Replacement or Repair in Mitral Valve Endocarditis William Osler
Transcription
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 Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org/subscriptions/ Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: [email protected] Reprints: Information about reprints can be found online at http://www.lww.com/reprints Downloaded from circ.ahajournals.org by on May 16, 2011 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 " Il est plus facile d'acheter un livre que de le lire, et plus facile de le lire que de le comprendre " " On ne demande conseil que pour appuyer ses convictions » William OSLER