October 4, 2023Journal of Thoracic and Cardiovascular Surgery7 citationsOpen Access

Outcomes of double-valve surgery for infective endocarditis are improving in the modern era

PMPaighton C. MillerWashington University in St. Louis LSLinda SchulteWashington University in St. Louis TMTheodore MarghituWashington University in St. Louis

Structured PICO

Does double valve surgery for infective endocarditis have improved survival in the modern era compared to earlier periods?

Population

211 patients with infective endocarditis (IE) who underwent combined aortic and mitral valve surgery at a tertiary care referral center between 2001 and 2021. Median age 56 years, 73% male.

Intervention

Combined aortic and mitral valve surgery (double valve surgery) in the modern era (after 2010)

Comparator

Combined aortic and mitral valve surgery before 2010

Outcome

30-day and 1-year mortality, and overall survivalhard clinical

Survival following high-risk double valve surgery for infective endocarditis has improved in the modern era, potentially due to earlier surgical intervention before significant disease progression.

Abstract

BACKGROUND: The incidence of infective endocarditis (IE) is rapidly increasing. Contemporary outcomes following high-risk double valve surgery (DVS) for IE are not well described. METHODS: Between 2001 and 2021, 211 patients with IE underwent combined aortic and mitral valve surgery at a tertiary care referral center. Data from the Society of Thoracic Surgeons registry, including demographics, operative details, and outcomes, were collected. Risk factors for 30-day and 1-year-mortality were analyzed. Survival was analyzed using Kaplan-Meier and Cox proportional hazards modeling. RESULTS: The study cohort had a male preponderance (73%), with a median age of 56 years (interquartile range IQR, 44 to 63 years). Forty-five patients (21%) had a history of intravenous (IV) drug abuse, 50 (24%) were on preoperative dialysis, and 50 (24%) had prosthetic valve endocarditis. Thirty-day and 1-year mortality were 14% (n = 30) and 30% (n = 61), respectively. On multivariable Cox regression adjusting for age, prosthetic valve endocarditis, postoperative intra-aortic balloon pump (IABP), history of dialysis (adjusted hazard ratio aHR, 1.9; 95% confidence interval CI, 1.3 to 2.9; P = .002) and IV drug abuse (aHR, 2.0; 95% CI, 1.1-3.5; P = .02) were predictive of decreased survival. Undergoing surgery after 2010 was predictive of improved survival (aHR, 0.5; 95% CI, 0.3 to 0.8; P = .006). These patients were more likely to undergo urgent/emergent surgery (83% vs 29%; P < .001) and less likely to have an aortic root abscess (40% vs 58%; P = .03) or to require the commando procedure (13% vs 33%; P = .002). CONCLUSIONS: In this large series evaluating outcomes of DVS for IE in the modern era, although the mortality risk remained elevated, improving outcomes may be associated with earlier surgical intervention before significant disease progression. Multidisciplinary evaluation for complex IE may be considered to better understand the optimal timing and repair strategy.

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