Replacement or Repair in Mitral Valve Endocarditis William Osler

Replacement or Repair in Mitral Valve Endocarditis
W. Osler!
William Osler
1849-1919
Replacement or Repair in Mitral Valve Endocarditis
CONCLUSION :
« We all know that feasibility depends not on the lesion but on
the experience of the surgeon, and it is more true in endocarditis
than for any other lesion …
…So, I mean, it is not the debate today » G Dreyfus
 MV Rep possible in the majority of cases
 Low Mortality
 Very good long-term results
 Few Reoperations and few Recurrence of EI
Replacement or Repair in Mitral Valve Endocarditis
Healed IE Easy repair
Replacement or Repair in Mitral Valve Endocarditis
Actve IE  More complexe
Replacement or Repair in Mitral Valve Endocarditis
‘Long term Results of Mitral Valve Repair in Active Endocarditis, Rachid Zegdi, et al.
Circulation. 2005;111:2532-2536 - HEGP“
•  From 1987 to 1994 : 49 Mitral IE è 37 repair
Reparability
75%
Def. = Surgery during the 6 weeks of antibiotherapy
è 31 patients (84%),
* valve resection
è 31 patients (84%),
* chord. Shorten. or transpo.è 19 Patients (51%)
* pericardial patch
è 16 Patients (43%),
* leaflet perforation suture è 4 Patients (11%).
* prosthetic annuloplasty
Secondarily, to improve the feasibility of MVRep, paucisymptomatic patients
(NYHA I to II) with severe mitral regurgitation (grade 3 to 4) were also included in
the hemodynamic deterioration group (12 patients, 32%).
Replacement or Repair in Mitral Valve Endocarditis
2534
Circulation
May 17,Repair
2005
‘Long term Results
of Mitral Valve
in Active Endocarditis,
Rachid
Zegdi, et al.
2534
Circulation
May 17, 2005
Circulation. 2005;111:2532-2536 “
Re-op.
•  37 Repairs 1987-1994
Mortality (3%)
Very good long-term results.
Recurrence of endocarditis  3%
Reoperation at 10-yearZegdi
 9%
et al
Survival
Mitral Valve Repair in Active Endocarditis
Figure 1. Survival rate after MVRep for native mitral valve endocarditis. Numbers in parentheses indicate number of patients
alive.
2
Long-Term Results of Mitral Valve Repair in Active Endocarditis
Rachid Zegdi, Mohamed Debièche, Christian Latrémouille, Djoulène Lebied,
Catherine Chardigny, Jean-Michel Grinda, Sylvain Chauvaud, Alain Deloche, Alain
Carpentier and Jean-Noël Fabiani
Circulation 2005;111;2532-2536; originally published online May 2, 2005;
DOI: 10.1161/01.CIR.0000165122.08660.1A
Figure 2. Rate of
freedom
mitral
after
MVRep
Circulation
is published by thefrom
American Heart
Association.reoperation
7272 Greenville Avenue, Dallas,
TX
Figure
Survival
rate endocarditis.
after MVRepNumbers
for nativeinmitral
valve endoTABLE 1. Main Results From Surgical Series of Valve Repair
in1. AE
for native
mitral valve
parentheses
72514
Copyright © 2005 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
ISSN: 1524-4539
carditis.
in patients
parentheses
indicate number of patients
indicateNumbers
number of
at risk.
alive.
The online version of this article, along with updated information and services, is
organ failure. Repeated
postoperative
echocardiography
relocated on the World Wide
Web at: Survival,
Population,
Operative
Follow-Up,*
Reoperation/Recurrence
Late
http://circ.ahajournals.org/cgi/content/full/111/19/2532
Recurrence of endocarditis was observed in 1 patient (3%;
vealed a competent mitral valve without any signs of persisn
Mortality, %
mo
of0 toEndocarditis
%
(y)
organ
failure.
Repeated
postoperative
echocardiography
re95% CI,
16).
This patient
had a mitral
and tricuspid valve
tent endocarditis.
vealed
competent
mitral phase
valve without
any signs pyogenes
of persisrepair aduring
the acute
of Streptococcus
Postoperative morbidity
out35 mainly included
2.5 low cardiac
30 (6–94)
0/0
NA
Dreyfus et al3 (1990)
tent
endocarditis.
endocarditis.
Thirteen
months
later,
he
developed
endocardiput syndrome (13 patients, 35%), transient complete AV
Postoperative
morbidity
mainlyaureus.
included
low cardiac
outtis
resulting from
Staphylococcus
A mitral
homograft
Fuzellier et al9block
35 pericardial effusion
5.7 (1 patient,
23 (1–63)
1/0
NA
(1994)
(3 patients, 8%),
3%)
put
syndrome
(13
patients,
35%),
transient
complete
AV
was implanted in the mitral and tricuspid position. However,
requiring
surgical drainage, and renal failure (1 patient, 3%)
11
Podesser et alnecessitating
22
9
45
(1–90)
2/0
87!12.5
(5)
(2000) hemodialysis.
block
(3 patients,
8%),episode
pericardial
effusion (1
patient, 3%)
53 months
later, a new
of endocarditis
(Streptococcus
No patient required placement of
12 a permanent pacemaker. Bleeding, mediastinitis, and stroke
untyped)
was
also
diagnosed.
requiring
surgical
drainage,
and
renal
failure
(1
Senni et al (2001)
13
0
73 (31–110)
1/0
100 (5) patient, 3%)
Four patients
(11%; 95% No
CI, 2patient
to 28) required
were reoperated.
Oneof
necessitating
hemodialysis.
placement
were not observed. Median intensive care unit stay and
was reoperated
onBleeding,
88 monthsmediastinitis,
laterNA
for deterioration
of
Sternik et al6 hospital
38
0/0
(2002) stay were 112
day (range, 1 to 0
28 days) and 10 days
a patient
permanent
pacemaker.
and stroke
an
aortic
homograft
while
the
MVRep
was
satisfactory.
He
(range, 5 to 38 days), respectively.
were not observed. Median intensive care unit stay and
*Mean follow-up
underwent
valve
replacement.
Indications
One (range).
patient (3%; 95% CI, 0 to 15.5) was reoperated on 9
hospital
staya mechanical
were 1 dayaortic
(range,
1 to
28 days) and
10 days
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Fig
fo
ind
95
re
en
tis
w
53
un
pa
Replacement or Repair in Mitral Valve Endocarditis
Ruttmann et al
Surgery for Acquired Cardiovascular Disease
68 mitral endocarditis.
TABLE 1. Patient characteristics
 34 repair
 34 replacement.
Mitral valve repair
(n ! 34)
Age, y
Male sex
Obesity, BMI "30 kg/m2)
Diabetes
Surgery for Acquired Cardiovascular Disease
Chronic obstructive pulmonary disease
Impaired renal function (creatinine "2 mg/dL)
Preoperative kidney failure
Ejection fraction
NYHA stage (mean)
NYHA stage IV (%)
TABLE 2. Perioperative characteristics
Previous septic embolization
Preexisting degenerative valvular disease
EuroSCORE (mean)
51.5 ! 17.0*
22 (64.7%)
3 (8.8%)
6 (17.6%)
6 (17.6%)
10 (29.4%)
6 (17.6%)
49% ! 12%
2.80 ! 0.87
7 (20.6%)
15 (44.2%)
15 (44.2%) Mitral valve repair
(n ! 34)
9.8 ! 4.2
Reparability
50%
Mitral valve replacement
(n ! 34)
P value
53.2 ! 13.1
.840
17 (50.0%)
.383
4 (11.8%)
.721
6 (17.6%)
.954
Ruttmann et al
5 (14.7%)
.701
12 (35.3%)
.479
3 (8.8%)
.476
53% ! 12%
.197
2.76 ! 0.55
.968
2 (5.9%)
.121
6 (17.6%)
.027
Mitral
valve
replacement
12 (35.3%)
.840
(n ! 34)
P value
9.7 ! 3.8
.760
Main
indication
for surgical
intervention
BMI, Body
mass index;
NYHA, New
York Heart Association. *Means ! SD.
Persistent sepsis
17 (50%)
6 (26.1%)
.005
Proceeded or imminent septic embolism
10 (29.4%)
15 (44.1%)
.2
5
Congestive
heartcolleagues
failure
7 (20.6%)
13 (38.2%)
.11
All patients
were receiving antibiotic
treatment and had to undergo
Dreyfus and
were the first to demonstrate
Mean
mitral
regurgitation
(grade
SD)
2.8
"
1.2*
2.7
"
1.0
.957
an operation because of the failure of conservative therapy (persisting
that valve repair is feasible in aortic and mitral endocarditis
«
Mitral
Valve
Repair
Provides
improved
Outcome
over and
Replacement
in
Positive
intraoperative
valve
culture
15 (44.1%)
19 (55.9%)
.332
sepsis,
embolic
events,
hemodynamic
instability).
All patients
in 1990.
Staphylococcal
endocarditis
13 (38.2%)
.145of
6-8
our
series were
diagnoses
notAustria.
only on the »
basis
active
IE.studies
E Rutmann
et al. JTCVS
2005described
; 13019in:(55.9%)
765-71
- given
Innsbruck,
Several
outcome
have confirmed
that mitral
Leaflet destruction
15
(44.1%)
11
(32.4%)
.394
the clinical Dukes criteria but also on the basis of preoperative and
valve repair is effective in patients with IE but were lacking
12,13
Replacement or Repair in Mitral Valve Endocarditis
68 Acute IE
34 Repairs
Reparability
50%
Death = 4 / groupe (11,8 %)
34 Remplacements
« In our patient cohort reconstructive
operations were exclusively performed
by 2 surgeons highly experienced in
mitral repair and might therefore be
responsible for the convincing
results ».
« Mitral Valve Repair Provides improved Outcome over Replacement in
active IE. E Rutmann et al. JTCVS 2005 ; 130 : 765-71»
were performed in all patients before surgery and the
echocardiograms were reviewed by an expert cardiologist.
The mean patient age was 34.4 ! 16.9 years in the MVP
group and 43.1 ! 1 4.9 years in the MVR group ( p = 0.007).
Preoperative data analysis showed that the only difference
between the two groups was age (Table 1).
Replacement or Repair in Mitral Valve Endocarditis
2.3. Surgical procedures
In 24 patients, a right minithoracotomy was adopted and
the 4th intercostal space was entered using an AESOP 3000.
3.1. Microorganisms
« Surgical results of active infective native mitral
valve endocarditis: repair versus
The detailed surgical procedures of the right minithoracotreplacement. Sung-Ho Jung et Al. Europ J Cardiovasc Surg 2011
omy approach were described in our previous report [12].
Preoperative blood cultures showed that microorganisms
Seoul St. Mary’s Hospital South Korea»
Myocardial protection was achieved with antegrade cardiwere present in 29 (70.7%) MVP patients and in 47 (77.0%)
oplegic solution infusion through the root cannula at the
MVR patients. The most common microorganism in the MVP
W
ascending aorta.
groupmini-thoracotomy)
was Staphylococcus aureus (n reparability
= 11), and was Viridans
HTKfrom
solution1994
was used
in all (24
102 Custodiol
Active IE
to 2009
group days
streptococci
(n = 20) in the MVR group
patients.
- 41 Repairs
è 16.3
of ATB
40,2(Table
% 2).
- 61 Replacements è
9.8 days of ATB
Table 1. Preoperative data.
Age (years)
Sex (male)
DM
Hypertension
NYHA FC " III
Preop Cr level
Dialysis dependent CRF
Impaired renal function (creatinine >2 mg/dl)
Preoperative septic embolization
LV EF (%)
Severe MR
Preop blood culture (+)
Mitral valve repair (n = 41)
Mitral valve replacement (n = 61)
p-value
34.4 ! 16.9
19 (46.3%)
5 (12.2%)
4 (9.8%)
8 (19.5%)
0.9 ! 0.5
0
2 (4.9%)
19 (46.3%)
64.1 !4.2
34 (82.9%)
29(70.7%)
43.1 ! 14.9
33 (54.1%)
8 (13.1%)
9 (14.8%)
20 (32.8%)
1.3 ! 1.3
2
7 (11.7%)
29 (47.5%)
62.7 !6.2
53(86.9%)
47(77.0%)
0.007
0.442
0.891
0.554
0.141
0.056
0.514
0.305
0.905
0.216
0.583
0.600
DM: diabetes mellitus; NYHA FC: New York Heart Association functional class; Cr: creatinine; CRF: chronic renal failure; LV EF: left ventricular ejection fraction; MR:
mitral regurgitation.
Replacement or Repair in Mitral Valve Endocarditis
of Pages 6
« Surgical results of active infective native mitral valve endocarditis: repair versus
replacement. Sung-Ho Jung et Al. Europ
J Cardiovasc Surg 2011
of Cardio-thoracic Surgery xxx (2011) xxx—xxx
3
Seoul St.
Hospital
South
S.-H.Mary’s
Jung et al.
/ European
JournalKorea»
of Cardio-thoracic Surgery xxx (2011) xxx—xxx
e
nt
Table 4. Surgical techniques.
MVP (n = 41)
MVR
p-value
ystemic emboli were observed in both
(n = 61) legs.
ere identified
in the specimen culture. On
Mitral valve repair
annuloplasty
29
day 19,Ring
the
patient had sudden
chest pain and
Leaflet resection
18
Pericardial patch
closure
10
sure dropped.
A transesophageal
echocardioNew chordae formation
11
ed rupture
oftransfer
the abdominal
Chordae
2 aorta. He did not
Mitral valve replacement
esuscitation.
Mechanical valve
55
Tissue valve
6
d patient
was a 46-year-old female
who
Valve or ring size (mm)
28.9 ! 2.4
28.8 ! 2.3
echanical
valve MVR. Preoperative
brain
Annulus reconstruction
1
2
Concomitant
procedure
was not
performed
due 4 to the need
for
ASD/PFO closure
4
Coronary
bypass surgery day1 6, mental 1function
gery. On
postoperative
TV repair
ed andSeptal
a myectomy
brain CT showed a 5 cm31 ! 5 cm
c
PDA ligation
1
td the basal
ganglia. The patient’s condition
Coronary bypass surgery
1
n
ultimately
time 0.204
CPB timeleading to death.
111.4 Prothrombin
! 34.7
101.1 ! 42.9
ACC time
72.7 ! 23.7
62.9 ! 26.9
0.062
!the event
was 1.96 INR. 21 (51.2%)
Right minithoracotomy
3 (4.9%)
<0.001
R
approach
eatient was being treated for a liver abscess
ASD: atrial septal
defect;to
PFO: patent
foramen ovale;and
TV: tricuspid
valve; PDA:
,
dysfunction
due
alcoholism
also
patent
ductus
arteriosus;
CPB:
cardiopulmonary
bypass;
ACC:
aorta
cross
t
led
diabetes
mellitus. He showed suddenclamp.
and severe mitral valve regurgitation due to
Replacement or Repair in Mitral Valve Endocarditis
566
FERINGA ET AL
MITRAL VALVE SURGERY FOR ENDOCARDITIS
« Mitral Valve Repair and Replacement in Endocarditis: A Systematic Review of
Literature. Harm H et al. Ann Thorac Surg 2007;83:564–71
Leiden, Atlanta, Rotterdam »
Ann Thorac Surg
2007;83:564 –71
Table 2. Outcome After Mitral Valve Repair Versus Mitral Valve Replacement
24 Studies
Mortality
Early ($ 30 days)
Late (! 30 days)
Morbidity
Early
Reoperation
Recurrent endocarditis
Thromboembolism
Cerebrovascular event
Late
Reoperation
Recurrent endocarditis
Thrombo-embolism
Cerebrovascular event
Mitral Valve Repair
(n & 470 patients)
Mitral Valve
Replacement
(n & 724 patients)
p Value
11/470 (2.3%) [13]
24/307 (7.8%) [10]
104/724 (14.4%) [17]
137/338 (40.5%) [8]
$ 0.0001
$ 0.0001
7/319 (2.2%) [9]
1/217 (0.5%) [8]
2/130 (1.5%) [4]
7/150 (4.7%) [5]
26/205 (12.7%) [5]
3/253 (1.2%) [8]
0/17 (0.0%) [2]
19/165 (11.5%) [4]
$ 0.0001
0.63
0.20
0.045
20/430 (4.7%) [12]
6/328 (1.8%) [11]
6/185 (3.2%) [6]
3/188 (1.6%) [5]
26/298 (8.7%) [9]
28/386 (7.3%) [9]
0/7 (0.0%) [1]
11/45 (24.4%) [2]
0.039
0.0013
0.15
$ 0.0001
Number of events/number of total patients (%) [number of studies with available data].
istics of infective endocarditis (native or prosthetic valve
from any of the 2 " 2 tables was zero, a 0.5 was added for
Replacement or Repair in Mitral Valve Endocarditis
« Mitral Valve Repair and Replacement in Endocarditis: A Systematic Review of
Literature. Harm H et al. Ann Thorac Surg 2007;83:564–71
Leiden, Atlanta, Rotterdam »
In conclusion : This systematic review of literature showed that mitral
valve repair is associated with good early and long-term results among
patients undergoing surgery for infective endocarditis. In-hospital and
long- term mortality rates were higher after mitral valve replacement.
Mitral valve repair should be considered in patients with endocarditis
referred for surgery.
the American College of Cardiology, and Journal of Thoracic and Cardiovascular Surgery). The reference lists of
the published original articles obtained through these
searches were manually screened for articles that may
have been missed. The investigators independently
reviewed the list with all the potentially relevant
manuscripts. Reviews and abstracts were excluded,
and only articles in English language were considered.
If more than one study was published from a center
concerning the same study population, only the study
with the largest number of patients was included in the
analysis.
Abstraction of Data
Replacement or Repair in Mitral
Valve
Endocarditis
The following
information
was derived from each article:
year of publication, characteristics of the study population (age, sex, previous mitral valve surgery), character-
« Unfortunately, a retrospective review like this has many of the problems of
outcome reporting for valvular surgery Studies
»
Including
Studies Including Mitral
Table 1. Clinical Characteristics of the Published Studies
Mitral Valve Repair
(n ! 13)
Number of patients with mitral valve repair
Number of patients with mitral valve replacement
Men (%)
Mean age (years)
Surgical acuity
Acute
Chronic
Time interval between start of antibiotic
treatment and surgery in acute cases
Indications for surgery
Congestive heart failure
Embolization
Large/mobile vegetation
Uncontrolled sepsis
Abscess
Microorganism
Streptococcus sp
Staphylococcus sp
Other
Culture negative/unknown
Perioperative findings
Perforation
Vegetation
Chordal rupture
Abscess
Complete leaflet destruction
Valve Replacement
(n ! 17)
p Value
74.3% [13]
50.7 " 8.4 [13]
724
74.2% [17]
49.5 " 9.1 [17]
0.98
0.62
66.3% [12]
33.7% [12]
21.9 " 3.8 [9]
77.8% [14]
22.2% [14]
20.3 " 10.6 [12]
470
55.2%
11.5%
32.9%
15.8%
0.0%
[9]
[10]
[9]
[10]
[9]
62.8%
14.3%
28.7%
37.4%
11.0%
[11]
[13]
[6]
[11]
[4]
42.6%
24.0%
12.5%
20.9%
[12]
[12]
[12]
[11]
42.1%
31.0%
7.1%
19.8%
[16]
[16]
[16]
[15]
29.9%
47.3%
41.0%
15.3%
0.0%
[11]
[11]
[11]
[10]
[1]
31.4%
65.2%
26.7%
14.9%
22.7%
[6]
[7]
[5]
[4]
[1]
# 0.0001
# 0.0001
0.66
0.020
0.11
0.24
# 0.0001
# 0.0001
0.89
0.0031
0.00029
0.63
0.63
# 0.0001
# 0.0001
0.83
# 0.0001
Replacement or Repair in Mitral Valve Endocarditis
La vraie vie è 497 EI en 2008 !
F Delahaye, C Suty-Selton, "
JF Obadia, V Le Moing, "
JM Frapier, S Chocron, X Duval, B Hoen"
"
pour le groupe d’étude de l’AEPEI"
Financement: PHRC 2007 (CHU Besançon), SFC, ESCMID, Novartis!
Replacement or Repair in Mitral Valve Endocarditis
La vraie vie è 497 EI en 2008 !
Mortality
19,9 % vs 26.4 %
F Delahaye, C Suty-Selton, "
JF Obadia, V Le Moing, "
JM Frapier, S Chocron, X Duval, B Hoen"
"
pour le groupe d’étude de l’AEPEI"
Financement: PHRC 2007 (CHU Besançon), SFC, ESCMID, Novartis!
Replacement or Repair in Mitral Valve Endocarditis
La vraie vie è 497 EI en 2008 !
Mortality
19,9 % vs 26.4 %
Reparability
26 %
F Delahaye, C Suty-Selton, "
JF Obadia, V Le Moing, "
JM Frapier, S Chocron, X Duval, B Hoen"
"
pour le groupe d’étude de l’AEPEI"
Financement: PHRC 2007 (CHU Besançon), SFC, ESCMID, Novartis!
Replacement or Repair in Mitral Valve Endocarditis
•  398 patients avec EI du cœur gauche"
•  Aortique
!40%!
•  aorto-mitrale:
•  Mitrale:
!
!15%
!45%!
!
!!
181 opérés!
"95 gestes mitraux isolés ou non"
- Réparation
- Mécanique
- Bioprothèse
!
26%!
!41%!
!33%!
!
« Treatment of Endocarditis with Valve
replacement : Tissue versus Mechanical
Prosthesis. 2001 ; 71 : 1164-71»
< 60ans
> 60ans
maneuvres,
by
mitral
nonprolapsing primary chordaedeairing
of residual
P1 andcardiopulmonary
P3.
continued
with
temporary
ventricular
pac
a wide
Subsequently to optimize coaptation between recontransesophageal echocardiogram showe
niques
structed PL and the anterior leaflet, a bilateral commispair with no MR (Fig. 1B). After two d
feasib
suroplasty was carried out withsive
4–0care,
prolene
reinforced
the patient was transferred
to
materi
with BPP pledgets. This was followed
by
a
posterior
ing stable, with a normal ECG and
no s
remodeling annuloplasty usingrent
a semicomplete
infection. He wasperianticoagulatedWe
wit
12 weeks.
A predischarge
scribe
cardial ring made out in the operating
room
out of the postoperativ
n
defect
same BPP using a 32-ring sizergram
and showed
suturedno
toresidual
the an-vegetations,
techni
nulus using interrupted suturesregurgitation,
(Fig. 2D). no tricuspid regurgitation,
Replacement or Repair in Mitral Valve Endocarditis
1) Chirurgie valvulaire è environ 50 % à la phase aigüe
Figure 1. (A) Intra-operative transoesophageal echo showing a posterior mitral valve leaflet vegetation (red arrow) and
severe mitral valve regurgitation. (B) Intra-operative transesophageal echo showing the repaired mitral valve with no
mitral valve regurgitation.
2)  Délai avant indication :
- hospitalisation - intervention chir.
è 15 j
nonprolapsing primary chordae of residual P1 and P3.
Subsequently to optimize coaptation between reconstructed PL and the anterior leaflet, a bilateral commissuroplasty was carried out with 4–0 prolene reinforced
with BPP pledgets. This was followed by a posterior
remodeling annuloplasty using a semicomplete pericardial ring made out in the operating room out of the
same BPP using a 32-ring sizer and sutured to the annulus using interrupted sutures (Fig. 2D).
right ventricle (RV) function. The function
valve remained unchanged.
Cultures of the excised valve showe
but the patient was continued on antib
weeks postoperatively and made a comp
His three-month follow-up echo is unrem
DISCUSSION
Surgery for infective mitral valve endoc
include resection/debridement of all inf
but this may leave behind insufficient au
tral valve tissue for an adequate repair.
et al.4 in their series have shown 78%
mitral valve repair for mitral valve endo
a wide variety of biological patch mater
niques. Lung et al.3 in their series also dem
feasibility of mitral valve repairs using bi
materials in the setting of mitral valve en
We however find that the techniques
scribed so far are related to patch repairs
defects not amenable for direct closure.
techniques described so far have bee
3) 398 EI du cœur gauche
- Prothèse valvulaire!
è 23%!
- Pas de valvulopathie connue +++
è 50%!
- Sur valvulopathie (Dyst > Rhum)
è 27%!
!
Figure 2. (A) Distribution of the infective process and the vegetations on th
4) Opérés par rapport aux non opérés"
of the posterior mitral valve leaflet with a defect measured to be 3.5 cm.
buttressed stitches of 4–0 prolene sutures with bovine pericardium ple
•  plus jeunes: 58 vs 67 ans (p < 0,0001)!
annulus. (D) Final appearance of the repair with the patch of bovine perica
and remodeling annuloplasty with semicircular biological ring.
•  plus d’I. cardiaque: 44% vs 28% (p = 0,0006)!
•  plus de végétations > 10 mm: 82% vs 58% (p < 0,0001)!
•  plus d’abcès: 39% vs 13% (p < 0,0001)!
•  moins d’EI mitrales: 33% vs 55% (p < 0,0001)!
•  mortalité hospitalière plus basse: 20% vs 26% (NS)!
!
Figure 2. (A) Distribution of the infective process and the vegetations on the posterior mitral valve leaflet. (B) Exte
Replacement or Repair in Mitral Valve Endocarditis
CONCLUSION
Replacement or Repair in Mitral Valve Endocarditis
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