Surgical treatment of aortic valve endocarditis: a 26-year
               experience

From June 1985 to January 2011, 174 patients were operated for aortic valve endocarditis. One hundred and thirty-eight (79.3%) patients were male and the mean age was 39.3±14.4 (9-77) years. Twenty-seven (15.5%) patients had prosthetic valve endocarditis. The mean duration of follow-up was 7.3±4.2 years (0.1-18.2) adding up to a total of 1030.8 patient/years.

Results:

Two hundred and eighty-two procedures were performed. The most frequently performed procedure was aortic valve replacement with mechanical prosthesis (81.6%). In-hospital mortality occurred in 27 (15.5%) cases. Postoperatively, 25 (14.4%) patients had low cardiac output and 17 (9.8%) heart block. The actuarial survival rates for 10 and 15 years were 74.6±3.7% and 61.1±10.3%, respectively. In-hospital mortality was found to be associated with female gender, emergency operation, postoperative renal failure and low cardiac output. The long term mortality was significantly associated with mitral valve involvement. Male gender was found to be a significant risk factor for recurrence in the follow-up.

Conclusion:

Surgery for aortic valve endocarditis has significant mortality. Emergency operation, female gender, postoperative renal failure and low cardiac output are significant risk factors. Risk for recurrence and need for reoperation is low.

Treatment Outcome; Aortic Valve; Endocarditis

Preoperative characteristic	n (%) or mean±SD	P1	P2	P3	P4
Age	39.3±14.4	ns	ns	ns	ns
Male / Female	138 (79.3%) / 36 (20.7%)	0.022	0.034	ns	ns
Fever	97 (55.7%)	ns	ns	ns
Septic emboli	27 (15.5%)	ns	ns	ns	ns
Central	14 (8.0%)
Peripheral	14 (8.0%)
NYHA Class
Class I	15 (8.6%)
Class II	64 (36.8%)
Class III	74 (42.5%)
Class IV	21 (12.1%)
Congestive heart failure	97 (55.7%)	ns	ns	ns	ns
Renal dysfunction	15 (8.6%)	ns	ns	ns	ns
Periprosthetic leakage	13 (7.5%)	ns	ns	ns
Previous cardiac surgery	32 (18.4%)	ns	ns	ns	ns
Mitral valve involvement	72 (41.4%)	ns	ns	ns	0.009
Aortic annulus involvement	42 (24.1%)	ns	ns	ns	ns
Prosthetic valve endocarditis	27 (15.5%)	ns	ns	ns	ns
Operation in the active phase	84 (48.3%)	ns	ns	ns	ns
Culture positive endocarditis	92 (52.9%)	ns	ns	ns	ns
LVD (EF<40%)	11 (6.3%)				ns
Emergency operation	26 (14.9%)	0.003	ns	ns	ns
ECG
Sinus rhythm	154 (88.5%)
AF	13 (7.5%)
AV block	4 (2.3%)
LBBB	2 (1.1%)
RBBB	1 (0.6%)

Microorganism	n (%)
Culture negative	82 (47.1%)
Streptococcus	51 (29.3%)
Staphylococcus	23 (13.2%)
Brucella	11 (6.3%)
MRSA	4 (2.3%)
Acinetobacter	1 (0.6%)
E. Coli	1 (0.6%)
Enterobacter	1 (0.6%)

Procedures	n (%) ^* * Percentages are the ratio to the number of patients. AVR: Aortic valve replacement. P1: Statistical significance for in-hospital mortality in logistic regression analysis. P2: Statistical significance for recurrence in logistic regression analysis. P3: Statistical significance for reoperation in logistic regression analysis. P4: Statistical significance for late mortality in logistic regression analysis	P1	P2	P3
Aortic valve replacement	142 (81.6%)
Redo AVR	13 (7.5%)
AVR with bioprosthesis	2 (1.1%)
Aortic reconstruction	3 (1.7%)
Primary repair of periprosthetic leak	4 (2.3%)
Aortic root replacement	22 (12.6%)
Bentall de Bono procedure	10 (5.7%)
Xenograft implantation	6 (3.4%)
Homograft implantation	5 (2.9%)
Cabrol procedure	1 (0.6%)
Aortic root enlargement	1 (0.6%)
Fistula repair	6 (3.4%)
Patch repair of a sinus Valsalva aneurysm repair	4 (2.3%)
Subaortic discrete membrane resection	4 (2.3%)
Aortic vegetectomy	3 (1.7%)
Drainage of subaortic abscess and patch repair	2 (1.1%)
Septal vegetectomy	1 (0.6%)
Patch repair of an ascending aortic pseudoaneurysm	1 (0.6%)
Graft interposition in the ascending aorta	1 (0.6%)
Patch repair of a ventricular septal defect	6 (3.4%)
Mitral valve procedures	72 (41.4%)
Mitral valve replacement	55 (31.6%)
Redo mitral valve replacement	4 (2.3%)
Mitral reconstruction	14 (8.0%)
Primary repair of periprosthetic leak	2 (1.1%)
Vegetectomy of mitral leaflets	1 (0.6%)
Tricuspid De Vega annuloplasty	3 (1.7%)
Coronary artery bypass grafting	2 (1.1%)
Primary repair of atrial septal defect	2 (1.1%)
Closure of patent ductus arteriosus	1 (0.6%)
Femoral embolectomy	1 (0.6%)
Pericardiectomy	1 (0.6%)
Concomitant procedure	81 (46.6%)	0.971	0.205	0.237

Perioperative characteristic	n (%)	P1	P2	P3	P4
Postoperative fever	45 (25.9%)	ns	ns	ns	ns
Postoperative atrioventricular block	17 (9.8%)	ns	ns	ns	ns
Low cardiac output	25 (14.4%)	0.011	ns	ns
Renal failure	34 (19.5%)	0.030	ns	ns
Need for dialysis	12 (6.9%)
Valvular destruction	120 (69.0%)	ns	ns	ns
Recurrence during follow-up	10 (5.7%)				ns
Reoperation during follow-up	8 (4.6%)				ns

Etiology for mortality	n (%)
Hospital mortality	27
Low cardiac output	15 (55.6%)
Low cardiac output + sepsis	7 (25.9%)
Sepsis	3 (11.1%)
Pulmonary complication	1 (3.7%)
Sudden death	1 (3.7%)
Late mortality	14
Cardiac	8 (57.1%)
Extracardiac	6 (42.9%)

Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br

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[1] Correspondence address: Taylan Adademir, Kartal Kosuyolu Heart and Research Hospital, Denizer Caddesi Cevizli Kavşağı, 2 - Cevizli/Kartal, İstanbul, Turkey - Zip code: 34000, E-mail: taylanadademir@gmail.com