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

Paighton C Miller; Linda J Schulte; Theodore Marghitu; ShengXiang Huang; Tsuyoshi Kaneko; Ralph J Damiano; Puja Kachroo

doi:10.1016/j.jtcvs.2023.09.072

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

J Thorac Cardiovasc Surg. 2023 Oct 4:S0022-5223(23)00898-X. doi: 10.1016/j.jtcvs.2023.09.072. Online ahead of print.

Authors

Paighton C Miller¹, Linda J Schulte², Theodore Marghitu¹, ShengXiang Huang¹, Tsuyoshi Kaneko², Ralph J Damiano², Puja Kachroo³

Affiliations

¹ Washington University School of Medicine, St. Louis, Mo.
² Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo.
³ Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo. Electronic address: puja@wustl.edu.

PMID: 37802331
DOI: 10.1016/j.jtcvs.2023.09.072

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.

Keywords: aortic valve; double valve; infective endocarditis; mitral valve.