Residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis.

To identify and understand residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis (IE), we categorized the intraoperative pathologic entities in patients with left-sided IE and correlated the pathology (noninvasive vs invasive) and organism with IE context (affected valve, native vs prosthetic [PVE]) and surgical results. From January 2002 to January 2011, 775 patients underwent surgery for active left-sided IE. Registries were queried, and endocarditis-related pathology was based on the echocardiographic findings and operative notes. Propensity adjustment and matching (55 pairs) were used for risk-adjusted outcome comparisons between the invasive aortic and mitral cases. A total of 395 patients had isolated aortic (PVE 59%, invasive 68%), 238 isolated mitral (PVE 29%, invasive 35%), and 142 combined aortic and mitral (PVE 44%, invasive 69%) IE. The 30-day survival was 92% and was similar for native valve endocarditis and PVE in all 3 valve combinations. Invasive versus noninvasive IE was associated with greater hospital mortality (11% vs 4.4%, P = .001). Patients with invasive IE had worse intermediate-term survival than those with noninvasive IE for mitral (P = .001) and aortic plus mitral (P = .02) IE but not for isolated aortic IE. This difference persisted in the matched patients. During the past decade, we have had low hospital mortality for surgically treated left-sided IE and have neutralized the added risk of PVE. However, outcomes remain worse for mitral versus aortic valve IE, with residual obstacles related to patient factors, inherent mitral valve anatomy in patients with invasive disease, and lack of an alternative mitral valve prosthesis optimal for IE.

Hussain ST ，Shrestha NK ，Gordon SM ，Houghtaling PL ，Blackstone EH ，Pettersson GB ... -  《-》

Surgical treatments for infective endocarditis involving valve annulus.

Ishikawa S ，Kawasaki A ，Neya K ，Abe K ，Suzuki H ，Koizumi S ，Shibuya H ，Horikawa M ，Ueda K ... -  《-》

Rarity of invasiveness in right-sided infective endocarditis.

The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right- versus left-sided IE in surgically treated patients. From January 2002 to January 2015, 1292 patients underwent surgery for active IE, 138 right-sided and 1224 left-sided. Among patients with right-sided IE, 131 had tricuspid and 7 pulmonary valve IE; 12% had prosthetic valve endocarditis. Endocarditis-related invasiveness was based on echocardiographic and operative findings. Invasive disease was rare on the right side, occurring in 1 patient (0.72%; 95% confidence interval 0.02%-4.0%); rather, it was limited to valve cusps/leaflets or was superficial. In contrast, IE was invasive in 408 of 633 patients with aortic valve (AV) IE (65%), 113 of 369 with mitral valve (MV) IE (31%), and 148 of 222 with AV and MV IE (67%). Staphylococcus aureus was a more predominant organism in right-sided than left-sided IE (right 40%, AV 19%, MV 29%), yet invasion was observed almost exclusively on the left side of the heart, which was more common and more severe with AV than MV IE and more common with prosthetic valve endocarditis than native valve IE. Rarity of right-sided invasion even when caused by S aureus suggests that invasion and development of cavities/"abscesses" in patients with IE may be driven more by chamber pressure than organism, along with other reported host-microbial interactions. The lesser invasiveness of MV compared with AV IE suggests a similar mechanism: decompression of MV annulus invasion site(s) toward the left atrium.

Hussain ST ，Shrestha NK ，Witten J ，Gordon SM ，Houghtaling PL ，Tingleff J ，Navia JL ，Blackstone EH ，Pettersson GB ... -  《-》

Surgical management of aortic root abscess: a 13-year experience in 172 patients with 100% follow-up.

The study objective was to evaluate the outcomes of surgery for active infective endocarditis with aortic root abscess formation. Between July 1996 and June 2009, 1161 patients underwent operation for aortic valve endocarditis, of whom 172 had aortic root abscess. The infected valve was native in 96 patients and prosthetic in 76 patients. Patients' mean age (± standard deviation) and logistic EuroSCORE-predicted risk of mortality were 62 ± 13 years and 23.1% ± 26%, respectively. Surgery was emergent in 96 patients (58%). The abscess involved the aortic annulus in 90 patients (52%), the intervalvular fibrous body in 81 patients (47%), and the mitral annulus in 21 patients (12%). Surgery consisted of radical resection of the abscess, reconstruction of the annulus with patches, and valve replacement. Estimated mean follow-up was 4.0 ± 0.3 years (range, 0-8.2 years). Thirty-day mortality was 25% (n = 43) (prosthetic valve endocarditis vs native valve endocarditis, 35.5% vs 16.7%, P = .005). Independent predictors of mortality were sepsis (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.2-10.7), renal insufficiency (OR, 3.3; 95% CI, 1.1-9.5), concomitant coronary artery bypass grafting (OR, 2.8; 95% CI, 1.1-7.0), and prosthetic valve endocarditis (OR, 2.4; 95% CI, 1.1-5.6). Survival at 1 and 5 years was 55% ± 4% and 50% ± 4%, respectively, and predicted by concomitant mitral endocarditis (OR, 3.2; 95% CI, 1.3-8.2), sepsis (OR, 2.7; 95% CI, 1.6-4.5), renal insufficiency (OR, 1.9; 95% CI, 1.1-3.4), and age (OR, 1.05; 95% CI, 1.02-1.07). Endocarditis recurred in 15 patients (8.7%) at a mean of 1.8 ± 2.4 years postoperatively (39 days to 6 years). The surgical treatment of aortic root abscess remains a challenge with relatively high perioperative morbidity and mortality, although long-term survival is satisfactory.

Leontyev S ，Borger MA ，Modi P ，Lehmann S ，Seeburger J ，Doenst T ，Mohr FW ... -  《-》

Surgery for infective endocarditis: determinate factors in the outcome.

Ishikawa S ，Kawasaki A ，Neya K ，Abe K ，Suzuki H ，Kadowaki S ，Nakamura K ，Ueda K ... -  《JOURNAL OF CARDIOVASCULAR SURGERY》