Better outcomes with mitral valve repair than replacement
Mitral valve (MV) repair appears to be associated with a lower mortality rate and better clinical outcomes in patients with infective endocarditis compared with MV replacement, according to review of previous studies presented at AFCC 2018.
A previous meta-analysis has shown that patients who underwent MV repair had a lower rate of mortality compared with MV replacement (in-hospital, 2.3 percent vs 14.4 percent and long-term, 7.8 percent vs 40.5 percent). [Ann Thorac Surg 2007;83:564-570]
In addition, patients who had MV repair had lower cerebrovascular events (early, 5 percent vs 11 percent and late, 2 percent vs 24 percent), lower rates of reoperation (2 percent vs 12 percent) and reinfection (2 percent vs 7 percent) vs those who had MV replacement.
In another study, more patients had better outcomes with MV repair than replacement. There were higher rates of reoperation-free survival (96 percent vs 68 percent) and reinfection-free survival (95 percent vs 73 percent). [Ann Thorac Surg 1997;63:1718-1724] “This is a very encouraging [result, which taught us] how to deal with this problem,” said Dr Taweesak Chotivatanapong from the Department of Cardiothoracic Surgery at Central Chest Institute of Thailand in Nonthaburi, Thailand.
With regard to safety, a previous study showed that no recurrent infection and reoperation for valve incompetency was observed among patients who had a valve repair during their early phase of active endocarditis, “which means that valve repair was good, safe, and a feasible strategy to deal with this infection … we have to hit earlier to get a better result,” said Chotivatanapong. [Ann Thorac Surg 1990;49:706-711]
He added that the optimal timing of surgery in patients with infective endocarditis who had cerebrovascular complications (ie, stroke) has been a subject of debate. Evidence from previous studies suggests that the procedure should not be delayed if the patient is not in coma and has no intracranial haemorrhage (class IIa level B), and after a transient ischaemic attack or a silent cerebral embolism (class I level B). [Interact Cardiovasc Thorac Surg 2012;14:72-80]
However, if intracranial haemorrhage is present, then surgery should be performed within 1 month, and this was corroborated by another study from Japan, said Chotivatanapong. [Eur J Cardiothorac Surg 2016;50:374-382]
“MV repair in [patients with] infective endocarditis is feasible, safe, reproducible, and stable … Resuscitation to improve condition, early surgical intervention, adequate debridement, and proper surgical techniques are important for good outcome,” he said. “Simplified and innovative techniques are now evolving and effective.”