Surgery for Mitral Valve Endocarditis* Ronald M. Becker, M.D.;• • William Frishman, M.D., F.C.C.P.;t and Robert W. M. Frater, M.B., Ch.B.*
The records of 20 patients who underwent mitral valve replacement for complications of bacterial encloarditls were reviewed. Although the Indications for surgery were the same as those for patients with aortle endocardiUs, major emboU (cerebral, coronary or retinal) prompted surgery in 8 of 20 patients, a muc:b higher lneideuc:e than reported for surgery in aortic valve endocarditi& Eighteen of the patients had mitral regwgitation; 14 of these bad severe congestive heart faDure, but the development of congestive faDure tended to be more insidions than In patients with aortic endocarditis. Continued septicemia despite appropriate antibiotics was the least common lndi-
Many recent articles have indicated the usefulness of surgery in patients with complications of bacterial endocarditis. Most centers have had far greater experience with endocarditis of the aortic valve than the mitral valve. In contrast, over the last decade we have encountered a large group of patients with mitral valve endocarditis requiring surgery. This article is an update on the surgical experience we presented in 1970.1 This favorable experience led us to pursue a more aggressive approach in the treatment of mitral endocarditis. While it was already clear that acute rupture of the aortic valve led to a virulently progressive form of cardiac failure, it appeared that rupture of the mitral valve might be different only in taking longer to cause death. We therefore set the indications for surgery in mitral endocarditis as: 1) mitral insufficiency accompanied by congestive heart failure, 2) failure of antibiotic therapy, 3) repeated embolism. Since 1968, 20 patients with mitral endocarditis, and one or more of the above indications for surgery, were operated upon at the Bronx Municipal Hospital Center or Albert Einstein College Hospital. The age range was 23 to 59 years with an average of 40. There were nine women and 11 men. From the Deparbnents of Surgery and Medicine, Albert Einstein College of Medicine, Bronx. •• Assistant ProfeSsor, Cardio-thoracic Surgery. tAssistant Professor, Cardiology. :Professor of Surgery and Chief, Division of Cardio-thoracic Surgery. September 19. Manuscript received July 31; revision ~ted lfeprint requem: Df'. Becket', HO&JJlttJl, Albert Eimleln College of MBdicine, 18i5 E1161ch.tmiw &ad. Bronz 10461 0
314 BECKER, FRISHMAN, FRATER
cation for surgery. Sixteen of the 20 patients were salvapd by surgery, although some bad major residnal defteifs, related mainly to preoperative emboU. These re-
suhs are a marked improvement In the expected 90-100 percent mortaUty rate for patients with these complications of endocarditis. The main reason for a poor result foUowing surgery was temporization leading to con· tlnued deterioration of vital functions preoperatively. Reinfection of the prosthesis did not occur, and we do not consider duration of preoperative antibiotic therapy an important factor In the decision to perform surgery.
REsuLTS Predisposing factors are summarized in Table 1. The most common factor was drug addiction, noted in seven patients.
Presentation and Diagnosis Evidence of infection: In all patients, the presenting symptom was fever, the duration of which was from one to as long as six months before treatment Weight loss, tiredness and weakness were common. On admission, the average hemoglobin level was 9.7 and white blood cell count 14,100. Blood cultures were positive (Table 2) in all patients, some with more than one organism. The unusual organisms (Pseudomonas, Candida, Hemophilus) were found exclusively in drug addicts, but addicts also commonly had the more usual organisms.
Cardiac Signs and Symptoms In six patients, murmurs of mitral stenosis and/ or Table 1-Pred&ptniq or Edolopc Faeor•l.eadiqeo Barerial Endocanliril in 20 Padenll Recent dental extractions
1
Recent mitral valve surgery
3
Chronic mitral valve disease
3
Intravenous drug addiction
7
Infectious process elsewhere
5
None identified
1
CHEST, 75: 3, MARCH, 1979
echocardiography (Fig 1). Echocardiography showed vegetations in four other patients.
Table 2-Dominant Or•tmi•m Re•pomible for Endocarditi1 in 20 Palien11
Pseudomonas
1
alpha-Streptococcus
11
Enterococcus
3
Candida albicans
1
Staphylococcus aureus
3
H emophilm parainfluenza
1
insufficiency were previously present. In 13, the murmur of mitral insufficiency appeared quite early in the course of the disease along with signs and symptoms of pulmonary congestion. Pulmonary hypertension, right heart failure and tricuspid insufficiency could be demonstrated in six patients in whom surgery was delayed several weeks or months from the onset of congestive failure. In the sickest patients, the murmurs were of moderate intensity (suggesting decreased cardiac output) and pulmonary rales were not very prominent (suggesting right ventricular failure ) . Cold, blue extremities with small, poorly sustained peripheral pulses were · present in four patients. In one patient, surgery was performed immediately after successful resuscitation for cardiorespiratory arrest. Four patients had cardiac catheterization. In three with congestive failure, pulmonary hypertension (average systolic pressure 62 mm Hg) and extremely low cardiac outputs (average cardiac index 1.5 L/ min/ m2 ) were noted. One patient with Candida endocarditis had entirely normal hemodynamic findings. The diagnosis in this patient was established by
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.,..,,- ~-......;. · .
r .
The records of 20 patients who underwent mitral valve replacement for complications of bacterial encloarditls were reviewed. Although the Indications for surgery were the same as those for patients with aortle endocardiUs, major emboU (cerebral, coronary or retinal) prompted surgery in 8 of 20 patients, a muc:b higher lneideuc:e than reported for surgery in aortic valve endocarditi& Eighteen of the patients had mitral regwgitation; 14 of these bad severe congestive heart faDure, but the development of congestive faDure tended to be more insidions than In patients with aortic endocarditis. Continued septicemia despite appropriate antibiotics was the least common lndi-
Many recent articles have indicated the usefulness of surgery in patients with complications of bacterial endocarditis. Most centers have had far greater experience with endocarditis of the aortic valve than the mitral valve. In contrast, over the last decade we have encountered a large group of patients with mitral valve endocarditis requiring surgery. This article is an update on the surgical experience we presented in 1970.1 This favorable experience led us to pursue a more aggressive approach in the treatment of mitral endocarditis. While it was already clear that acute rupture of the aortic valve led to a virulently progressive form of cardiac failure, it appeared that rupture of the mitral valve might be different only in taking longer to cause death. We therefore set the indications for surgery in mitral endocarditis as: 1) mitral insufficiency accompanied by congestive heart failure, 2) failure of antibiotic therapy, 3) repeated embolism. Since 1968, 20 patients with mitral endocarditis, and one or more of the above indications for surgery, were operated upon at the Bronx Municipal Hospital Center or Albert Einstein College Hospital. The age range was 23 to 59 years with an average of 40. There were nine women and 11 men. From the Deparbnents of Surgery and Medicine, Albert Einstein College of Medicine, Bronx. •• Assistant ProfeSsor, Cardio-thoracic Surgery. tAssistant Professor, Cardiology. :Professor of Surgery and Chief, Division of Cardio-thoracic Surgery. September 19. Manuscript received July 31; revision ~ted lfeprint requem: Df'. Becket', HO&JJlttJl, Albert Eimleln College of MBdicine, 18i5 E1161ch.tmiw &ad. Bronz 10461 0
314 BECKER, FRISHMAN, FRATER
cation for surgery. Sixteen of the 20 patients were salvapd by surgery, although some bad major residnal defteifs, related mainly to preoperative emboU. These re-
suhs are a marked improvement In the expected 90-100 percent mortaUty rate for patients with these complications of endocarditis. The main reason for a poor result foUowing surgery was temporization leading to con· tlnued deterioration of vital functions preoperatively. Reinfection of the prosthesis did not occur, and we do not consider duration of preoperative antibiotic therapy an important factor In the decision to perform surgery.
REsuLTS Predisposing factors are summarized in Table 1. The most common factor was drug addiction, noted in seven patients.
Presentation and Diagnosis Evidence of infection: In all patients, the presenting symptom was fever, the duration of which was from one to as long as six months before treatment Weight loss, tiredness and weakness were common. On admission, the average hemoglobin level was 9.7 and white blood cell count 14,100. Blood cultures were positive (Table 2) in all patients, some with more than one organism. The unusual organisms (Pseudomonas, Candida, Hemophilus) were found exclusively in drug addicts, but addicts also commonly had the more usual organisms.
Cardiac Signs and Symptoms In six patients, murmurs of mitral stenosis and/ or Table 1-Pred&ptniq or Edolopc Faeor•l.eadiqeo Barerial Endocanliril in 20 Padenll Recent dental extractions
1
Recent mitral valve surgery
3
Chronic mitral valve disease
3
Intravenous drug addiction
7
Infectious process elsewhere
5
None identified
1
CHEST, 75: 3, MARCH, 1979
echocardiography (Fig 1). Echocardiography showed vegetations in four other patients.
Table 2-Dominant Or•tmi•m Re•pomible for Endocarditi1 in 20 Palien11
Pseudomonas
1
alpha-Streptococcus
11
Enterococcus
3
Candida albicans
1
Staphylococcus aureus
3
H emophilm parainfluenza
1
insufficiency were previously present. In 13, the murmur of mitral insufficiency appeared quite early in the course of the disease along with signs and symptoms of pulmonary congestion. Pulmonary hypertension, right heart failure and tricuspid insufficiency could be demonstrated in six patients in whom surgery was delayed several weeks or months from the onset of congestive failure. In the sickest patients, the murmurs were of moderate intensity (suggesting decreased cardiac output) and pulmonary rales were not very prominent (suggesting right ventricular failure ) . Cold, blue extremities with small, poorly sustained peripheral pulses were · present in four patients. In one patient, surgery was performed immediately after successful resuscitation for cardiorespiratory arrest. Four patients had cardiac catheterization. In three with congestive failure, pulmonary hypertension (average systolic pressure 62 mm Hg) and extremely low cardiac outputs (average cardiac index 1.5 L/ min/ m2 ) were noted. One patient with Candida endocarditis had entirely normal hemodynamic findings. The diagnosis in this patient was established by
~
MV !·..::..
.,..,,- ~-......;. · .
r .
