative period becomes one of the important tasks in resuscitation. The need to maintain balance between the coagulation and anticoagulation systems of hemostasis requires constant monitoring of the coagulation system and careful administration of anticoagulants.&#x0D; The aim. To demonstrate an example of an alternative scheme of anticoagulant therapy in a patient with postopera-tive gastrointestinal bleeding after cardiac surgery for infectious endocarditis.&#x0D; Materials and methods. We present a clinical case of treatment of acute gastrointestinal bleeding in the early post-operative period in a patient after cardiac surgery for infectious aortic valve endocarditis. The 56-year-old patient K. was taken to the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine by ambulance with a diagnosis: Infectious endocarditis of the aortic and mitral valves. Combined aortic defect with a predominance of insufficiency, mitral regurgitation, tricuspid insufficiency. Pulmonary arterial hypertension. Degree II respiratory failure. Ischemic heart disease: non-Q-wave myocardial infarction (as of October 29, 2020), RCA stenting (November 2, 2020), post-infarction atheroscle-rotic cardiosclerosis. Degree III hypertension, stage 2, risk 4. Heart failure 2B, functional class III. A salvage cardiac surgery was performed: aortic valve replacement. Mitral and tricuspid valve plastics. On day 2 of the postoperative period, against the background of anticoagulant therapy prescribed according to international recommendations, gastrointestinal bleeding developed. Anticoagulant therapy regimen was adjusted. The proposed scheme of hemostasis control allowed to normalize the blood parameters and to avoid blood loss. On day 10 of the postoperative period, standard scheme of anticoagulant ther-apy could be renewed, and the patient was transferred to the therapeutic department under the supervision of cardiologist.&#x0D; Conclusions. The proposed variant of anticoagulant therapy in the postoperative period in a patient operated on for infectious endocarditis created the conditions for normalization of hemostasis. Complete withdrawal of anticoagulants and transfer of patients to a continuous infusion of heparin under the control of APTT with a target value allows not only to control the risk of bleeding, but also to prevent thrombosis.

Outcomes of surgery for extensive infective endocarditis.

Extensive infective endocarditis (EIE) involving the valve annulus or the intervalvular fibrous body (IFB) is a treatment challenge. We sought to clarify the outcomes of patients undergoing surgery for EIE. We retrospectively reviewed all 197 consecutive patients who underwent an operation for infective endocarditis (IE) between 2005 and 2016 in the Helsinki University Hospital. Thirty-five (18%) patients had EIE, of which 17 (9%) infection extended to IFB. Patients with EIE had higher EuroSCORE II (24.4% vs. 12.4% p < .001), higher frequency of diabetes (29% vs. 13% p = .017), more often NYHA Class IV (83% vs. 56% p = .02), aortic (97% vs. 45% p < .001), multivalve (40% vs. 11% p < .001), and prosthetic valve IE (37% vs. 9% p < .001), and underwent more often emergency surgery (46% vs. 29% p = .042). Thirty-day mortality was 9% in the EIE group and 7% in the non-EIE group (p = .720). Survival of patients with EIE at 5 years was 60% and with non-EIE 71% (p = .029). The frequency of complications was higher in EIE (54%) than in non-EIE patients (25%) (p < .001), due to the higher need for permanent pacemaker implantations (34% vs. 4% p < .001). Freedom from re-operations at 5 years was 91% in the EIE group and 97% in the non-EIE group (p = .203). Early mortality of surgery for EIE was comparable with non-EIE. Midterm survival was lower after surgery for EIE than after surgery for non-EIE but there was no difference in survival of patients with IE limited to the valve annulus amenable to patch repair and patients with endocarditis requiring IFB reconstruction.

Prognostic impact of cardiac surgery in left-sided infective endocarditis according to risk profile

ObjectiveTo evaluate the prognostic impact of urgent cardiac surgery on the prognosis of left-sided infective endocarditis (LSIE) and its relationship to the basal risk of the patient and to the...

Preoperative serum albumin: a promising indicator of early mortality after surgery for infective endocarditis.

BackgroundDespite novel improvements in the diagnosis and treatment of infective endocarditis (IE), there has been no significant improvement in the survival rate of IE, which indicates that many details still need to be optimized in the preoperative assessment. We sought to evaluate preoperative serum albumin as a biomarker for predicting early mortality after IE surgery.MethodsBetween October 2013 and June 2019, patients with a definite diagnosis of IE were enrolled in this study. Patients’ albumin levels at admission were used as the preoperative albumin levels. Restricted cubic spline and multivariate logistic regression analyses were performed to evaluate the relationship between albumin and early mortality. Receiver operating characteristic curve analyses were performed to assess the role of albumin in predicting early mortality and compare the predictive capacity of traditional models with models that included albumin.ResultsOf the 276 IE patients, 20 (7.2%) died in hospital or within 30 days of surgery. Hypoalbuminemia (an albumin level <3.5 g/dL) was present in 109 (39.5%) patients. The multivariate logistic regression analysis showed that preoperative albumin was inversely associated with early mortality [adjusted odds ratio (OR) =0.22 per 1 g/dL, 95% confidence interval (CI): 0.07–0.65, P=0.006] after full adjustment. Preoperative albumin had value in predicting early mortality [area under the curve (AUC) =0.72, 95% CI: 0.61–0.84; P<0.01]. After adding albumin to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Charlson score, the predictive ability of the model was further improved (EuroSCORE II: AUC =0.55; 95% CI: 0.42–0.67 to AUC =0.72; 95% CI: 0.61–0.84; Charlson score: AUC =0.73; 95% CI: 0.64–0.83 to AUC =0.78; 95% CI: 0.68–0.88).ConclusionsPreoperative serum albumin is inversely associated with early mortality after IE surgery, and is a promising prognostic indicator in preoperative risk stratification assessments of IE patients.

Analysis of sleep characteristics and clinical outcomes of 139 adult patients with infective endocarditis after surgery.

BACKGROUNDLittle is known about the postoperative sleep quality of infective endocarditis patients during hospitalization and after discharge. AIMTo investigate the sleep characteristics of infective endocarditis patients and to identify potential risk factors for disturbed sleep quality after surgery. METHODSThe Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale were used to assess patient sleep quality. Logistic regression was used to explore the potential risk factors. RESULTSThe study population (n = 139) had an average age of 43.40 ± 14.56 years, and 67.6% were men (n = 94). Disturbed sleep quality was observed in 86 patients (61.9%) during hospitalization and remained in 46 patients (33.1%) at 6 mo after surgery. However, both PSQI and Epworth Sleepiness Scale scores showed significant improvements at 6 mo (P < 0.001 and P = 0.001, respectively). Multivariable logistic regression analysis showed that the potential risk factors were age (odds ratio = 1.125, 95% confidence interval: 1.068-1.186) and PSQI assessed during hospitalization (odds ratio = 1.759, 95% confidence interval: 1.436-2.155). The same analysis in patients with PSQI ≥ 8 during hospitalization suggested that not using sleep medication (odds ratio = 15.893, 95% confidence interval: 2.385-105.889) may be another risk factor. CONCLUSIONThe incidence of disturbed sleep after infective endocarditis surgery is high. However, the situation improves significantly over time. Age and early postoperative high PSQI score are risk factors for disturbed sleep quality at 6 mo after surgery.

Repair of Isolated Native Mitral Valve Endocarditis: A Propensity Matched Study

In the setting of chronic primary mitral regurgitation, the benefit of mitral valve repair over replacement is well established. However, data comparing outcomes for mitral valve surgery for endocarditis is limited. We sought to determine whether mitral valve repair offers traditional advantages over replacement in the endocarditis population. Retrospective review of our institutional mitral valve database (N=8,181) was performed between 1998 and 2019 for all adult patients undergoing isolated mitral valve surgery for endocarditis. Patients were stratified by mitral valve repair or replacement and propensity score matching was performed to adjust for differences in baseline characteristics and degree of valve damage. Overall, 267 surgeries (124 repair, 153 replacement) met inclusion criteria during the study period. Following propensity matching, the repair cohort was associated with shorter initial ventilator times (5.6 vs 7.9 hours, p=0.05), shorter ICU (28 vs 52 hours, p=0.03), and hospital lengths of stays (7 vs 11 days, p < 0.01). Thirty-day mortality (0% vs 2.1%, p=0.01) and 10-year survival (88% vs 86%, p=0.55) were similar between cohorts. Patients in the repair cohort were less likely to require repeat mitral valve intervention at our institution for recurrent endocarditis than those in the replacement cohort (0% vs 10.6%, p=0.03). Mitral valve repair is safe, when feasible, in the setting of isolated native valve endocarditis and may provide patients faster recovery. Experienced mitral surgeons should approach this patient population with a "repair if feasible" methodology.

Role of Concomitant Coronary Artery Bypass Grafting in Valve Surgery for Infective Endocarditis.

Background: It is current practice to perform concomitant coronary artery bypass grafting (CABG) in patients with infective endocarditis (IE) who have relevant coronary artery disease (CAD). However, CABG may add complexity to the operation. We aimed to investigate the impact of concomitant CABG on perioperative outcomes in patients undergoing surgery for IE. Methods: We retrospectively used data of surgically treated IE patients between 1994 and 2018 in six German cardiac surgery centers. We performed inverse probability weighting (IPW), multivariable adjustment, chi-square analysis, and Kaplan–Meier survival estimates. Results: CAD was reported in 1242/4917 (25%) patients. Among them, 527 received concomitant CABG. After adjustment for basal characteristics between CABG and no-CABG patients using IPW, concomitant CABG was associated with higher postoperative stroke (26% vs. 21%, p = 0.003) and a trend towards higher postoperative hemodialysis (29% vs. 25%, p = 0.052). Thirty-day mortality was similar in both groups (24% vs. 23%, p = 0.370). Multivariate Cox regression analysis after IPW showed that CABG was not associated with better long-term survival (HR: 1.00, 95% CI: 0.82–1.23, p = 0.998). Conclusion: In endocarditis patients with CAD, adding CABG to valve surgery may be associated with a higher likelihood of postoperative stroke without adding long-term survival benefits. Therefore, in the absence of critical CAD, concomitant CABG may be omitted without impacting outcome. The results are limited due to a lack of data on the severity of CAD, and therefore there is a need for a randomized trial.

Outcomes after Surgery for Endocarditis among Intravenous Drug Users and Nonusers.

The optimal treatment strategy for intravenous drug users (IVDU) with infective endocarditis (IE) is controversial. We therefore sought to investigate outcomes among IVDUs after surgery for IE. We retrospectively reviewed all 192 consecutive patients who underwent an operation for IE between 2005 and 2016 in the Helsinki University Hospital. Forty-seven patients (24.5%) were IVDUs and 145 (75.5%) were non-IVDUs. Mortality and reinfection and reoperation rates were evaluated. IVDUs were younger (29.9 vs. 63.8 years, p < 0.001) and had less cardiovascular risk factors and lower EuroSCORE II (4.3 vs. 7.3%, p < 0.001), but Staphylococcus aureus infection (66.0 vs. 23.4%, p < 0.001), tricuspid valve endocarditis (34.0 vs. 2.8%, p < 0.001), and liver disease (63.8 vs. 2.8%, p < 0.001) occurred more often in IVDUs than in non-IVDUs. Thirty-day mortality of IVDUs was 8.5% and that of non-IVDUs was 6.9% (p = 0.711). Survival of IVDUs at 5 years was 70.8 ± 7.4% and survival of non-IVDUs was 67.9 ± 4.7% (p = 0.678). Relative to an age- and sex-matched general population, IVDUs had 58.6 (95% confidence interval [CI]: 33.7-101.9; p < 0.001) and non-IVUD 4.4 (95% CI: 3.1-6.2; p < 0.001) standardized mortality ratio. IVDUs had a higher reinfection rate at 5 years (25.8 ± 7.7% vs. 3.0 ± 1.7%, p < 0.001) and a higher early reoperation rate than non-IVDUs (10.6 vs. 1.4%, p = 0.003). IVDUs and non-IVDUs had comparable survival at 5 years, but IVDUs had a very significantly increased risk of death in comparison to an age- and sex-matched general population. IVDUs had higher reinfection and early reoperation rates. Survival was poor after medically treated reinfection.