Surgical Management Of Infective Endocarditis Research Articles

The Surgical Treatment of Infective Endocarditis: A Comprehensive Review.

Infective endocarditis (IE) is a severe cardiac complication with high mortality rates, especially when surgical intervention is delayed or absent. This review addresses the expanding role of surgery in managing IE, focusing on the variation in surgical treatment rates, the impact of patient demographics, and the effectiveness of different surgical approaches. Despite varying global data, a notable increase in surgical interventions for IE is evident, with over 50% of patients undergoing surgery in tertiary centres. This review synthesizes information from focused literature searches up to July 2023, covering preoperative to postoperative considerations and surgical strategies for IE. Key preoperative concerns include accurate diagnosis, appropriate antimicrobial treatment, and the timing of surgery, which is particularly crucial for patients with heart failure or at risk of embolism. Surgical approaches vary based on valve involvement, with mitral valve repair showing promising outcomes compared to replacement. Aortic valve surgery, traditionally favouring replacement, now includes repair as a viable option. Emerging techniques such as sutureless valves and aortic homografts are explored, highlighting their potential advantages in specific IE cases. The review also delves into high-risk groups like intravenous drug users and the elderly, emphasizing the need for tailored surgical strategies. With an increasing number of patients presenting with prosthetic valve endocarditis and device-related IE, the review underscores the importance of comprehensive management strategies encompassing surgical and medical interventions. Overall, this review provides a comprehensive overview of current evidence in the surgical management of IE, highlighting the necessity of a multidisciplinary approach and ongoing research to optimize patient outcomes.

Suppressive antibiotic therapy for infectious endocarditis

ObjectivesSuppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE. MethodsWe conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT. ResultsThe MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95–457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse. ConclusionMortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis.

Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE. We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group. 61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients. Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.

Characteristics, risk factors and outcomes of patients managed for left-sided infective endocarditis: a prospective study in a high-volume center

Abstract Background Although medical and surgical management of infective endocarditis (IE) have improved in the recent decades, the associated mortality remains high. Available prospective data are scarce, and further knowledge from prospective cohorts could help improving the prognosis of patients with IE. Objective To describe the characteristics and outcomes of left-sided IE and to determine the risk factors associated to in-hospital mortality in a high-volume center. Methods From 15 September 2020 to 15 February 2023, all patients with left-sided IE managed in a tertiary center of cardiology were included in this prospective, observational study. The diagnosis of IE was made according to current guidelines and management was collegially discussed by the endocarditis team. Determinants of in-hospital death were assessed using a multivariate logistic regression model including any covariate associated in univariate analysis (p<0.1). Results A total of 185 patients were included during the study period. Median age was 68 [56 – 76] years, 141 (76%) patients were males, and 75 (41%) cases involved a prosthetic valve. Aortic valve, mitral valve and involvement of both valves were observed in 111 (60%), 48 (26%) and 26 (14%) patients, respectively. Multimodal cardiac imaging, including cardiac computed tomography (CT) and/or PET-FDG, was used in 64 (35%) of all cases, and 49/75 (65%) patients with valvular prosthesis. Severe valvular regurgitation was identified in 56 (30%) patients, root abscess and/or false aneurysms in 57 (31%) patients. A pathogen agent was identified in 169 (91%) patients, and the most frequent germs were Staphylococcus (30%), Streptococcus (30%) and Enterococcus (17%). A severe initial presentation requiring intensive care unit (ICU) admission was observed in 42 (23%) patients. Cardiac surgery was performed in 102 (55%) cases, and 41 (22%) patients required an emergent surgery. A total of 37 (20%) patients died during the initial in-hospital phase, mostly from cardiac or neurovascular causes. In a multivariate analysis, hypertension (Odd ratio (OR) = 3.3; 95% confidence interval (CI): 1.4 – 10), bi-valvular endocarditis (OR = 3.1; 95%CI: 1.0 – 9.5), unidentified pathogen (OR = 4.3; 95%CI: 1.7 – 15) and chronic alcoholic abuse (OR = 16.4; 95%CI: 3.7 – 87.9) were independently associated with increased in-hospital mortality (Table). Conclusion Severe initial presentation requiring an ICU admission and/or urgent cardiac surgery was common among patients with left-sided IE. Chronic alcoholic abuse and unidentified pathogen appear as major determinants of in-hospital mortality.Table

Contemporary surgical management of infective endocarditis of the aortic root

Contemporary surgical management of infective endocarditis of the aortic root

Surgical management of infective endocarditis: an analysis of early and 1 year result in native valve patients at vietnam heart institute from 2018 to 2019

Background: about 50% of infective endocarditis patients require surgery, but mortality and complications rates are still high, both the immediate postoperative period and 1 year follow-up.
 Study: To find out the early (first 30 days) and up to 1 year mortality and complication rates in native valve infective endocarditis patients after surgery. [1]
 Subjects and methods: 66 native valve infective endocarditis patients were operated at the Vietnam Heart Institute- Bach Mai Hospital, followed up to 1 year after surgery.
 Methods: longitudinal follow-up retrospective, cross-sectional observational study.
 Results: The mortality rate in the first 30 days was 9.1%, the additional mortality rate after 1 year was 1.7%, the cumulative mortality rate up to 1 year after surgery was 10.6. %, the survival rate was 89.4%. IE recurrence rate was 1.5%. The most common complications in the early postoperative period: renal failure (9.1%) and pleural effusion (9.1%), pneumonia (6.1%) cerebrovascular accident (3%) and atrioventricular block (1.5%). Follow- up to 1 year, 33.3% of patients had to be re-hospitalized due to cardiovascular events.

Successful Debulking of Tricuspid Valve Vegetation Using Suction Filtration and Veno-Venous Bypass

Tricuspid valve endocarditis with recurrent septic pulmonary emboli is an indication for surgery. In this report, we present a case of right-sided infective endocarditis (RSIE) in a female patient with a history of intravenous drug use (IVDU). The patient was admitted with multiple chief complaints of fatigue, chills, fever, cough, chest pain, and shortness of breath. She was found to have a large 1.8 cm (W) x 2.4 cm (L) mobile tricuspid valve vegetation on transthoracic echocardiogram (TTE). Despite being on appropriate antibiotics, the patient failed to improve clinically. Cardiothoracic surgery (CTS) evaluated the patient for surgical management of infective endocarditis (IE) given the size of vegetation, persistent bacteremia, and clinical deterioration. However, the risk/benefit ratio for open-heart surgery was high, given the history of active IVDU and hemodynamic instability. The patient underwent percutaneous extraction of the vegetation using suction filtration and veno-venous bypass and her condition significantly improved clinically afterward. We discuss the importance of suction filtration and veno-venous bypass in managing tricuspid valve endocarditis as an alternative in patients who are not ideal candidates for surgery and the need for more evidence regarding its effectiveness compared to surgery.

Prosthesis choice for surgical treatment of left-sided native valve infective endocarditis: Determinants and impact on outcomes

Surgical treatment is required in approximately half of the patients with infective endocarditis (IE) because of severe complications. To date there is no recommendation favoring a specific valve substitute for IE treatment and accordingly there is a wide variation in routine surgical management of these patients. The purpose of this study is to describe surgical practices in our center and to investigate the impact on clinical outcomes. All patients with native valve left-sided IE, who underwent valve replacement surgery with a mechanical or biological prosthesis in our institution between 1 January 2006 and 31 December 2018 were enrolled in this retrospective study. A total of 303 patients were included (mean age = 58 years, 80% men). Patients in whom a biological valve was chosen (64%, n = 194) were older and had more comorbid conditions compared to patients who received a mechanical valve (36%, n = 109). In hospital mortality was respectively 19% ( n = 36) in the bioprosthesis group avec 3% ( n = 3) in the mechanical valve group ( P < 0.0001). The mortality rates at 1 and 3 years were 35% and 41% in the biological valve group, these rates were 8% and 15% in the mechanical valve group. Factors associated to in hospital and mid term mortality were age, comorbid conditions, hemodynamic failure, a double valve replacement or associated bypass surgery. The type of the implanted valve substitute was not independently associated with mortality. For surgical management of IE, a biological valve is the most used valve substitute in our institution. Mechanical valves seem to be implanted in a very selected and low-risk patient subgroup. The valve substitute does not appear to be related to in hospital nor to midterm mortality rates.

Early and intermediate outcomes for surgical management of infective endocarditis

ObjectiveThe treatment of active infective endocarditis (IE) presents a clinical dilemma with uncertain outcomes. This study sets out to determine the early and intermediate outcomes of patients treated surgically for active IE at an academic medical center.MethodsA retrospective chart review was conducted to identify patients who underwent surgical intervention for IE at our institution from July 1st, 2011 to June 30th, 2018. In-patient records were examined to determine etiology of disease, surgical intervention type, postoperative complications, length of stay (LOS), 30-day in-hospital mortality, and 1-year survival.ResultsTwenty-five patients underwent surgical intervention for active IE. The average age of the patients was 47 ± 14 years old and most of the patients were male (N = 15). The majority of the patients had the mitral valve replaced (N = 10), with the remaining patients having tricuspid (N = 8) and aortic (N = 7) valve replacements. The etiology varied and included intravenous drug use (IVDU), and presence of transvenous catheters. The 30-day in-hospital mortality was 4% with 1 patient death and the 1-year survival was 80%. The average LOS was 27 days ±15 and the longest LOS was 65 days.ConclusionsSurgical management of IE can be difficult and challenging however mortality can be minimized with acceptable morbidity. The most common complication was CVA. The average LOS is longer than traditional adult cardiac surgery procedures and the recurrence rate of valvular infection is not minimal especially if the underlying etiology is IVDU.

Predictors of early mortality after surgical treatment of infective endocarditis: a single-center experience.

Surgical management of infective endocarditis continues to be challenging and is associated with significant morbidity and mortality. The objective of our study was to determine the risk factors and conditions associated with poor early infective endocarditis surgical treatment outcomes-30-day postoperative mortality. A total of 124 patients who underwent surgery for infective endocarditis at the Hospital of Lithuanian University of Health Sciences Kaunas Clinics from January 2010 to December 2017 were retrospectively included in this study. The primary endpoints were 30-day postoperative mortality and identification of risk factors associated with it. Secondary endpoints were early postoperative outcomes and complication rates. During the study period, 124 patients with infective endocarditis underwent cardiac surgery, presenting an overall 30-day postoperative mortality rate of 10.48%. Mean age was 58 ± 14.4 years with 95 (76.61%) males. Independent predictive factors of early mortality were age >63 years (odds ratio = 6.4, 95% confidence interval = 1.66-24.66, p = 0.003), body mass index >30 kg/m² (odds ratio = 7.74, 95% confidence interval = 2.20-27.27, p = 0.003), and ischemic heart disease (odds ratio, 6.6, 95% confidence interval = 1.62-26.90, p = 0.003), as well as intraoperative parameters-prolonged aortic cross-clamp >84.5 minutes (odds ratio = 3.79, 95% confidence interval = 1.10-13.08, p = 0.03) and cardiopulmonary bypass time >107.5 minutes (odds ratio = 10.0, 95% confidence interval = 1.26-79.58, p = 0.023). Staphylococcus aureus infection (odds ratio = 5.04, 95% confidence interval = 1.29-19.64, p = 0.012), infective endocarditis-related intracardiac complication such as paravalvular abscess detected by transesophageal echocardiography (odds ratio = 4.32, 95% confidence interval = 1.31-14.25, p = 0.01), and infective endocarditis complicated by septic or cardiogenic shock (odds ratio, 18.43, 95% confidence interval = 4.59-73.98, p = 0.001) were statistically significant factors for increased risk of 30-day postoperative mortality. Surgical treatment of infective endocarditis showed good results in our center. The independent predictors of 30-day postoperative mortality for patients who underwent cardiac surgery for infective endocarditis were age, body mass index, ischemic heart disease, prolonged aortic cross-clamp and cardiopulmonary bypass time, Staphylococcus aureus infection, paravalvular abscess, and septic or cardiogenic shock.

Making the Cut: Perspectives on the Surgical Management of Infective Endocarditis Among People Who Use Intravenous Drugs

In this article we review the perspectives in the literature around surgical treatment for infective endocarditis (IE) in people who use intravenous drugs (PUID). PUID are at increased risk for IE; however, controversy exists regarding how to best manage these patients. We explore the outcomes for surgical treatment in PUID with IE, contrasting these with patients with IE who do not use drugs. We describe some of the perspectives in the literature around second valve replacement for PUID with IE, arguing that moralistic arguments are not on the basis of evidence and perpetuate the stigma experienced by PUID who seek treatment for IE. Finally, we explore the role of substance use interventions in the treatment of PUID with IE, and advocate for further evidence. PUID with IE are a highly stigmatized patient subgroup for whom best practice management strategies are not always implemented, emphasizing the need for further research and advocacy.

Results of surgical management of infective endocarditis associated with Staphylococcus aureus.

Staphylococcus aureus (SA) is a leading cause of infective endocarditis (IE), and such cases are on the rise. Our objective was to evaluate the clinical outcomes of surgical intervention in patients with SA-associated IE and to identify the factors associated with outcomes. Between 2009 and 2017, 585 patients underwent valve surgery for definitive left-sided IE at 14 affiliated hospitals. Their medical records were retrospectively reviewed, and the preoperative variables and clinical results of patients with (n = 117) or without SA infection (n = 468) were compared. The SA group had a more critical preoperative condition with higher rates of chronic haemodialysis, preoperative embolic events and preoperative inflammation levels, as well as worse renal function. In-hospital mortality was 20% and 7% in the patients with or without SA infection, respectively. The overall survival rate at 1 year and 5 years was 72% and 62% in the SA group, and 88% and 81% in the non-SA group, respectively (P < 0.001). The Cox hazard analysis revealed that methicillin-resistant SA infection was an independent risk factor for overall mortality in the SA group. The rate of freedom from recurrence of endocarditis at 1 year and 5 years was 95% and 90% in the SA group and 96% and 92% in the non-SA group, respectively (P = 0.43). The short- and mid-term outcomes after valve surgery for active IE in patients with SA are still challenging. Methicillin-resistant SA infection is an independent predictor of mid-term mortality.

Surgical management of infective endocarditis: risk factors affecting early outcome

Objective To evaluate the risk factors affecting the early outcome of surgical treatment of infective endocarditis (IE). Background IE represents a series of clinical conditions with high in-hospital mortality, so early diagnosis and treatment can improve outcomes. Diagnosis depends on constant history and classic manifestations like sustained bacteremia or fungemia or active valvulitis. IE is a medical-surgical disease in which surgical treatment is a part of the therapeutic process rather than a result of the failure of medical treatment. Patients and methods A prospective cohort study was conducted on 50 consecutive patients diagnosed with definite IE and underwent cardiac surgery after being admitted to the Cardiothoracic Surgical Department, National Heart Institute, Giza, Egypt, during the period from December 2015 till March 2017. Preoperative, intraoperative, and postoperative data as potential predictors of mortality were tested. Results Our results showed that rheumatic heart disease was the most common underlying cardiac disease. Native valve endocarditis was present in 31 (62%) and prosthetic valve endocarditis in 19 (38%) patients. Mean Euro SCORE II was 5.71%. The hospital mortality was 22%, whereas the 6-month mortality was 10%. Congestive heart failure, embolization, and periannular extension of infection are the most powerful predictors of hospital mortality and also 6-month mortality. Conclusion Surgery for IE continues to be challenging. Euro SCORE II has a good discrimination ability to predict in-hospital mortality in IE surgery. Satisfactory results can be obtained with valve repair in IE.

Invited Commentary

Invited Commentary

Utility of Brain Magnetic Resonance Imaging in the Surgical Management of Infective Endocarditis

Brain magnetic resonance imaging (MRI) is frequently obtained in patients with infective endocarditis, yet its utility in predicting outcomes for valve replacement surgery in patients is unknown. The objective of this study was to determine how brain MRI findings impact clinical management and outcomes. Demographic and clinical data from electronic medical records at Mayo Clinic were retrospectively reviewed for patients hospitalized with definite or possible infective endocarditis according to the modified Duke criteria between January 1, 2007 and December 31, 2014. There were 364 patients included in the study. Cardiac valve replacement surgery was performed in 195 of 364 (53.6%) patients, and 95 (48.7%) of the surgical patients underwent preoperative MRI, which was associated with preoperative neurologic symptoms in 56 of 95 (58.9%) patients (odds ratio = 12.92; 95% confidence interval, 5.98-27.93; P <.001). Postoperative neurologic complications occurred in 24 of 195 (12.3%) patients, including new ischemic stroke in 4 of 195 (2.1%) and new intracerebral hemorrhage in 3 of 195 (1.5%). No patients with microhemorrhages developed postoperative hemorrhage. No significant differences existed in rates of postoperative complications between patients with and those without preoperative MRI. There were no substantial associations between preoperative MRI findings and postoperative neurologic complications, functional outcomes as described by the modified Rankin Scale score, or 6-month mortality. In patients undergoing valve replacement surgery, preoperative MRI findings were not associated with differences in postoperative outcomes, irrespective of finding or timing of valve replacement surgery.

Single Centre Review of Surgically Managed Infective Endocarditis

Purpose: Infective endocarditis (IE) is a life-threatening illness that requires early intervention. We sought to identify the outcomes of all patients who underwent surgical intervention for IE at an Australian tertiary hospital. Methodology: The study institution's Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database was searched for all patients who underwent valve surgery with active IE between 2000 and 2015. Additional data was obtained by reviewing medical records. Results: There were 133 patients who underwent surgical management of IE. Mean patient age was 54 ± 16 years. A history of IV drug use was present in 23% (31/133) of patients. The commonest infective agents were Staphylococcus aureus in 32% (42/133), of which 14% were MRSA (6/42), Streptococcus viridans in 15% (20/133), and Enterococcus faecalis in 13% (17/133). A single valve procedure was performed in 75% (100/133), while multiple valve procedures were performed in 25% (33/133). The surgical procedures were: aortic valve surgery in 68% (90/133), mitral valve surgery in 47% (63/133) and tricuspid valve surgery in 10% (13/133). Surgical mortality was 15% (20/133). On univariate analysis having emergency surgery (p = 0.003), cross clamp time (p = 0.015) and cardiopulmonary bypass time (p = 0.03) were identified as significant risk factors for mortality. On multivariable analysis emergency surgery (p = 0.021) was identified as a significant risk factor for mortality. Conclusion: Surgery for infective endocarditis is associated with substantial early mortality. Emergency surgery is associated with increased risk of mortality. A multidisciplinary approach with early referral to cardiothoracic surgery is indicated.

Surgical management of infective endocarditis complicated by ischemic stroke.

Embolism to the central nervous system is a frequent and important complication of infective endocarditis. While early surgery improves outcomes in many groups of patients with infective endocarditis, ischemic stroke secondary to septic embolism carries the risk of hemorrhagic transformation and neurological deterioration with heparinization and cardiopulmonary bypass. We review the literature regarding the surgical management of infective endocarditis in patients with cerebral emboli.

Surgical Management of Infective Endocarditis Complicated by Embolic Stroke: Practical Recommendations for Clinicians.

There has been an overall improvement in surgical mortality for patients with infective endocarditis (IE), presumably because of improved diagnosis and management, centered around a more aggressive early surgical approach. Surgery is currently performed in approximately half of all cases of IE. Improved survival in surgery-treated patients is correlated with a reduction in heart failure and the prevention of embolic sequelae. It is reported that between 20% and 40% of patients with IE present with stroke or other neurological conditions. It is for these IE patients that the timing of surgical intervention remains a point of considerable discussion and debate. Despite evidence of improved survival in IE patients with earlier surgical treatment, a significant proportion of patients with IE and preexisting neurological complications either undergo delayed surgery or do not have surgery at all, even when surgery is indicated and guideline endorsed. Physicians and surgeons are caught in a common conundrum where the urgency of the heart operation must be balanced against the real or perceived risks of neurological exacerbation. Recent data suggest that the risk of neurological exacerbation may be lower than previously believed. Current guidelines reflect a shift toward early surgery for such patients, but there continue to be important areas of clinical equipoise. Individualized clinical assessment is of major importance for decision making, and, as such, we emphasize the need for the functioning of an endocarditis team, including cardiac surgeons, cardiologists, infectious diseases specialists, neurologists, neurosurgeons, and interventional neuroradiologists. Here, we present 2 illustrative cases, critically review contemporary data, and offer conceptual and practical suggestions for clinicians to address this important, common, and often fatal cardiac condition.

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.

Invited Commentary

The authors [1Dohmen P.M. Binner C. Mende M. et al.Outcome of aortic valve replacement for active infective endocarditis in patients on chronic hemodialysis.Ann Thorac Surg. 2015; 99: 532-538Scopus (13) Google Scholar] address an important topic: the surgical management of infective endocarditis in end stage renal disease (ESRD). With the increasing numbers of patients with ESRD, more cardiac surgeons will likely be operating on such patients, thus making this article an important reference for what to anticipate in short-term complications, high mortality, and poor long-term outcomes.The patient ESRD and valvular heart disease complicated with acute endocarditis is the penultimate complex patient because of the multiplicity of acute and chronic risk factors that affect the immune system, hemodynamics, fluid management, and local structural disturbances caused by the infective process.In this article, the authors reported a high 30-day postoperative complication rate affecting 66.7% of patients, a 42.2% 30-day mortality, a 1-year survival that did not reach 30%, and zero survival at 54 months.These results are not too far removed from what we have reported in a retrospective study conducted at Emory University–affiliated hospitals on all patients with ESRD requiring valve surgery, with operative mortality of 19.9%, median survival of 1.2 years, 2-year survival for isolated aortic valve cases of 40%, and 10-year survival of 18% [2Thourani V.H. Sarin E.L. Keeling W.B. et al.Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.Ann Thorac Surg. 2011; 91: 1127-1134Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar].Every surgeon who operates on patients with ESRD and acute endocarditis should be familiar with this paper. The surgeon should also inform patients and families of the potentially high risk for associated complications and reduced short- and long-term survival benefit. The authors [1Dohmen P.M. Binner C. Mende M. et al.Outcome of aortic valve replacement for active infective endocarditis in patients on chronic hemodialysis.Ann Thorac Surg. 2015; 99: 532-538Scopus (13) Google Scholar] address an important topic: the surgical management of infective endocarditis in end stage renal disease (ESRD). With the increasing numbers of patients with ESRD, more cardiac surgeons will likely be operating on such patients, thus making this article an important reference for what to anticipate in short-term complications, high mortality, and poor long-term outcomes. The patient ESRD and valvular heart disease complicated with acute endocarditis is the penultimate complex patient because of the multiplicity of acute and chronic risk factors that affect the immune system, hemodynamics, fluid management, and local structural disturbances caused by the infective process. In this article, the authors reported a high 30-day postoperative complication rate affecting 66.7% of patients, a 42.2% 30-day mortality, a 1-year survival that did not reach 30%, and zero survival at 54 months. These results are not too far removed from what we have reported in a retrospective study conducted at Emory University–affiliated hospitals on all patients with ESRD requiring valve surgery, with operative mortality of 19.9%, median survival of 1.2 years, 2-year survival for isolated aortic valve cases of 40%, and 10-year survival of 18% [2Thourani V.H. Sarin E.L. Keeling W.B. et al.Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.Ann Thorac Surg. 2011; 91: 1127-1134Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar]. Every surgeon who operates on patients with ESRD and acute endocarditis should be familiar with this paper. The surgeon should also inform patients and families of the potentially high risk for associated complications and reduced short- and long-term survival benefit. Outcome of Aortic Valve Replacement for Active Infective Endocarditis in Patients on Chronic HemodialysisThe Annals of Thoracic SurgeryVol. 99Issue 2PreviewThe high risk of morbidity and mortality for patients on hemodialysis who are undergoing cardiac surgery is increased for those with active infective endocarditis (AIE). This retrospective observational single-center study evaluated the impact of chronic hemodialysis on the outcome of aortic valve replacement in patients with aortic AIE. Full-Text PDF