Valvular Perforation in Left‐sided Native Valve Infective Endocarditis

Abstract

Background: Left-sided native valve infective endocarditis (LNVIE) can result in mitral (MP) and aortic (AP) valve perforation, the prognostic significance of which remains poorly defined. Hypothesis: Valvular perforation is associated with worse outcomes. Methods: Retrospective review of patients with LNVIE during 1998-2005 was performed to examine characteristics and outcome predictors of LNVIE complicated by valve perforation. Patients were stratified as: group A: MP or AP detected by transesophageal echocardiography (TEE) or surgery; group B: no TEE evidence of MP or AP. Results: A total of 123 patients were included (group A = 47, group B = 76). In group A, 35 patients (74.5%) had MP alone, 11 (23.4%) had AP alone, and 1 patient had both. Severe valvular insufficiency was encountered more in group A (85.1% versus 59.2%, p = 0.003), so was hemodialysis (40.4% versus 17.1%, p = 0.004) and indications for valvular surgery (93.6% versus 77.6%, p = 0.02). Group A had a higher rate of in-hospital death (31.9% versus 15.8%, p = 0.04). Among patients who had an indication for valvular surgery, the in-hospital mortality rate for those who underwent valvular surgery was 16.7% in group A, and 7.9% in group B (p = 0.4), compared to those who did not undergo surgery (71.4% versus 33.3%, p = 0.04). Amongst survivors, hospital stay was on average 9.2 d longer in group A (38.9 versus 29.7 d, p = 0.05). Univariate analysis revealed association between lower survival and valvular perforation (odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.17-0.95), that was lost after adjusting for hemodialysis. Conclusions: Valve perforation complicating LNVIE is associated with hemodialysis, severe valvular insufficiency, and significant morbidity and mortality. Compared to conservative management, early surgical intervention is associated with improved survival.

Echocardiographic Findings Predict In-Hospital and 1-Year Mortality in Left-Sided Native Valve Staphylococcus aureus Endocarditis

“…Even when surgery was accounted for in our multivariable model, the presence of an abscess was associated with in-hospital death and both perforation and abscess were associated with 1-year mortality in S. aureus LNVIE and streptococcal LNVIE. The finding that perforation is an independent marker of mortality concurs with a study conducted by Bachour and colleagues who found that a valve perforation complicating LNVIE is associated with high mortality in a retrospective review of 123 LNVIE cases [11]. Abscess is a life-threatening complication that cannot be cured with antibiotic therapy alone.…”

“…However, data for left ventricular ejection fraction (LVEF) and LV dimensions were not captured, yet may add incremental prognostic value in IE. Finally, inconsistencies exist regarding the causative pathogen and risk of tissue destruction such as fistulas, perforation or abscess formation [10,11]. …”

Real Time Three‐Dimensional Transesophageal Echocardiographic Evaluation of Aortic Valve Perforation

“…[1][2][3][4][5] This was the most common etiology in our population, seen in 60% of the patients (Figs. [1][2][3][4][5] This was the most common etiology in our population, seen in 60% of the patients (Figs.…”

“…1,[3][4][5][8][9][10][11][12][13][14][15][16] The major strength of the recently introduced RT3DTEE is its ability to provide precise spatial orientation of cardiac anatomy; it also shows the interstructural spatial relationships and displays the aortic and mitral valve anatomy from the surgeon's perspective. 1,[3][4][5][8][9][10][11][12][13][14][15][16] The major strength of the recently introduced RT3DTEE is its ability to provide precise spatial orientation of cardiac anatomy; it also shows the interstructural spatial relationships and displays the aortic and mitral valve anatomy from the surgeon's perspective.…”

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Two-dimensional transthoracic echocardiography (2DTTE) and transesophageal echocardiography (TEE) with Doppler and color flow imaging are the standard techniques utilized to define the anatomic fault and to quantify AR. Aortic valve (AV) perforation may be caused by infective endocarditis, surgical, or catheter-related iatrogenic injuries, chest trauma and spontaneous rupture of a leaflet fenestration.…”