Mitral valve repair for infective endocarditis- Insights from the CAMPAIGN register

S. Saha¹, M. Luehr², C. Weber², M. Misfeld³, P. Akhyari⁴, S. Tugtekin⁵, M. Diab⁶, K. Matschke⁵, T. Doenst⁷, M. Borger⁸, T. Wahlers², A. Lichtenberg⁹, C. Hagl^10
1Ludwig Maximilian University of Munich, Munich, Bayern ²University Hospital of Cologne, Cologne, Nordrhein-Westfalen ³Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig,, Leipzig, Sachsen ⁴University Hospital Aachen, Aachen, Nordrhein-Westfalen ⁵University Hospital Carl Gustav Carus, Dresden Heart Center, Dresden, Sachsen ⁶Friedrich-Schiller University Jena, Jena, Thuringen ⁷University Hospital Jena, Department of Cardiothoracic Surgery, Jena, Thuringen ⁸Leipzig Heart Center, Leipzig, Sachsen ⁹University Hospital Duesseldorf, Dusseldorf, Nordrhein-Westfalen ¹⁰Ludwig Maximilian University Munich, Munich, Bayern

Purpose: The incidence of mitral valve endocarditis has increased since the guideline chance in 2009. However, the appropriate method to address the infected MV is still controversially debated among cardiac surgeons. The aim of this study was to compare the indications and outcomes of MV repair vs. replacement for infective endocarditis.

Methods: The Clinical Multicenter Project of Analysis of Infective Endocarditis in Germany (CAMPAIGN) registry (n=4917) was established by 6 high-volume university centers in 2016. All CAMPAIGN patients had underwent open heart valve surgery for IE. Retrospective data search identfied 1735 patients (35.3%) operated on the MV for IE. MV repair was performed in 154 patients (8.9%) while 1581 patients (91.1%) underwent MV replacement. Univariate analysis was used to determine potential risk factors. Survival estimation was performed with the Kaplan-Meier methods with the log-rank test. Data are presented as medians (25th-75th quartiles) or absolute values (percentages).

Results: Patients undergoing MV repair (70 yrs (63-75)) were younger than those undergoing MV replacement (68 yrs (61-74; p< 0.001)) and had a lower EuroSCORE II (9.7% (7.7-31.6) vs. 12.9% (6.2-25.7; p< 0.001)). Patients undergoing MV repair had a lower rate of multiple valve IE: (20.1% (n=31) vs. 28.9% (n=439; p=0.024). Concomitant aortic valve endocarditis was significantly higher in the replacement group (19.5% vs 27.4%; p=0.035). Patients in the MV repair group had significantly higher rates of severe mitral regurgitation: 55.6% (n=79) vs. 37.9% (n=529; p< 0.001) whereas patients in the replacement group showed significantly higher incidence of MV stenosis (0% vs. 19.9%; p< 0.001). More than one third of patients in the MV replacement group received mechanical valves (n=557; 35.2%). In addition, patients in the MV replacement group significantly more often concomitant aortic valve (p=0.030) and CABG (p=0.046) surgery. Postoperatively, ICU stay was significantly longer in the MV replacement group: (5d (2-8) vs. 5d (1-12)p < 0.001). The 30-day mortality 0 (0.0) vs 28 (1.8); p=0.103), rates of adverse cerebrovascular events or the need for dialysis were comparable. Respective survival estimation at 1 (78% vs. 65%) and 5 years (70 vs. 58%) was significantly better in the MV repair group (p=0.023).

Conclusion: MV repair may be performed in individuals with local IE of the MV with good early and mid-term postoperative results. However, in the presence of extensive IE with MV destruction, stenosis or multiple valve endocarditis, MV replacement is recommended. Mitral valve repair should be performed where possible.

Identify the source of the funding for this research project: No funding supported this project