title: Factors influencing the results of double-valve surgery in patients with fulminant endocarditis: the importance of valve selection.
abstract: BACKGROUND
  Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome.
  
  
  METHODS
  Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age (+/-SD) was 53 +/- 14.2 years; there were 37 men and 16 women.
  
  
  METHODS
  The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion.
  
  
  RESULTS
  All patients with destructive endocarditic doublevalve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis. Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 +/- 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 +/- 10.4 mm Hg and 12 +/- 5.7 mm Hg, respectively, for the homografts and 24 +/- 8.4 mm Hg and 15 +/- 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular out- flow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation.
  
  
  CONCLUSIONS
  The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany. siniawski@dhzb.de
authors.forename: Henryk
authors.initials: H
authors.lastname: Siniawski
authors.forename: Onnen
authors.initials: O
authors.lastname: Grauhan
authors.forename: Michael
authors.initials: M
authors.lastname: Hofmann
authors.forename: Miralem
authors.initials: M
authors.lastname: Pasic
authors.forename: Yuguo
authors.initials: Y
authors.lastname: Weng
authors.forename: Charles
authors.initials: C
authors.lastname: Yankah
authors.forename: Hans
authors.initials: H
authors.lastname: Lehmkuhl
authors.forename: Roland
authors.initials: R
authors.lastname: Hetzer
mesh_terms: D004696:Endocarditis / Q000453:epidemiology*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006350:Heart Valve Prosthesis / Q000706:statistics & numerical data*; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000453:epidemiology* / Q000601:surgery*; D016459:Prosthesis-Related Infections / Q000401:mortality* / Q000517:prevention & control*; D012086:Reoperation / Q000401:mortality; D018570:Risk Assessment / Q000379:methods; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome