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Mitral valve repair is considered to be the procedure of choice for any type of mitral regurgitation, including infective endocarditis, in terms of left ventricular function and event-free survival. We reviewed 120 consecutive patients who underwent mitral valve repair for active or healed endocarditis between 1991 and 2008. The repair rate for patients with infective endocarditis was 90% during the same period. The patients comprised 72 men and 48 women whose mean age was 48 +/- 17 years. Of the 120 patients, 40 underwent mitral valve repair during the active phase of infective endocarditis. The repair procedures included patch grafting using glutaraldehyde-treated autologous pericardium in 39 patients and chordal reconstruction using expanded polytetrafluoroethylene (ePTFE) in 57 patients which were combined with a prosthetic ring in 82 patients. The 10-year survival rates including hospital death and freedom from reoperation were 92 +/- 4% and 96 +/- 2%, respectively. Mitral valve repair for active or healed endocarditis can be performed with low operative mortality rates. Complex mitral valve repair using autologous pericardium and/or ePTFE for neochordae expands the possibility of repair, is durable, and is associated with excellent long-term results.

Objectives: To evaluate the changes in the clinical background to infective endocarditis and identify the contributing factors to in-hospital deaths over the last 20 years., Methods: Seventy-five patients (mean age 48.2 +/- 24.0 years) with infective endocarditis treated between January 1984 and December 2003 at our hospital were evaluated retrospectively. The patients were divided into two groups (first decade, n = 26 and second decade, n = 49)., Results: The infection route was unknown in 65% of the patients, but the oral route was the most common known route (16.0%). Congenital heart disease (24.0%)was the most common background disease, followed by valvular heart disease (22.7%), and post prosthetic valve replacement (22.7%). The mitral valve was most frequently infected(56.0%), followed by the aortic valve (34.7%). Multi-valve infection was present in 13.3% of the patients. Although the frequency of streptococcal endocarditis reduced, that of staphylococcal endocarditis increased in the second decade. The overall in-hospital mortality was 26.7%, but slightly improved in the second decade (34.6% vs 22.4%, p = 0.26). The overall in-hospital mortality was similar between the surgically treated group and the non-surgically treated group (25.0% vs 27.3%, NS). In the surgically treated group, in-hospital mortality was lower in the second decade than the first decade, but higher in the group treated for active infective endocarditis. Multivariate analysis found age > or = 51 years, renal insufficiency, neurological abnormality, and culture negative as predictors of in-hospital mortality., Conclusions: Rapid and appropriate primary medical treatment are important in the active phase of infective endocarditis. Age > or = 51 years was the strongest predictor of in-hospital infective endocarditis death.

To elucidate clinical features of infective endocarditis in the elderly, 20 elderly patients aged > or = 60 years were compared in detail with 30 others aged < 60 years retrospectively. Twelve of the 20 elderly patients had a calcific aortic valve or an artificial device as a predisposing heart disease, whereas 16 middle-aged patients had mitral valve prolapse or congenital heart disease (p = 0.001). The prevalence of major extracardiac disorders such as neurological disease were higher in the elderly than in the middle (9/20 vs 3/30; p < 0.01). The frequency of infected valve was similar; mitral in 8, aortic in 11 and other valves or congenital defect in 2 in the elderly versus 14, 11 and 6, respectively in the middle. Among 39 patients in whom causative microorganisms were identified, staphylococcus epidermidis was most frequently identified in the elderly (5/20), whereas streptococcus species was found in the middle (12/30). Time from the onset of symptoms to correct diagnosis was usually delayed in the entire group; the delay was longer particularly in the elderly than in the middle-aged patients (72 +/- 87 vs 36 +/- 32 days; p < 0.1). Maximal body temperature was less in the elderly than in the middle-aged patients (38.5 +/- 0.7 vs 39.3 +/- 1.1 degrees C; p < 0.01), whereas peak level of C-reactive protein (10.4 +/- 6.1 vs 13.0 +/- 7.9 mg/dL), the incidences of heart failure (9/20 vs 10/30), and embolic complications (7/20 vs 10/20) were similar in the 2 groups. Cardiac operation was performed less in the elderly than in the middle-aged patients (9/20 vs 21/30; p < 0.08). Five elderly patients had disease-related mortality, whereas only one middle-aged patient died (p = 0.02). These results suggest that although predisposing heart disease and causative microorganism in infective endocarditis are different between the elderly and middle-aged patients, the incidence of major complications are similar. However, due to the delay of correct diagnosis in the elderly who usually have major extracardiac disorders, the prognosis of infective endocarditis in the elderly is poor.

Between April 1975 and December 1995, 33 patients with active infective endocarditis underwent surgical treatment at our hospital. The location of diseased valve was shown as ; 18 in aortic, 11 in mitral, and 4 in aortic and mitral position. Of these, 14 patients had an annular abscess or mycotic aneurysm. All patients achieved antibiotic therapy previously, and predominant indication for operation was congestive heart failure. All patients underwent valve replacement. The reconstructive procedures for 14 patients with paravalvular involvement were as follows ; direct closure : 5 cases, direct closure+tilted prosthesis technique : 5 cases, and another 4 cases were, patch closure of VSP resulting from a septal abscess, patch closure+translocation, translocation, and reconstruction of annulas with pericardial patch. There were five (15.2%) operative and hospital deaths and actuarial survival rate was 81% and 61% at 5 and 10 years after operation. Including one who died early after operation, there were 5 cases with postoperative paravalvular leakage and its main cause were persistent infection. In conclusion, it considered that the principles of treating active infective endocarditis is to decide the optimal timing for operation, debride the infected tissue, and close the defect completely.

Thirty-two active infectious endocarditis patients who underwent 36 surgical procedures (23 NVEs, 13 PVEs) in last 10 years were reviewed. Seven patients (19.4%) died early postoperatively, 3/23 (13%) in NVEs and 4/13 (31%) in PVEs, and the causes of death were LOS in 5, MOF in one and cerebral bleeding in one. NVE patients of double valve deterioration who developed cardiogenic shock had poor operative results, 3 death in 4 (75%) despite of circulatory assist. Aortic PVEs who underwent Danielson's translocation technique also showed 3 death in 4 (75%). Five in 25 survivors (20%) developed late death and 3 of them were related with reinfection of prosthetic valve. We concluded that surgical treatment for active IE provides reasonable results, although they are still challenging for double valve NVEs and aortic PVEs, for which aortic root replacement using homograft would be the procedure of choice.

From 1981 to 1996, 48 consecutive patients, aged range 1 to 72 years, underwent surgical treatment for infective endocarditis. The infection was in the aortic valve in 10 patients, the mitral valve in 17, the aortic and mitral valves in 7, mixed aortic, mitral and tricuspid valves in one, the tricuspid valve in 9, the pulmonary valve in 3, and the other in 2, thirty-seven patients had native valve endocarditis (NVE) of which 22 cases were in the active stage. Seven cases had active prosthetic valve endocarditis (PVE) and 4 had VSD patch infection. The overall hospital mortality rate was 14.6% (7/48). The hospital mortality rate of NVE was 2.7% (1/37) and that of active NVE was 4.5% (1/22). That of PVE was 71.4% (5/7) and one of 4 cases with VSD patch infection was lost, so the mortality rate of the prosthetic material infection was 54.5% (6/11). Only 1 patient required reoperation for persistent infection. There were 2 late deaths caused by noncardiac disease. Thirty-nine of the total IE patients are now survived. These data demonstrate excellent results in patient with NVE undergoing the surgical treatment at the early phase, and support the premise that patients with active PVE should have also early surgical intervention.

The results of surgical treatment of active native infective endocarditis in 24 patients were analyzed. Fifteen of 24 (63%) patients were successfully cured by operation. Three of the 8 patients with severe cardiac failure who underwent emergency operation died of low cardiac output syndrome and bleeding early postoperatively. One of the 6 patients with late death had preoperative cerebral embolism and died of multiple organ failure. Five of them had annular infection. Among 6 patients with annular infection, 3 patients who had Staphylococcus epidermidis and Gram negative bacterium as a causative microorganism had a short duration within 4 weeks from the onset to operation. Two died suddenly in the long-term period after surgery because of prosthetic valve detachment. The second operation were required for other 4 patients because of prosthetic valve endocarditis or perivalvular leakage. Three of them were lost from low cardiac output syndrome. These findings suggested that delayed surgical intervention may be a major causative factor resulting in high surgical mortality. For patients with active native infective endocarditis, an early aggressive operation should be considered prior to congestive heart failure and the destruction of the annulus.

From October, 1982, to December, 1995, 22 patients with active infective endocarditis underwent surgical treatment. Of 22 patients, 12 patients (group P) demonstrated microorganisms on blood culture obtained at the operation and/or in the excised valve, and 10 patients (group N) showed acute inflammatory reaction in the excised valve microscopically. Operative mortality in group P was significantly higher than that in group N (50% versus 0%,p < 0.01). Especially in group P, five of six patients (83%) with uncontorolled infection for more than eight days died within 30 days of operation. This showed that prolonged preoperative periods of uncontrolled infection influenced the surgical outcome of active infective endocarditis. In conclusion, patients who do not promptly response to antibiotic treatment must be considered for early operation within seven days of the diagnosis of infective endocarditis to decrease operative mortality. The plasma level of CRP and definition of sepsis may be useful as indicators of uncontrolled infection.

Between 1977 and June 1996, 183 patients underwent operation for infective endocarditis (IE) at our institution. Long-term mortality and morbidity were analyzed according to the STS/AATS guidelines (1988). Operative mortality including hospital deaths was 4.9% in all patients. Actuarial survival (including all deaths) at 10 postoperative years was 79.6% after AVR (n = 91), 87.9% after MVR (n = 40) and 90.0% after DVR (n = 46). There was no significant difference among 3 groups. Reoperation free and freedom from all valve-related mortality and morbidity at 10 years were 94.0% and 70.4% after AVR, 90.9% and 83.7% after MVR and 93.4% and 79.7% after DVR, respectively. And the differences among 3 groups were not significant in both freedom proportions. Overall results in this series of patients were acceptable. However, several patients with active IE and extensive perivalvular abscess were not saved even if translocation method and/or other advanced surgical procedures were applied. Introduction of aortic valve homografts might be a key factor for successful treatment for patients with extensive IE lesion.

From January 1980, through December 1995, 60 patients underwent surgical treatment of infective endocarditis (IE) at Sakakibara Hospital. Of 60 patients, 40 showed active endocarditis and 20 healed endocarditis at the time of operation. The over-all hospital mortality was 10% (6/60). The complication of cerebral accident (embolism and bleeding) was related to a higher incidence of operative mortality. The reconstructions of destruction and disruption of ventricular-aortic or mitral-aortic continity in the presence of acute infection of the annular tissue were in need of radical and complex surgical techniques. It is recommended to follow up these patients thoughtfully and to perform reoperation or re-reoperation before a patient develops severe heart failure or multiple organ failure.

From September, 1978, through January, 1993, 67 patients (mean age: 44 years) underwent surgical treatment for infective endocarditis (IE) at Kagoshima University. Of 67 patients, 36 showed active endocarditis and 31 healed endocarditis at the time of operation. The over-all hospital mortality was 22.4% (15/67). Risk factors associated with operative mortality by univariate analysis included increased blood urea concentration (BUN), increased cardiothoratic ratio, higher New York Heart Association functional class, infection status (active/healed), aortic valve infection, prolonged aortic cross-clamp time, annular abscess, and calendar year. The patients were operated earlier in the latter part of this series (1988-1993. Multiple logistic regression analysis demonstrated three factors to be statistically significant: BUN, operative year, and aortic valve infection. Complete survival information was obtained in all 52 discharged patients with a mean follow-up time of 4.8 years. There were 5 late deaths including 3 patients with valve related complication. The actuarial survival rate at 10 years after operation excluding hospital mortality was 89%, 92% for active infection 88% for healed infection. The actuarial freedom from valve related complication was 86% at 10 years. The degree of activity of the infection is not a risk factor for operative mortality by multiple logistic regression analysis. We conclude that surgical intervention should be undertaken without delay in the patients with IE before development of hemodynamic deterioration causing renal dysfunction and hypercatabolism.

To elucidate the surgical results and long-term prognosis in valvular heart disease, including infective endocarditis, in the elderly, 110 patients with valvular heart disease who underwent surgical treatment and 29 patients with infective endocarditis were studied. Among the patients with valvular heart disease, 52 patients (21 elderly, 31 young) underwent aortic valve replacement, 46 patients (24 elderly, 22 young) mitral valve replacement, and 12 patients (6 elderly, 6 young) double valve replacement. There were only 2 operative deaths (1 elderly, 1 young). The 5-year survival rate was 91.2% in elderly patients and 92.3% in younger patients. The five-year event-free rate was 67.3% in elderly patients and 79.0% in younger patients. Among 29 patients with infective endocarditis, surgical treatment was successfully performed in six of the 13 elderly patients and 10 of the 16 younger patients. There were two deaths among the younger patients and no death among the elderly patients, although recurrence was found in 2 elderly patients. Good results can be obtained from surgical intervention in elderly patients, provided they are risk-stratified before surgery followed by appropriate management.

Clinical manifestations and the results of management of infective endocarditis were reported. Of 46 patients, 17 cases received medical treatment alone (group A), and 29 cases underwent surgical interventions (group B). Affected valves were aortic in 29, and mitral in 24. In group B, however, infection occurred on the aortic valve in 22, and on the mitral valve in 11. Aortic valve was more often affected in group B than in group A (p less than 0.05). Embolic complications were observed in 5 of group A, 4 of whom had involvement of cerebral vessels, and in 4 of group B, all of whom had cerebral emboli. Of 8 cerebral embolic episodes, 6 emboli originated from mitral valvular lesions. In group A, 6 (35.3%) died of cerebral accidents or acute heart failure within 30 days after the onset of illness. In group B, 20 cases were operated on at chronic stage, and 9 cases underwent operation at active stage. Various procedures, alleged to be the most favorable, were selected to the individual patient. No mortality was found in the former group, but one patient (11.1%) in the latter group died of multiple organ failure 31 days after surgery. All patients, who were operated on at active stage, received intravenous administration of antibiotics for 6 to 8 weeks after the operation. Comparing the actuarial survival rate of group A and group B, group B was superior to group A for initial 4 years, but no significant difference was discernible thereafter.

We reviewed fourty-six patients who had undergone surgery for infective endocarditis in the past fifteen years and identified risk factors affecting the outcome. Twenty-nine patients had infection of the native valve only, 11 had infective endocarditis associated with congenital heart disease, and 6 had prosthetic valve endocarditis. Overall hospital mortality was 6.5%. Prosthetic valve endocarditis carried a higher mortality (33%) than native valve endocarditis (3.4% or congenital heart disease with infective endocarditis (0%). For the patients with active endocarditis, the early mortality rate was higher (13%) than with inactive endocarditis (3.2%). Staphylococcal infections were more likely to cause severe valve destruction and residual infection than streptococcal infection. Our results indicated that surgical management of infective endocarditis should be done after the completion of adequate antibiotic therapy. Early diagnosis should reduce the mortality, prevent fatal complications, and lead to qualitative improvement of infective endocarditis.