Patient-prosthesis mismatch in patients undergoing bioprosthetic aortic valve implantation increases risk of reoperation for structural valve deterioration.

OBJECTIVES: Patient-prosthesis mismatch has been identified as a risk factor for mortality after aortic valve replacement and for structural valve deterioration (SVD) in patients receiving a bioprosthetic aortic valve. The aim of the present study was to compare the incidence of aortic valve bioprosthesis replacement for SVD in patients with mismatch to a population without mismatch. METHODS: Three hundred eighty-seven adult patients who underwent aortic valve replacement with a bioprosthesis from 1974 to 2009 were retrospectively reviewed. Mismatch was considered to be present if the anticipated indexed effective orifice area was <0.70 cm(2) /m(2) . The median follow-up period was 7.2 years. Follow-up was 97% complete. RESULTS: Patient-prosthesis mismatch was present in 12% of the study population (n = 47). Ten-year freedom from reoperation for aortic bioprosthesis replacement was 74.3 ± 3.2%. During follow-up, 111 patients underwent reoperation for aortic bioprosthesis replacement. Causes of aortic bioprosthesis replacement were SVD of the bioprosthesis (n = 96), paravalvular leak (n = 10), and acute endocarditis (n = 5). According to unadjusted Kaplan-Meier analysis, patients with mismatch had a higher incidence of aortic bioprosthesis replacement for SVD when compared with patients without mismatch (log rank test: p 0.05). This result was confirmed by multivariable Cox regression analysis, which identified two independent predictors of aortic bioprosthesis replacement for SVD: patients' age (hazard ratio (HR) 0.967) and patient-prosthesis mismatch (HR 2.161). CONCLUSION: Patients suffering from mismatch were twice as likely to undergo reoperation for aortic bioprosthesis replacement for SVD than those without mismatch.

Long-term survival of salvage cardiac transplantation for infective endocarditis.

Cardiac transplantation has been rarely performed in patients with infective endocarditis. A 31-year-old man developed aortic endocarditis due to Brucella melitensis. He presented with fever and developed acute myocardial infarct, severe aortic regurgitation, and heart failure. Aortic valve replacement did not improve cardiac function; hence, an emergent cardiac transplantation was carried out. Eighteen years later, he is doing well and living an active and productive life. Only 6 patients have received a cardiac transplant as part of the treatment of active infective endocarditis. This patient shows how cardiac transplantation may be successfully used as salvage therapy for patients with infective endocarditis who are not candidates for valve replacement or have severe and irreversible myocardial damage.

Surgical treatment of prosthetic valve endocarditis in patients with double prostheses: is single-valve replacement safe?

OBJECTIVE: Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected. METHODS: Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome. RESULTS: Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83-18.72). All were considered cured and relapses were not observed. CONCLUSIONS: TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome.

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump.

Vascular complications associated with intraaortic balloon pump placement are quite common and predominantly related to femoral or iliac damage. Iatrogenic injury of the thoracic aorta is less usual and often fatal. Surgery for the lesions of the descending thoracic aorta still has a relatively high morbidity and mortality. Endovascular covered stentgraft prostheses have become a less invasive therapeutic approach to lesions of the thoracic aorta, especially in patients with high surgical risk. We describe a case of perforation of the thoracic aorta caused by an intraaortic balloon pump. The injury was confirmed by aortography and successfully repaired by implantation of an endovascular stent-graft via the left common iliac artery.

Recambio valvular por insuficiencia aórtica severa tras cirugía conservadora según técnica de David / Valve replacemente in severe aortic regurgitation produced after a valve sparing operation with David's technique

La reconstrucción valvular aórtica tiene gran interés en el tratamiento de la insuficiencia aórtica severa causada por dilatación del anillo valvular asociada a anuloectasia aórtica. Si la válvula es normal y queremos evitar problemas derivados de las prótesis y la anticoagulación de por vida, utilizaremos técnicas como la descrita por David para preservación valvular aórtica. Aunque los resultados a largo plazo suelen ser buenos, en algunos casos como en el que aquí nos ocupa se produce una intensa fibrosis en la válvula nativa que evoluciona hacia una insuficiencia aórtica severa que precisa reoperación. Describimos aquí la evolución cronológica del deterioro valvular, el momento en que se indicó la reintervención y la cirugía que se hizo (AU)