Annular abscesses in surgical endocarditis: Anatomic, clinical, and operative features

Background. The aim of this study was to determine patterns of anatomic, cl inical, and operative features in surgical endocarditis (SE) with annular a bscess (AA). Methods. The study consisted of a retrospective analysis of SE cases with A A between 1981 and 1997. Results. A total of 41 cases with AA were found in 106 consecutive SE cases . There was a higher incidence of AA in aortic (37 of 71 [52%]) (p < 0.01) compared to mitral (6 of 42 [14.3%]) or tricuspid (0 of 12) infections. How ever, the mitral abscesses had a greater tendency toward fistula or pseudoa neurysm formation (4 of 6 [67%]) than other valve abscess cavities (7 of 46 [15%]) (p < 0.01). Severe heart failure (p < 0.01), heart block (p < 0.05) , and fistula/pseudoaneurysm (p < 0.001), were more often found in SE with AA than without. There were 46 separate aortic AA in 37 instances of aortic valve SE. Of these, 31 of 46 (67%) were less than 1 cm (group 1), 10 of 46 (22%) were large but confined to a given cusp annulus (group 2), 4 of 46 ( 8.6%) were large between multiple cusps (group 3), and 1 of 46 (2.2%) was c ircumferential (group 4). There were four instances of aortoventricular dis continuity. Group 1 abscesses were repaired by local closure without a patc h significantly more often than the other groups. The mortality of SE with AA was significantly greater for larger AA (groups 3 and 4, 3 of 5 [60%]) t han for smaller AA (groups 1 and 2, 0 of 36) (p < 0.001). There were six se parate mitral AA in six instances of mitral SE, five requiring patch repair . The 30-day operative mortality for AA cases was 3 of 41 (7.3%) compared t o 2 of 65 (3.1%) without AA. All AA mortalities involved large AA in the ao rtic valve position. Of 35 mechanical valves placed for AA, only one requir ed subsequent removal for prosthetic endocarditis. Conclusions. Annular abscesses are most frequent in aortic AA, but fistulas /pseudoaneurysms are more frequent in mitral AA. Small to moderate aortic A A can be managed by local closure without an increased mortality compared t o SE without AA. Patients with large aortic AA have a higher operative mort ality. Mechanical prostheses are safe and effective for the majority of pat ients with AA. (C) 2000 by The Society of Thoracic Surgeons.