David Bleetman1, Amer Harky1, Damian Balmforth1, Matthew Shaw2, Benjamin Adams1, Prity Gupta1, Kit Wong1, Carmelo Di Salvo1, Neil Roberts1, Kulvinder Lall1, John Yap1, Wael I. Awad1, Mohamad Bashir1,4, Rakesh Uppal1,31Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, UK
2Research & Development, Liverpool Heart & Chest Hospital, Thomas Drive, Liverpool L14 3BE, UK
3William Harvey Research Institute, Basement, Heart Centre, Charterhouse Square, London EC1M 6BQ, UK
4Electronic correspondence: Drmobashir@outlook.com
Background and aim of the study: Mitral valve surgery is the definitive treatment for acute infective endocarditis of the mitral valve. Depending on severity, both repair and replacement have been proposed. Based on a number of small studies, repair is recommended when technically feasible, but other studies have shown that many centers mainly perform replacement. The aim of the present study was to describe the feasibility of mitral valve repair (MVP) for bacterial endocarditis, and the efficacy of mitral valve replacement (MVR) relative to MVP at a large UK center.
Methods: Between 1999 and 2016, a total of 449 patients was admitted to the authors’ institution with mitral valve endocarditis, and underwent surgery. The study was retrospective and single-center in nature, with primary outcome measured as in-hospital mortality and secondary outcome being follow up mortality. Patients were grouped according to procedure type, and potential differences in preoperative and intraoperative factors were analyzed. Survival charts were produced using the Kaplan-Meier technique, and comparisons made using log-rank tests. To account for differences in case mix, a propensity score was developed for MVP group members.Results: A total 342 patients (76.2%) underwent MVR, and 107 (23.8%) had MVP.
Before matching, MVP patients were younger at presentation (54 versus 59 years; p = 0.028), and the proportion of females was similar in both groups (68-71%; p = 0.57). MVR patients had a higher NYHA class ≥III (59% versus 48%; p = 0.038), higher logistics EuroSCORE (11.8 versus 5.1; p <0.001), and a higher rate of redo-sternotomy (24% versus 7.5%; p <0.001). There were no significant differences in operative parameters of both groups before or after matching, nor in the rate of concomitant procedures. In-hospital and 10-year mortalities were not statistically significantly different in the unmatched or propensity-matched data sets.
Conclusion: The present study was the largest single- center experience in the UK to date, and provided long-term data for up to 10 years demonstrating MVR non-inferiority to MVP in the context of mitral valve bacterial endocarditis. The study findings suggest that complete removal of the infected valve and prosthetic replacement is an acceptable option for patients in whom MVP is not achievable.
Presented in part at the 31st Annual Meeting of the European Association for Cardio-Thoracic Surgery, 10th October 2017, Vienna, Austria.
The Journal of Heart Valve Disease 2018-19;28:44-52
|Is Replacement Inferior to Repair for Native Mitral Valve Endocarditis? A Single-Center Experience with 10-year Follow Up|
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