Tricuspid valve repair and replacement for infective endocarditis.

Infective endocarditis represents a challenging and life-threatening clinical condition affecting native and prosthetic heart valves, endocardium, and implanted cardiac devices. Right-sided infective endocarditis account for approximately 5-10% of all infective endocarditis and are often associated with intravenous drug use, intracardiac devices, central venous catheters, and congenital heart disease. The tricuspid valve is involved in 90% of right-side infective endocarditis. The primary treatment of tricuspid valve infective endocarditis is based on long-term intravenous antibiotics. When surgery is required, different interventions have been proposed, ranging from valvectomy to various types of valve repair to complete replacement of the valve. Percutaneous removal of vegetations using the AngioVac system has also been proposed in these patients. The aim of this narrative review is to provide an overview of the current surgical options and to discuss the results of the different surgical strategies in patients with tricuspid valve infective endocarditis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01650-0.

Three Decades of Experience with Aortic Prosthetic Valve Endocarditis.

The objective of this study was to evaluate early and long-term outcomes of patients with aortic prosthetic valve endocarditis (a-PVE) treated with a prosthetic aortic valve (PAV), prosthetic valved conduit (PVC), or cryopreserved aortic homograft (CAH). A total of 144 patients, 115 male and 29 female, aged 67 ± 12 years, underwent surgery for a-PVE at our institution between 1994 and 2021. Median time from the original cardiac surgery was 1.9 [0.6-5.6] years, and 47 (33%) patients developed an early a-PVE. Of these patients, 73 (51%) underwent aortic valve replacement (AVR) with a biological or mechanical PAV, 12 (8%) underwent aortic root replacement (ARR) with a biological or mechanical PVC, and 59 (42%) underwent AVR or ARR with a CAH. Patients treated with a CAH had significantly more circumferential annular abscess multiple valve involvement, longer CPB and aortic cross-clamping times, and needed more postoperative pacemaker implantation than patients treated with a PAV. No difference was observed in survival, reoperation rates, or recurrence of IE between patients treated with a PAV, a PVC, or a CAH. CAHs are technically more demanding and more often used in patients who have extensive annular abscess and multiple valve involvement. However, the use of CAH is safe in patients with complex a-PVE, and it shows excellent early and long-term outcomes.

Twenty-Year Experience with Surgery for Native and Prosthetic Mitral Valve Endocarditis.

Background and Objectives: To evaluate the early and long-term results of surgical treatment of isolated mitral native and prosthetic valve infective endocarditis. Materials and Methods: All patients undergoing mitral valve repair or replacement for infective endocarditis at our institution between January 2001 and December 2021 were included in the study. The preoperative and postoperative characteristics and mortality of patients were retrospectively reviewed. Results: A total of 130 patients, 85 males and 45 females, with a median age of 61 ± 14 years, underwent surgery for isolated mitral valve endocarditis during the study period. There were 111 (85%) native and 19 (15%) prosthetic valve endocarditis cases. Fifty-one (39%) patients died during the follow-up, and the overall mean patient survival time was 11.8 ± 0.9 years. The mean survival time was better in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (12.3 ± 0.9 years vs. 8 ± 1.4 years; p = 0.1), but the difference was not statistically significant. Patients who underwent mitral valve repair had a better survival rate compared to patients who had mitral valve replacement (14.8 ± 1.6 vs. 11.3 ± 1 years; p = 0.06); however, the difference was not statistically significant. Patients who underwent mitral valve replacement with a mechanical prosthesis had a significantly better survival rate compared to patients who received a biological prosthesis (15.6 ± 1.6 vs. 8.2 ± 0.8 years; p < 0.001). Patients aged ≤60 years had significantly better survival compared to patients aged >60 years (17.1 ± 1.1 vs. 8.2 ± 0.9; p < 0.001). Multivariate analysis showed that the patient's age >60 years at the time of surgery was an independent risk factor for mortality, while mitral valve repair was a protective factor. Eight (7%) patients required reintervention. Freedom from reintervention was significantly higher in patients with mitral native valve endocarditis compared to patients with prosthetic valve endocarditis (19.3 ± 0.5 vs. 11.5 ± 1.7 years; p = 0.04). Conclusions: Surgery for mitral valve endocarditis is associated with considerable morbidity and mortality. The patient's age at the time of surgery represents an independent risk factor for mortality. Mitral valve repair should be the preferred choice whenever possible in suitable patients affected by infective endocarditis.

Cryopreserved aortic homografts for complex aortic valve or root endocarditis: a 28-year experience.

OBJECTIVES: The aim of this study was to evaluate early- and long-term outcomes of cryopreserved aortic homograft (CAH) implantation for aortic valve replacement (AVR) or aortic root replacement (ARR) in patients with or without complex infective endocarditis. METHODS: All adult patients undergoing AVR or ARR with CAH at our institution between January 1993 and July 2021 were included in the study. RESULTS: One hundred four patients, 75 males and 29 females, aged 59 ± 17 years, underwent AVR or ARR with CAH for infective endocarditis (n = 94, 90%) or aortic valve disease (n = 10, 10%). There were 33 (35%) native valve endocarditis and 61 (65%) prosthetic valve endocarditis, which were complicated by annular abscess in 77 (82%) patients, mitral valve endocarditis in 13 (14%) and tricuspid valve endocarditis in 13 (14%). The mean cardiopulmonary bypass time was 214 ± 80 min and the mean aortic cross-clamping time was 164 ± 56 min. There were 12 (12%) hospital deaths and 7 (7%) postoperative low cardiac output syndrome requiring extracorporeal membrane oxygenation in 4 patients and intra-aortic balloon pump in 3. Thirty-nine (42%) patients died during the follow-up (94% complete). The mean survival time was 13.9 ± 1.2 years. Twenty-five patients (26%) underwent late reoperation for aortic homograft degeneration (n = 17, 18%), homograft endocarditis (n = 6, 7%), homograft dehiscence (n = 1, 1%) and mitral valve regurgitation (n = 1, 1%). The mean survival free from reintervention was 15.7 ± 1.2 years. CONCLUSIONS: AVR or ARR with a CAH for complex endocarditis is associated with satisfactory hospital survival, considering the critical patient presentation at surgery, and excellent survival free from recurrent infection. Need for reoperation late after surgery is similar to other biological prostheses.

Short-term outcome of adenosine-lidocaine-magnesium polarizing cardioplegia in humans.

OBJECTIVES: Hyperkalaemic depolarized myocardial arrest is the cornerstone of myocardial protection, although some potassium-related cytotoxicity has been demonstrated. Polarized arrest has gained interest because of a reported better myocardial protection in preclinical studies. The goal of this study was to analyse the quality of myocardial protection and hospital outcome after normokalaemic adenosine-lidocaine-magnesium (ALM) blood polarizing cardioplegia, compared to hyperkalaemic blood Buckberg depolarizing cardioplegia, in elective routine adult cardiac surgery. METHODS: One thousand consecutive elective adult cardiac patients [627 undergoing ALM-polarizing cardioplegia (ALM-POL) vs 373 Buckberg depolarized cardioplegia (BUCK-DEPOL)] who were operated on were analysed. Perioperative leakage of high-sensitivity troponin I (Hs-TnI), peripheral lactate, inotropic and vasoactive daily requirement [maximal vasoactive inotropic score (VISMAX)], hospital mortality and morbidity were collected and compared in the overall population and in the propensity score (PS) matched population (206 pairs). RESULTS: A significantly lower leakage of Hs-TnI during hospitalization was detected in patients receiving ALM-POL versus those receiving BUCK-DEPOL (group time P < 0.001 for overall population and PS matched pairs). The maximum value of postoperative Hs-TnI was also lower after ALM-POL (P < 0.001 in both cohorts), and spontaneous recovery of sinus rhythm at aortic declamping was higher (P < 0.001 in favour of ALM-POL). Maximal VISMAX during hospitalization was significantly higher after BUCK-DEPOL in both cohorts (P = 0.019 for overall population; P = 0.031 for PS matched population), with significantly higher VISMAX on the day of surgery in BUCK-DEPOL PS matched patients (P = 0.042). No other significant differences in hospital morbidity and mortality were found. CONCLUSIONS: Despite comparable short-term clinical outcomes, ALM-POL cardioplegia proved superior in terms of quality of myocardial protection compared to BUCK-DEPOL cardioplegia in elective routine adult cardiac surgery.