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Redo Mitral Valve Surgery for Active Prosthetic Infective Endocarditis
Piroze M. Davierwala, Sergey Leontyev, Christian Binner, Bettina Pfannmueller, Martin Misfeld, Michael Borger, Friedrich Mohr.
Herzzentrum, Leipzig, Germany.

Objective: Redo mitral valve (MV) surgery for active prosthetic endocarditis in patients, who have already undergone previous MV repair or replacement, continue to pose a challenge. The aim of this study was to evaluate the early and long-term outcomes of reoperations in this high-risk patient subset and identify the factors that predict poor outcomes. Methods: Demographic, preoperative, intraoperative and postoperative data were prospectively collected on 1566 patients with active infective endocarditis undergoing heart valve surgery with or without combined procedures. Of these, 123 patients, who underwent redo MV surgery for active endocarditis following previous MV operations were identified and formed the focus of this study. Eighty-nine patients had previously undergone MV replacement and 34 MV repair, with or without combined procedures. Predictors of in-hospital and long-term mortality were identified by multivariate stepwise logistic and Cox regression analysis, respectively. Results: The mean age was 64±11 years. The mean time interval between primary and redo surgery was 5.7±6.6 years. Staphylococcus aureus (33.4%, 41 patients) was the commonest infective organism. A total of 58 (47.2%) patients suffered septic emboli, and 16 (13%) patients were in cardiogenic shock prior to surgery. The mean logistic EuroSCORE was 53.3±29.9%. Emergent surgery was performed on 58 (47.2%) patients. In-hospital mortality was 26.8% (33 patients). Double valve endocarditis (odds ratio [OR]:2.4,95% confidence interval [CI]:1.1-5.7,p=0.04) was identified as the only significant independent predictor of in-hospital mortality. The mean survival at 5 and 10 years was 40±1% and 34±1%, respectively. However, when in-hospital mortality was excluded, the corresponding long-term survival was 55±6% and 47.8±7%. Pulmonary hypertension (OR:1.9,95%CI:1.1-3.5,p=0.01), preoperative dialysis (OR:3.1,95%CI:1.5-6.5,p=0.02) and insulin-dependent diabetes mellitus (OR: 2.3, 95%CI:1.3-4.2,p=0.002) independently predicted long-term mortality. Conclusions: Redo MV surgery for active endocarditis in patients, who have undergone previous MV surgery is challenging and is associated with a high in-hospital mortality, especially in patients with double valve endocarditis. The type of infective organism and peripheral septic embolization do not influence early outcomes. Survivors have acceptable long-term outcomes. Hence, despite poor early outcomes, surgery is mandated in this patient cohort, in whom, conservative management commonly results in near 100% mortality.

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