AORTIC-VALVE ENDOCARDITIS - DETERMINANTS OF EARLY SURVIVAL AND LATE MORBIDITY

Background Aortic valve surgery for endocarditis remains a high-risk p rocedure. The objective of this study was to analyze the interaction b etween the various subsets of endocarditis (native, prosthetic, healed , and active), timing of surgery, and their influence on early and lat e outcomes. Methods and Results During a 20-year period starting Janua ry 1972, 200 patients underwent aortic valve replacement for infective endocarditis (age range, 13 to 88 years; median, 53 years). There wer e 51 (26%) females, and 109 (55%) were in New York Heart Association f unctional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 132 (66%) and 68 (34%) patients, respectively. Surgery was required in 120 (60%) during the active phase (AE) and 80 (40%) during the healed phase (HE) of en docarditis. The main indication for surgery in the healed group was pr ogressive congestive heart failure. The indications for the active gro up were congestive heart failure (68%), continuing active sepsis (70%) , echocardiographic vegetation (28%), peripheral emboli (30%), and arr hythmias (13%). Streptococcal infections predominated in NVE, staphylo coccal in PVE and AE; culture-negative endocarditis predominated in th e healed group. Isolated aortic valve surgery was performed in 68% of the patients, and concomitant procedures (32%) included mitral valve a nd coronary bypass procedures. The overall operative mortality (OM) wa s 12.5%. The OM was 7.5% and 22% for NVE and PVE, respectively (P=.004 ), and 7% for HE versus 15% for AE (P=.06). The OM for early PVE was 3 3% versus 18% for late PVE (P<.05). Multivariate logistic regression a nalysis identified PVE and New York Heart Association functional class IV to be independent predictors for early death. Recurrent endocardit is occurred 26 times in 24 patients (11 early, 13 late), with three op erative deaths in the early group, all due to residual staphylococcal infections. Freedom from recurrent endocarditis was Significantly diff erent between HE (96+/-3% and 86+/-6% at 5 and 10 years, respectively) and AE (89+/-3% and 83+/-4%, respectively) (P=.02). Long-term surviva l for discharged patients was 81+/-3% and 63+/-5% at 5 and 10 years, r espectively, with no significant difference between NVE, PVE, AE, and HE. Conclusions These data suggest that for active endocarditis, surge ry should be delayed to achieve a healed status provided there is-no p ressing need for immediate surgery. Patients with staphylococcal endoc arditis, particularly on a prosthesis, should be operated on sooner an d should be covered with antibiotics for an extended period to prevent recurrent PVE. This study stresses the need for aggressive antibiotic prophylaxis, particularly in the presence of a prosthesis.