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. 2020 Sep 1;58(3):544-550.
doi: 10.1093/ejcts/ezaa079.

A structured approach to native mitral valve infective endocarditis: Is repair better than replacement?

Rufin J Defauw  1 , Anton Tomšič  1 , Thomas J van Brakel  1 , Nina Ajmone Marsan  2 , Robert J M Klautz  1 , Meindert Palmen  1
Affiliations

A structured approach to native mitral valve infective endocarditis: Is repair better than replacement?

Rufin J Defauw et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients.

Methods: Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and 'patch' repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed.

Results: In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504-2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002-6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52).

Conclusions: Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.

Keywords: Infective endocarditis; Mitral valve repair; Mitral valve replacement.

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Figures

Figure 1:
Figure 1:
Overall survival for all patients for the whole study period. No statistically significant difference was observed between repair and replacement groups (P = 0.052).
Figure 2:
Figure 2:
Overall survival in the early and late phase after surgery. No difference in overall survival was observed in the early phase (within 1 year after surgery). A significant difference in overall survival, favouring mitral valve repair, was observed in the late phase (beyond 1 year after surgery).
Figure 3:
Figure 3:
Freedom from recurrence of infective endocarditis. No significant difference was observed between repair and replacement groups (P = 0.47).
Figure 4:
Figure 4:
Freedom from mitral valve reintervention. No significant difference was observed between repair and replacement groups (P = 0.52).
None
See this image and copyright information in PMC

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