LONG-TERM RESULTS OF OPERATION FOR PARAVALVULAR ABSCESS

Background. Operation for infective endocarditis with paravalvular abs cess is reportedly associated with high mortality and morbidity rates. In an attempt to improve surgical outcome, an approach of radical res ection of the abscess and inflamed tissues and reconstruction of the h eart with either fresh or glutaraldehyde-fixed bovine pericardium was adopted by two surgeons at our institution. Methods. From 1979 to 1995 , 70 consecutive patients with active infective endocarditis and parav alvular abscess underwent operation. Their mean age was 49 years (rang e, 16 to 75 years), and 50 patients (71%) were men. Thirty-four patien ts had native and 36 had prosthetic valve endocarditis (8 had had comp osite replacement of the aortic valve and ascending aorta). Most patie nts (78%) were in New York Heart Association functional class IV. The principal indication for operation was cardiogenic or septic shock in 11 patients, or one or more of the following: persistent sepsis despit e adequate antibiotic therapy in 36, congestive heart failure in 31, a nd recurrent emboli in 16. Staphylococci were responsible for the infe ction in 37 patients (53%). The abscess was in the mitral annulus in 1 1 patients, in the aortic root in 44, and in the aortic root and at le ast one other annulus in 15. After wide resection of the abscess, we r econstructed the heart and annuli with autologous or bovine pericardiu m. Mechanical heart valves were implanted in 36 patients, bioprosthese s in 30, and aortic homografts in 2; valve repair was possible in 2. S ixteen patients required composite replacement of the ascending aorta and aortic valve. Results. There were 9 operative deaths (13%). Infect ions caused by staphylococci and infections in multiple annuli were as sociated with increased operative mortality rates. Only 1 patient had persistent infection and required reoperation. The mean follow-up was 56 +/- 40 months. There were 12 late deaths, mostly cardiac. The actua rial survival including operative deaths was 64% +/- 8% at 8 years, In 8 patients, recurrent infective endocarditis developed 10 to 102 mont hs after operation. The freedom from recurrent endocarditis was 76% +/ - 10% at 8 years. Conclusions. This experience indicates that radical resection of the abscess and re-construction of the heart with pericar dium yield an excellent chance of eradicating the infection in patient s with infective endocarditis and paravalvular abscess. The type of va lve implanted may not be as important as radical resection of the absc ess; These patients appear to have a greater than average risk of recu rrent endocarditis.