Mitral valve surgery in acute infective endocarditis: long-term outcomes of mitral valve repair versus replacement

Abstract

Aims Timing and surgical strategies in acute infective endocarditis are still questionable. We sought to investigate clinical outcomes of patients undergoing mitral valve repair (MVR) compared with mitral valve replacement [mitral valve prosthesis (MVP)] for acute infective endocarditis. Methods From 2004 to 2019, 109 consecutive patients with acute mitral valve infective endocarditis were retrospectively investigated. Patients were divided into two groups according to surgical strategy: MVR 53/109 (48.6%) versus MVP 56/109 (51.4%). Primary end points were in-hospital mortality and overall survival at 10 years. Secondary end point was the freedom from infective endocarditis relapse. Results Our institutional surgical approach for infective endocarditis allowed us to achieve MVR in 48.6% of patients. Hospital mortality was comparable between the two groups [MVR: 1/53 (1.9%) versus MVP: 2/56 (3.6%), P = 1.000]. Overall 10-year survival was 80.0 ± 14.1 and 77.2 ± 13.5% for MVR and MVP, respectively (P = 0.648). MVR showed a lower incidence of infective endocarditis relapse compared with MVP (MVR: 93.6 ± 7.1 versus MVP: 80.9 ± 10.8%, P = 0.041). At Cox regression, infective endocarditis relapse was an independent risk factor for death (hazard ratio 4.03; 95% confidence interval 1.41–11.52; P = 0.009). Conclusion The tendency to postpone surgery in stable patients with mitral infective endocarditis allowed achievement of MVR in almost 50% of patients. Although repair remains the approach of choice in our institution, no differences between MVR and MVP were reported in terms of early/late survival. However, MVP had a higher incidence of infective endocarditis relapse that represents an independent risk of mortality.

Surgical repair and replacement for native mitral valve infective endocarditis

“…A very recent paper by Di Bacco et al 22 reported a repair rate of about 50% in a population that shared similar preoperative clinical and microbiology characteristics with our patients. They found at 10 years similar survival and risk of mitral reoperation for patients who had valve repair and valve replacement, but a significantly lower probability of infection relapse in patients who underwent mitral repair compared with patients who had a valve prosthesis.…”

“…A higher rate of valve repair – up to 50–70% of mitral infective endocarditis cases – has been associated with the practice of specialist mitral surgeons and in the context of comprehensive valve centres 3,11,16 . However, the repair cohorts in these studies had a lower proportion of acute endocarditis and urgent cases, 22 included younger patients with a lower prevalence of cardiogenic shock and chronic renal failure 16 and limited tissue destruction 3 …”

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers

“…Patients’ preoperative condition and severity of tissue destruction might limit successful repair or increase the complexity of treatment; nevertheless, use of a prosthetic valve should be limited due to the risk of reinfection [ 5 , 6 , 7 ]. A timely surgical treatment has shown potential to improve clinical outcomes in appropriately selected patients [ 8 ].…”