Surgical treatment for active infective prosthetic valve endocarditis: 22-year single-centre experience.
OBJECTIVE
We retrospectively analysed the profile and outcome of surgically treated patients with active infective prosthetic valve endocarditis (PVE) over a period of 22 years.


METHODS
Between May 1986 and December 2008, a total of 1313 patients with active infective endocarditis (AIE) were operated on, 349 (26.6%) of them for PVE. Of these, 77 (22.1%) had to be operated upon due to early PVE (≤60 days, n=55 men, median age: 58 years) and 272 (77.9%) due to late PVE (n=200 men, median age: 63 years). A large proportion of patients were referred to our department with advanced endocarditis and in a condition of cardiac and pulmonary decompensation. A total of 226 (64.8%) patients developed periannular abscess. Operations consisted of 80 aortic valve, 45 mitral valve, 39 double valve and 165 aortic root replacements, 134 of them with a homograft. Perioperative characteristics, probability of survival, freedom from recurrence and predictors for hospital mortality were analysed. Follow-up (maximum: 19.4 years) was completed in 96.3% (total: 1118 patient-years).


RESULTS
There was high early and late mortality. Overall in-hospital mortality was 28.4% (99/349). The 30-day, 1-, 5- and 10-year survival for the whole PVE study population was 71.4 ± 2.4%, 58.7 ± 2.7%, 44.5 ± 3% and 31.7 ± 3.5% with no significant differences between the early and late PVE patients: 67 ± 5.4%, 55.9 ± 5.8%, 49.4 ± 6.2% and 29.7 ± 7.6%, compared to 72.4 ± 3%, 60 ± 3%, 43.5 ± 3.3% and 31.1 ± 3.8% (p=0.93). Predictors of early mortality were mechanical support (risk ratio (RR): 4.3), emergency operation (RR: 2.1), preoperative high doses of catecholamines (RR: 1.8), mitral valve replacement (RR: 1.5) and age at operation (RR: 1.1). Freedom from re-operation due to recurrent endocarditis at 10 years was 85.8 ± 5.6% for early PVE compared to 92.1 ± 2.3% for late PVE patients (p=0.17). Staphylococcus aureus (S. aureus) (18.1%) was the most frequent causative micro-organism.


CONCLUSIONS
Surgery for active infective PVE continues to be challenging. It not only carries a high in-hospital mortality but is also associated with a high long-term mortality risk. Early PVE patients were in a more severe condition than late PVE patients. Preoperative status, complications and co-morbidity of PVE patients strongly predict early outcome. Because of the potential risk of late complications, PVE patients need close clinical follow-up.
Musci
Michele
M
Deutsches Herzzentrum Berlin, Department of Cardiothoracic and Vascular Surgery, Augustenburger Platz 1, 13353 Berlin, Germany. musci@dhzb.de
Hübler
Michael
M
Amiri
Aref
A
Stein
Julia
J
Kosky
Susanne
S
Meyer
Rudolf
R
Weng
Yuguo
Y
Hetzer
Roland
R
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D004697:Endocarditis, Bacterial / Q000601:surgery*; D004812:Epidemiologic Methods; D005260:Female; D006350:Heart Valve Prosthesis / Q000382:microbiology*; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D016459:Prosthesis-Related Infections / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation / Q000706:statistics & numerical data; D016896:Treatment Outcome; D055815:Young Adult