1
|
Long-term outcome for the surgical treatment of infective endocarditis with a focus on intravenous drug users.
Rabkin DG, Mokadam NA, Miller DW, Goetz RR, Verrier ED, Aldea GS.
Ann Thorac Surg. 2012 Jan;93(1):51-57
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
We reviewed our experience with surgical procedures for infective endocarditis (IE) in order to evaluate modern outcomes and objectively examine our institutional preferences, including the use of bioprostheses in intravenous drug users (IVDUs) regardless of age and prompt surgical intervention in patients with either septic cerebral emboli or active infection.
METHODS:
Review of medical records was conducted from February 1999 to November 2010. The Social Security Death Index was used to determine death from any cause in the postoperative period. Hospital records were used to identify infectious complications, recurrent endocarditis, and reoperation.
RESULTS:
Sixty-four patients were identified as IVDUs and 133 patients as non-IVDUs. Survival at 30 days, 1 year, 5 years, and 10 years for IVDUs and non-IVDUs was 91.2% versus 93.6%, 77.5% versus 83.0%, 46.7% versus 71.1%, and 41.1% versus 52.0%, respectively. Cox regression analysis identified intravenous drug use as an independent risk factor for diminished survival (p=0.03), although not for reoperation (p=0.95) despite 95.3% of IVDUs receiving bioprostheses versus 73.7% of non-IVDUs (p=0.0002, Fisher's exact test). Forty-three patients were identified as having preoperative septic cerebral emboli; none had a perioperative hemorrhagic event. Active infection approached significance as an independent risk factor for the composite end point of recurrent IE and perioperative infection (odds ratio 2.8; 95% confidence interval, 0.777 to 10.9; p=0.12, Fisher's exact test).
CONCLUSIONS:
Bioprostheses are reasonable for IVDUs undergoing valve replacement for IE regardless of age. Prompt surgical intervention in the setting of septic cerebral emboli is justified; in the setting of active infection it is less clear.
|
|
2
|
Type 2 diabetes mellitus is associated with faster degeneration of bioprosthetic valve: results from a propensity score-matched Italian multicenter study.Results From a Propensity Score–Matched Italian Multicenter Study
Lorusso R, Gelsomino S, Lucà F, De Cicco G, Billè G, Carella R, Villa E, Troise G, Viganò M, Banfi C, Gazzaruso C, Gagliardotto P, Menicanti L, Formica F, Paolini G, Benussi S, Alfieri O, Pastore M, Ferrarese S, Mariscalco G, Di Credico G, Leva C, Russo C, Cannata A, Trevisan R, Livi U, Scrofani R, Antona C, Sala A, Gensini GF, Maessen J, Giustina A.
Circulation. 2012 Jan 31;125(4):604-614
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration.
METHODS AND RESULTS:
Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score–matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM (P<0.001), respectively. Seven-year freedom from valve deterioration was significantly lower in patients with DM (73.2% [95% confidence interval, 61.6–85.5] versus 95.4% [95% confidence interval, 83.9–100], P<0.001). In Cox regression models with robust SEs that accounted for the clustering of matched pairs, DM was the strongest predictor of structural valve degeneration (hazard ratio 2.39 [95% confidence interval 2.28–3.52]). When we allowed for interaction between type 2 DM and other key risk factors, DM remained a significant predictor beyond any potentially associated variable.
CONCLUSIONS:
Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.
|
|
3
|
Outcomes after surgical treatment of native and prosthetic valve infective endocarditis.
Manne MB, Shrestha NK, Lytle BW, Nowicki ER, Blackstone E, Gordon SM, Pettersson G, Fraser TG.
Ann Thorac Surg. 2012 Feb;93(2):489-493
Link to Article View Abstract |
|
|
Abstract
BACKGROUND:
The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes.
METHODS:
A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up.
RESULTS:
Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p<0.01), but long-term survival was not significantly different (35% versus 29%; p=0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p<0.05), 6-month mortality (23% versus 15%; p=0.05), and 1-year mortality (28% versus 18%; p=0.02) compared with non-S aureus IE.
CONCLUSIONS:
Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.
|
|
4
|
Long-term outcomes of mechanical valve replacement in patients with atrial fibrillation: impact of the maze procedure.
Bum Kim J, Suk Moon J, Yun SC, Kee Kim W, Jung SH, Jung Choo S, Song H, Hyun Chung C, Won Lee J.
Circulation. 2012 May 1;125(17):2071-2080
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
The long-term benefits of the maze procedure in patients with chronic atrial fibrillation undergoing mechanical valve replacement who already require lifelong anticoagulation remain unclear.
METHODS AND RESULTS:
We evaluated adverse outcomes (death; thromboembolic events; composite of death, heart failure, or valve-related complications) in 569 patients with atrial fibrillation-associated valvular heart disease who underwent mechanical valve replacement with (n=317) or without (n=252) a concomitant maze procedure between 1999 and 2010. After adjustment for differences in baseline risk profiles, patients who had undergone the maze procedure were at similar risks of death (hazard ratio, 1.15; 95% confidence interval, 0.65-2.03; P=0.63) and the composite outcomes (hazard ratio, 0.82; 95% confidence interval, 0.50-1.34; P=0.42) but a significantly lower risk of thromboembolic events (hazard ratio, 0.29; 95% confidence interval, 0.12-0.73; P=0.008) compared with those who underwent valve replacement alone at a median follow-up of 63.6 months (range, 0.2-149.9 months). The effect of superior event-free survival by the concomitant maze procedure was notable in a low-risk EuroSCORE (0-3) subgroup (P=0.049), but it was insignificant in a high-risk EuroSCORE (≥4) subgroup (P=0.65). Furthermore, the combination of the maze procedure resulted in superior left ventricular (P<0.001) and tricuspid valvular functions (P<0.001) compared with valve replacement alone on echocardiographic assessments performed at a median of 52.7 months (range, 6.0-146.8 months) after surgery.
CONCLUSION:
Compared with valve replacement alone, the addition of the maze procedure was associated with a reduction in thromboembolic complications and improvements in hemodynamic performance in patients undergoing mechanical valve replacement, particularly in those with low risk of surgery.
|
|
5
|
Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: three successive population-based surveys
Duval X, Delahaye F, Alla F, Tattevin P, Obadia JF, Le Moing V, Doco-Lecompte T, Celard M, Poyart C, Strady C, Chirouze C, Bes M, Cambau E, Iung B, Selton-Suty C, Hoen B; AEPEI Study Group.
J Am Coll Cardiol. 2012 May 29;59(22):1968-1976
Link to Article
View Abstract |
|
|
Abstract
OBJECTIVES:
The goal of this study was to evaluate temporal trends in infective endocarditis (IE) incidence and clinical characteristics after 2002 French IE prophylaxis guideline modifications.
BACKGROUND:
There are limited data on changes in the epidemiology of IE since recent guidelines recommended restricting the indications of antibiotic prophylaxis of IE.
METHODS:
Three 1-year population-based surveys were conducted in 1991, 1999, and 2008 in 3 French regions totaling 11 million inhabitants age ≥20 years. We prospectively collected IE cases from all medical centers and analyzed age- and sex-standardized IE annual incidence trends.
RESULTS:
Overall, 993 expert-validated IE cases were analyzed (323 in 1991; 331 in 1999; and 339 in 2008). IE incidence remained stable over time (95% confidence intervals given in parentheses/brackets): 35 (31 to 39), 33 (30 to 37), and 32 (28 to 35) cases per million in 1991, 1999, and 2008, respectively. Oral streptococci IE incidence did not increase either in the whole patient population (8.1 [6.4 to 10.1], 6.3 [4.8 to 8.1], and 6.3 [4.9 to 8.0] in 1991, 1999, and 2008, respectively) or in patients with pre-existing native valve disease. The increased incidence of Staphylococcus aureus IE (5.2 [3.9 to 6.8], 6.8 [5.3 to 8.6], and 8.2 [6.6 to 10.2]) was not significant in the whole patient population (p = 0.228) but was significant in the subgroup of patients without previously known native valve disease (1.6 [0.9 to 2.7], 3.7 [2.6 to 5.1], and 4.1 [3.0 to 5.6]; p = 0.012).
CONCLUSIONS:
Scaling down antibiotic prophylaxis indications was not associated with an increased incidence of oral streptococcal IE. A focus on avoidance of S. aureus bacteremia in all patients, including those with no previously known valve disease, will be required to improve IE prevention
|
|
6
|
Early Surgery versus Conventional Treatment for Infective Endocarditis
Kang DH, Kim YJ, Kim SH, Sun BJ, Kim DH, Yun SC, Song JM, Choo SJ, Chung CH, Song JK, Lee JW, Sohn DW.
N Engl J Med. 2012 Jun 28;366(26):2466-2473
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
The timing and indications for surgical intervention to prevent systemic embolism in infective endocarditis remain controversial. We conducted a trial to compare clinical outcomes of early surgery and conventional treatment in patients with infective endocarditis.
METHODS:
We randomly assigned patients with left-sided infective endocarditis, severe valve disease, and large vegetations to early surgery (37 patients) or conventional treatment (39). The primary end point was a composite of in-hospital death and embolic events that occurred within 6 weeks after randomization.
RESULTS:
All the patients assigned to the early-surgery group underwent valve surgery within 48 hours after randomization, whereas 30 patients (77%) in the conventional-treatment group underwent surgery during the initial hospitalization (27 patients) or during follow-up (3). The primary end point occurred in 1 patient (3%) in the early-surgery group as compared with 9 (23%) in the conventional-treatment group (hazard ratio, 0.10; 95% confidence interval [CI], 0.01 to 0.82; P=0.03). There was no significant difference in all-cause mortality at 6 months in the early-surgery and conventional-treatment groups (3% and 5%, respectively; hazard ratio, 0.51; 95% CI, 0.05 to 5.66; P=0.59). The rate of the composite end point of death from any cause, embolic events, or recurrence of infective endocarditis at 6 months was 3% in the early-surgery group and 28% in the conventional-treatment group (hazard ratio, 0.08; 95% CI, 0.01 to 0.65; P=0.02).
CONCLUSIONS:
As compared with conventional treatment, early surgery in patients with infective endocarditis and large vegetations significantly reduced the composite end point of death from any cause and embolic events by effectively decreasing the risk of systemic embolism.
|
|
7
|
Impact of early surgical treatment on postoperative neurologic outcome for active infective endocarditis complicated by cerebral infarction.
Yoshioka D, Sakaguchi T, Yamauchi T, Okazaki S, Miyagawa S, Nishi H, Yoshikawa Y, Fukushima S, Saito S, Sawa Y.
Ann Thorac Surg. 2012 Aug;94(2):489-95.
Link to Article View Abstract |
|
|
Abstract
BACKGROUND:
The optimal timing of surgical intervention for infective endocarditis (IE) with cerebrovascular complications remains controversial because the risk of perioperative intracranial hemorrhage is still unclear. The aim of this study was to investigate the prevalence of acute cerebral infarction (CI) in patients with IE and its hemorrhagic risk after valve operations.
METHODS:
We retrospectively evaluated 102 consecutive patients (35 with neurologic symptoms; 67 without neurologic symptoms) who underwent diffusion-weighted magnetic resonance imaging (DW-MRI) before valve operations for left-sided active IE between 2005 and 2010. The prevalence of acute CI and its postoperative neurologic outcome were evaluated.
RESULTS:
Acute CI was detected preoperatively in 64 of 102 (62.7%) patients. Of the 64 patients with acute CI, 34 underwent surgical treatment within 14 days after diagnosis of CI (early group), whereas the other 30 patients underwent operation after more than 14 days (delayed group). Postoperative CI deterioration was confirmed in 1 patient in each group. Furthermore, in 43 of the patients with acute CI who were followed with postoperative neuroimaging, hemorrhagic transformation was confirmed in only 1 patient in the delayed group. However new ectopic intracranial hemorrhage was confirmed in 2 patients in the early group and 3 patients in the delayed group.
CONCLUSION:
The risk of postoperative hemorrhagic transformation of preoperative acute CI was low, even in patients who underwent early operation. Our data suggested that there is no benefit for delaying surgical treatment beyond 2 weeks to prevent hemorrhagic transformation in patients with CI. However ectopic intracranial hemorrhage sometimes occurs regardless of the timing of surgical treatment.
|
|
8
|
Durability of pericardial versus porcine bioprosthetic heart valves.
Grunkemeier GL, Furnary AP, Wu Y, Wang L, Starr A.
J Thorac Cardiovasc Surg 2012;144:1381-6
Link to Article
View Abstract |
|
|
Abstract
OBJECTIVES:
To compare the probability, and modes, of explantation for Carpentier-Edwards pericardial versus porcine valves.
METHODS:
Our porcine series began in 1974 and our pericardial series in 1991, with annual prospective followup.
We used the Kaplan-Meier method and Cox regression for estimation and analysis of patient mortality, and
the cumulative incidence function and competing risks regression for estimation and analysis of valve durability
RESULTS:
Through the end of 2010, we had implanted 506 porcine and 2449 pericardial aortic valves and 181 porcine
and 163 pericardial mitral valves. The corresponding total and maximum follow-up years were 3471 and 24,
11,517 and 18, 864 and 22, and 645 and 9. The corresponding probabilities (cumulative incidence function) of
any valve explant were 7%, 8%, 22%, and 8%, and of explant for structural valve deterioration were 4%, 5%,
16%, and 5%at 15 years for the first 3 series and at 8 years for the fourth (pericardial mitral valve) series. Using
competing risks regression for structural valve deterioration explant, with age, gender, valve size, and concomitant
coronary bypass surgery as covariates, a slight (subhazard ratio, 0.79), but nonsignificant, protective effect
was found for the pericardial valve in the aortic position and a greater (subhazard ratio, 0.31) and almost significant
(P ¼ .08) protective effect of the pericardial valve in the mitral position. Leaflet tear was responsible for
61% of the structural valve deterioration explants in the porcine series and 46% in the pericardial series.
CONCLUSION:
Using competing risks regression, the pericardial valve had a subhazard ratio for structural valve deterioration explant of less than 1 in both positions, approaching statistical significance in the mitral position. The mode of structural valve deterioration was predominantly leaflet tear for porcine valves and fibrosis/calcification for pericardial valves.
|
|
9
|
Incidence of postoperative atrial fibrillation in patients undergoing minimally invasive versus median sternotomy valve surgery.
Mihos CG, Santana O, Lamas GA, Lamelas J.
J Thorac Cardiovasc Surg 2012;1-6
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
Atrial fibrillation (AF) after cardiac surgery is associated with increased morbidity and hospital length of stay. Our objective was to determine whether a minimally invasive approach to isolated valve surgery reduced the incidence of postoperative AF.
METHODS:
Patients without a history of arrhythmia, who underwent isolated aortic or mitral valve surgery between January 2005 and August 2011, were included. The incidence of postoperative AF in those who underwent a minimally invasive approach was compared with that of patients undergoing median sternotomy surgery. Resource utilization was approximated on the basis of intensive care unit and total hospital lengths of stay.
RESULTS:
A total of 571 patients were identified (413 minimally invasive and 158 median sternotomy). No significant differences in baseline characteristics existed between groups. The incidence of postoperative AF (25% vs 37%; P = .002), use of intraoperative blood products (52% vs 83%; P < .001), and prolonged intubation (≥24 hours) (12% vs 20%; P = .008) were significantly less in the minimally invasive group. The intensive care unit and hospital lengths of stay were 45 hours (interquartile range [IQR], 28-66 hours) versus 53 hours (IQR, 45-91 hours) (P < .001), and 5 days (IQR, 4-7 days) versus 8 days (IQR, 6-11 days) (P < .001) for the minimally invasive and median sternotomy groups, respectively. Multivariable analysis revealed a decreased risk of postoperative AF in patients undergoing minimally invasive surgery (odds ratio, 0.4; 95% confidence intervals, 0.24-0.66; P < .001).
CONCLUSIONS:
A minimally invasive approach for isolated valve surgery reduces postoperative AF and resource use when compared with median sternotomy.
|
|
10
|
Increased risk of left heart valve regurgitation associated with benfluorex use in patients with diabetes mellitus: a multicenter study.
Tribouilloy C, Rusinaru D, Maréchaux S, Jeu A, Ederhy S, Donal E, Réant P, Arnalsteen E, Boulanger J, Ennezat PV, Garban T, Jobic Y.
Circulation. 2012 Dec 11;126(24):2852-8.
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
Benfluorex was withdrawn from European markets in June 2010 after reports of an association with heart valve lesions. The link between benfluorex and valve regurgitations was based on small observational studies and retrospective estimations. We therefore designed an echocardiography-based multicenter study to compare the frequency of left heart valve regurgitations in diabetic patients exposed to benfluorex for at least 3 months and in diabetic control subjects never exposed to the drug.
METHODS AND RESULTS:
This reader-blinded, controlled study conducted in 10 centers in France between February 2010 and September 2011 prospectively included 376 diabetic subjects previously exposed to benfluorex who were referred by primary care physicians for echocardiography and 376 diabetic control subjects. Through the use of propensity scores, 293 patients and 293 control subjects were matched for age, sex, body mass index, smoking, dyslipidemia, hypertension, and coronary artery disease. The main outcome measure was the frequency of mild or greater left heart valve regurgitations. In the matched sample, the frequency and relative risk (odds ratio) of mild or greater left heart valve regurgitations were significantly increased in benfluorex patients compared with control subjects: 31.0% versus 12.9% (odds ratio, 3.55; 95% confidence interval, 2.03-6.21) for aortic and/or mitral regurgitation, 19.8% versus 4.7% (odds ratio, 5.29; 95% confidence interval, 2.46-11.4) for aortic regurgitation, and 19.4% versus 9.6% (odds ratio, 2.38; 95% confidence interval, 1.27-4.45) for mitral regurgitation.
CONCLUSION:
Our results indicate that the use of benfluorex is associated with a significant increase in the frequency of left heart valve regurgitations in diabetic patients. The natural history of benfluorex-induced valve abnormalities needs further research.
|
|
11
|
Clinical outcomes of redo valvular operations: a 20-year experience.
Fukunaga N, Okada Y, Konishi Y, Murashita T, Yuzaki M, Shomura Y, Fujiwara H, Koyama T.
Ann Thorac Surg. 2012 Dec;94(6):2011-6.
Link to Article
View Abstract |
|
|
Abstract
BACKGROUND:
A higher operative mortality rate has been reported after redo valvular procedures than after the primary operation.
METHODS:
Outcomes of 330 consecutive patients undergoing 433 redo valvular operations at our institute during a 20-year period (January 1990 to December 2010) were reviewed retrospectively. The mean follow-up was 6.4 years (range, 0.05 to 1.3 years). Logistic regression analysis was used to identify factors associated with hospital death.
RESULTS:
The overall hospital mortality rate was 6.7% (29 of 433 procedures). Logistic regression analysis identified only advanced New York Heart Association (NYHA) class as an independent predictor of hospital death. Overall survival at 5, 10, and 15 years was 83.6%±2.2%, 70.7%±3.4%, and 61.5%±4.5%, respectively. The 5-, 10-, and 15-year survivals for the first redo vs more than second redo groups were 86.5%±2.4% vs 74.7%±5.5%, 71.8%±3.9% vs 66.8%±6.6%, and 60.2%±5.7% vs 63.1%±7.2%, respectively (log-rank P=0.505). The 5- and 10-year survivals for NYHA class I/II vs III/IV patients were 91.5%±2.1% vs 70.4%±4.5% and 77.8%±4.1% vs 58.5%±5.6%, respectively (log-rank p<0.005).
CONCLUSION:
Redo valvular operation in NYHA class III/IV patients is associated with high hospital death and poor long-term survival. To achieve low hospital death and good long-term survival, redo operations, including more than third redo operations, should be performed in patients with lower NYHA class.
|
|
| |