Complex multivalve operations for infective endocarditis

Introduction

Infective endocarditis (IE) has remained stable over time, however, the type of IE and rate of surgical intervention has changed. Patients are now more elderly, rheumatic heart disease is less common and invasive cardiac procedures with implantations are increasing. Moreover, intravenous substance abuse leading to IE is on the rise. In turn, the population requiring surgical intervention has increased in complexity [ , ]. About 40%–45% of all patients with IE will ultimately require surgical intervention, which has plateaued since the 2007 guidelines for antibiotic prophylaxis for IE [ , ]. Regardless, there is still a significant proportion of patients requiring surgical intervention for IE, and with this comes the need for complex surgical approaches for multivalvular IE [ ]. Indications for the surgical treatment of IE include valvular dysfunction leading to heart failure, new-onset conduction abnormality, those with persistent septic pulmonary or systemic emboli, persistent vegetation greater than 1 cm or persistent left-sided endocarditis after full treatment of antibiotics in highly virulent organisms such as S. aureus , fungi or multidrug-resistant organisms. [ ]

Since IE requiring surgical intervention requires extensive debridement of all involved tissues, there are frank indications for a multivalvular operation with or without intervalvular fibrous body and atrial reconstructions. While double-valve operations are most common, there are case reports of triple and quadruple valve replacements for IE [ ]. The presentation and surgical management of double-valve replacement/repair of the aortic and mitral valve will be of focus here, but principles of double-valve endocarditis can be applied to even more complex situations. Additionally, the topic of single valve endocarditis is a focus of this text elsewhere.

Epidemiology

Data are limited on multivalvular involvement in IE. In one single-center study of 1571 patients undergoing surgical intervention for IE, 46% underwent aortic valve replacement (AVR), 31% underwent mitral valve replacement (MVR), 14% underwent combined AVR and MVR (of which 11% had intravalvular fibrous body (IFB) involvement). Of those with IFB involvement, all had replacement of the AVR and MVR. An additional 16% had repair of the tricuspid valve. Other concomitant procedures included aortic root replacement (60%), ascending aorta or partial arch replacement (20%), and coronary artery bypass grafting (32%) [ ]. In another single-center study of 72 patients with IE of the aortic valve with mitral involvement, annular involvement was present in 12.5% [ ]. Thus, multivalvular IE can require extensive surgical repair after completely eliminating infective tissues. Inpatient mortality has been reported to be 18% with a five-year survival rate ranging between 25% and 94% in those with double-valve endocarditis with or without IFB involvement [ , ]. Mid to long-term follow-up of 37 patients with invasive aortic IE with IFB and anterior mitral valve involvement repaired with an aortomitral homograft, revealed an in-hospital mortality of 8%, postdischarge mortality of 5%, and one-year and three-year survival rates of 91% and 82%, respectively [ ].