Faculty Bibliography

BACKGROUND:Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. METHODS:All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. RESULTS:Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and 180 days (hazard ratio [HR], 9.8; 95% confidence interval [CI], 2.7-35.3) but not before 90 days (HR, 0.38; 95% CI, 0.05-3.1) or after 180 days (HR, 1.8; 95% CI, 0.8-3.8). Among patients who injected drugs, reoperation and death contributed equally to the outcome, whereas among patients who did not inject drugs, reoperation for IE was far less common. CONCLUSIONS:Between 3 and 6 months after operation for IE, patients who inject drugs have a hazard of death or reoperation that is about 10 times that of patients who do not inject drugs. Before and after, the HRs are much smaller and not statistically significant.

OBJECTIVES/OBJECTIVE:To identify and understand residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis (IE), we categorized the intraoperative pathologic entities in patients with left-sided IE and correlated the pathology (noninvasive vs invasive) and organism with IE context (affected valve, native vs prosthetic [PVE]) and surgical results. METHODS:From January 2002 to January 2011, 775 patients underwent surgery for active left-sided IE. Registries were queried, and endocarditis-related pathology was based on the echocardiographic findings and operative notes. Propensity adjustment and matching (55 pairs) were used for risk-adjusted outcome comparisons between the invasive aortic and mitral cases. RESULTS:A total of 395 patients had isolated aortic (PVE 59%, invasive 68%), 238 isolated mitral (PVE 29%, invasive 35%), and 142 combined aortic and mitral (PVE 44%, invasive 69%) IE. The 30-day survival was 92% and was similar for native valve endocarditis and PVE in all 3 valve combinations. Invasive versus noninvasive IE was associated with greater hospital mortality (11% vs 4.4%, P = .001). Patients with invasive IE had worse intermediate-term survival than those with noninvasive IE for mitral (P = .001) and aortic plus mitral (P = .02) IE but not for isolated aortic IE. This difference persisted in the matched patients. CONCLUSIONS:During the past decade, we have had low hospital mortality for surgically treated left-sided IE and have neutralized the added risk of PVE. However, outcomes remain worse for mitral versus aortic valve IE, with residual obstacles related to patient factors, inherent mitral valve anatomy in patients with invasive disease, and lack of an alternative mitral valve prosthesis optimal for IE.

Destruction of the mitral-aortic (or mitroaortic) intervalvular fibrosa (IVF) by infective endocarditis is a marker of advanced pathology. Patients are at high risk, as they are sicker, have more comorbidities and have more advanced pathology, requiring a difficult operation that includes debriding and reconstructing the IVF. The anatomy and surgical techniques for that reconstruction are presented and discussed. Operative risk is high and remains high for the first year, before becoming equivalent to that of conventional operations for endocarditis. Current outcomes are better than in the past, but there is room for further improvement.