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Eur J Cardiothorac Surg 2007;31:592-599. doi:10.1016/j.ejcts.2007.01.002
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Reconstructive surgery in active mitral valve endocarditis: feasibility, safety and durability

^a Division of Cardiothoracic and Vascular Surgery, Université Catholique de Louvain, Brussels, Belgium
^b Division of Cardiology, Université Catholique de Louvain, Brussels, Belgium
^c Division of Internal Medicine, Université Catholique de Louvain, Brussels, Belgium

Received 16 September 2006; received in revised form 19 December 2006; accepted 4 January 2007.

^_* Corresponding author. Address: Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium. Tel.: +32 2 764 6111; fax: +32 2 764 8960. (Email: Laurent.DeKerchove{at}clin.ucl.ac.be; ldekerchove{at}hotmail.com).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Objective: To evaluate timing for surgery and management of complex valve lesions in patients with active mitral valve (MV) endocarditis. Results are based on 13 years of experience with MV repair in active endocarditis. Method: Between 1993 and 2005, 81 patients were operated for active MV endocarditis, of which 63 (or 78%) had MV repair. For all patients, the median time between diagnosis and surgery was 10 days. Diverse surgical techniques were applied to restore MV competence. In 59% of the patients, pericardial patches, tricuspid autograft or partial MV homografts were used as leaflet substitutes. In addition, prosthetic rings were employed in 44% of the patients. Results: The overall operative mortality was 17.5%. However, considering only patients in preoperative NYHA class I or II, the operative mortality could be reduced to 4.8%. NYHA class 3, elevated age (above 70 years) and history of valvular were the three independent risks factors for early mortality in our multivariate analysis. The average follow-up time was 60 ± 37 months. During this period, five late deaths occurred, two of which were cardiac-related. The overall 5- and 10-year survival rate was 73 ± 12% and 69 ± 13%, respectively. In hospital survivors, freedom from cardiac death after 5 and 10 years was 93 ± 8%. Three early and five late MV reoperations occurred in seven patients, of them four could have MV re-repair. Only one endocarditis recurrence occurred after 4 months in a chronic haeamodialysed patient. Freedom from MV reoperation was 89 ± 10% and 72 ± 24% at 5 and 10 years, respectively. Ten-year freedom from MV replacement and from endocarditis recurrence were 95 ± 5% and 98 ± 1%, respectively. Annular abscesses and calcified or rheumatic MV disease were two independent risk factors associated with reoperation in our multivariate analysis. During the follow-up period, all patients were in NYHA class I or II; 89% of patients had mitral regurgitation grade I, only 11% had grade II on transthoracic echocardiography. Conclusion: Using diverse and advanced techniques of MV repair, a reparability rate of 80% can be reached among patients with active endocarditis. We demonstrate that a high level of safety and excellent durability of MV repair can be obtained even for complex repairs.

Key Words: Mitral valve repair • Active endocarditis • Native valve endocarditis

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Since the early nineties, many authors have reported the excellent results of mitral valve (MV) repair [1–4] in acute and healed endocarditis. However, severity and heterogeneity of endocarditis lesions, multiple valves endocarditis and precarious haemodynamic status are all conditions that explain the relatively low rate of MV repair in this aetiology. In degenerative disease, reparability rate ranges from 80 to 90% [5], whereas in endocarditis, it ranges from 35 to 50% [2,4,6–10] with only few exceptions [1,3,11,12]. The advantages of MV repair over replacement, also reported by some authors in the setting of endocarditis [4,7,10], promote the efforts to increase the reparability rate in this challenging indication.

In patients with MV infective endocarditis, indication and timing of surgery are typically determined by the clinical presentation of the disease. It is usually recommended to delay surgery until completion of antibiotic therapy. However, recent guidelines have been defined to describe situations that mandate urgent surgery. These specific cases are (i) the presence of heart failure due to severe MV regurgitation, (ii) persistent sepsis despite adequate antibiotic therapy, (iii) the involvement of resistant or aggressive microorganisms, (iv) locally uncontrolled infection, (v) septic emboli and finally (vi) large vegetations (>10 mm) [13].

The objective of this study was to review 13 years of our experience in reconstructive surgery for active MV endocarditis.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Between 1993 and 2005, 81 patients underwent surgery for active native MV endocarditis. The following study is based on 63 of these patients (78%) that had MV repair. Endocarditis was defined as active when (i) positive cultures were obtained (by preoperative haemoculture or intraoperative culture) or when a macroscopically infected valve was detected and (ii) for patients operated within 6 weeks after diagnosis during the antibiotic therapy [14–17].

All patients diagnosed with endocarditis were preoperatively assessed with transthoracic (TTE) and transoesophagial echocardiography (TEE). If necessary, repeated TEE were performed in order to follow the lesions and to support a decision for surgery.

In presence of preoperative neurologic complication, indication for surgery was discussed by a multidisciplinary team of neurologist, intensivist, cardiologist and cardiac surgeon. Patients’ age, type and severity of neurologic deficit and long-term functional prognosis were the principal factors guiding the therapeutic attitude. Early surgery was advised in patients with small non-haemorragic lesion and few neurologic deficit. In case of intracranial bleeding or massive stroke, surgery was delayed to avoid anticoagulation drugs during a 10–15 days period and to allow appropriate follow-up of the neurologic status. Patients in coma with poor prognosis of recovery were excluded for surgery.

2.1 Timing of surgery
During the study period, we progressively performed surgery earlier during the course of endocarditis (Fig. 1 ). This approach is believed to avoid further destruction of the valve as previously suggested by Dreyfus et al. [1]. In our current protocol, under appropriate indication, surgery was promptly performed; this implies that in some situations preoperative antibiotics were administered for only a few days prior to surgery. Following this approach, the mean and median times between the first and the last third of the study period were decreased from 18 ± 10 to 10 ± 9 days and from 17 to 6 days, respectively (Fig. 1). Twenty-six patients (41% of the patient population) were operated on during the first week of antibiotic therapy, 12 patients (20%) during the second week, 9 patients (14%) during the third week and 16 patients (25%) within the fourth to the sixth week. For all patients, antibiotic therapy started at diagnosis was completed after surgery, with a total duration of 6–8 weeks as recommended by current guidelines [13].

View larger version (20K): [in this window] [in a new window]   Fig. 1. Mean and median length of preoperative antibiotic therapy (y-axis) according to the study periods (x-axis).

The most common microorganisms responsible for endocarditis were Streptococcus (for 29 patients, 46%) and Staphylococcus (for 20 patients, 32%) species. No microorganism could be identified in five patients (Table 2 ).

After careful examination of the valve and the complete resection of infected tissues, the feasibility of MV repair was evaluated. Extensive destruction of a single leaflet or the presence of abscess did not contraindicate MV repair. However, the extensive destruction of both leaflets or poor quality of the remaining tissues (through calcification, retraction or thickening) did usually prompt MV replacement.

A list of the techniques used to repair the MV is provided in Table 4 . In half of the patients, several techniques had to be applied to achieve MV continence. Biological patches were used as a substitute for the leaflet defect in 37 patients (59%). Glutaraldehyde-treated autologous pericardium or bovine pericardium, due to increased availability, were the most used patches (22 patients). The tricuspid valve autograft, preferred for commisural reconstruction, was used in six patients. Posterior leaflet transposition, commonly known as the flip-over technique, was performed in five patients with destruction of the anterior leaflet free edge. A posterior MV homograft was only used once. Finally, in 11 patients with destruction of the basis of anterior leaflet by mitro-aortic abscess, mitro-aortic continuities were repaired with bovine pericardium (in eight patients) or anterior mitral leaflet from aortic homograft (in three patients).

Associated procedures were performed in 24 patients (38%) and were mostly related to concomitant aortic valve endocarditis (seven homografts, four AV repair, four Ross, four bioprosthesis and one Bentall). Nine patients, for whom infection had spread deeply through perivalvular tissues, bovine pericardium was used to reconstruct the cardiac cavities and fibrous skeleton of the heart. Eight patients had TV repair and four had CABG. The mean aortic cross-clamp and cardio-pulmonary bypass times were 130 ± 42 and 100 ± 34 min, respectively.

2.5 Follow-up data
Mean follow-up period was 59 ± 37 months (ranging between 9 and 156 months). Survival status was obtained by telephone contact with the patients, their relatives or the referring physician, and from review of visit or hospital records. Cause of death was categorized between cardiac or non-cardiac. Cardiac death was defined as related to congestive heart failure, myocardial infarction, cardiac arrest or sudden death.

2.6 Statistical analysis
Data are reported as mean ± standard deviation. Survival curves were computed with the Kaplan–Meier method (Prism 2.0, GraphPad Software Inc., CA, USA). A log-rank test was used to compare curves. Twenty-four variables, listed in the Appendix A, were tested in uni- and multivariate analysis for calculating endpoints, operative mortality and MV reoperation. In bivariate analyses, the association of continuous independent variables with each outcome variable was tested with Student's t-test for independent samples. The association of binary independent variables with outcome variables was tested with Cochran–Mantel–Haenszel statistics. Multiple logistic regression modelling was then performed. Statistical as well as clinical criteria were used in the model: first, variables significant at the p < 0.1 were entered and second, clinically meaningful variables were added. A stepwise strategy was used. Results were considered statistically significant at the p 0.05 level. All p-values are two-tailed. The SAS software (release 9.1) was used in the statistical analysis (SAS Institute Inc., Cary, NC, USA).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
3.1 Early postoperative outcomes
Immediate postoperative transoesophagial echocardiography indicated no residual MR in 48 patients (76.2%) and MR grade 1 in 13 patients (21.6%). In only two patients (3.2%), a residual MR of grade 2 was accepted because of advanced age. No MV stenosis was observed at this time.

Eleven patients (17.4%) died either during their hospital stay or within 30 days from their operation. The causes of death were congestive heart failure (2), sepsis (2), multiple organ failure (2), perioperative stroke (2), sudden death (2) and respiratory failure (1). In univariate analysis, criteria such as female gender (p = 0.008), older than 70 years (p = 0.0015), history of valve disease (p = 0.07), diabetes mellitus (p = 0.008), renal dysfunction (plasma creatinine >2 mg/dl, p = 0.005) and severe symptomatic heart failure (NYHA class III and cardiogenic shock, p = 0.0001) were predictive for early death. In multivariate analysis, only criteria such as severe symptomatic heart failure (NYHA class III and cardiogenic shock) (p = 0.009), older than 70 years (p = 0.02), history of valve disease (p = 0.045) and female gender (p = 0.049) were independent risk factors. Considering severity of congestive heart failure, operative mortality was 4.8% (2 out of 42 patients) in patients with preoperative NYHA class I or II, 30% (4 out of 12 patients) in class III and IV and 55% (5 out of 9 patients) in patients with congestive heart failure.

Twenty patients (31.7%) had postoperative complications. Three patients (4.7%) needed an early MV reoperation during the first postoperative week. The cause of failure of the repair was identified as suture dehiscence in three of them. One had dehiscence of a posterior quadrangular resection, another of a pericardial patch and the last one of a papillary muscle of a tricuspid autograft. The last two patients died, one from mediastinitis that was present at reoperation and the second from multiple organ failure. Other significant complications included reoperation for bleeding or tamponnade (seven cases), prolonged artificial ventilation (four cases), permanent pacemaker implantation (two cases), mediastinitis (one case), myocardial infaction (one case) and stroke (one case).

3.2 Long-term outcomes
Five patients died during follow-up: two from sudden cardiac death and three from cancer. At 5 and 10 years, overall survival was 73 ± 12% and 69 ± 13%, respectively, and freedom from cardiac death in hospital survivors showed to be 93 ± 8%. (Fig. 2a and b).

View larger version (16K): [in this window] [in a new window]   Fig. 2. (a) Kaplan–Meier overall actuarial survival; (b) Kaplan–Meier actuarial survival showing freedom from late cardiac death in hospital survivors; (c) Kaplan–Meier curve for freedom from MV reoperation in the all population and in the subgroups of patients having MV repair with or without patch; (d) Kaplan–Meier curve for cardiac-related event-free survival.

One patient required aortic valve replacement and coronary artery bypass graft surgery after 3 months. All patients with late reoperations had an uneventful postoperative course. At 5 and 10 years, freedom from MV reoperation was 89 ± 10% and 72 ± 24%, respectively (Fig. 2c). At 10 years, freedom from MV replacement and endocarditis recurrence were 95 ± 5% and 98 ± 1%, respectively. In univariate analysis, renal failure (need for haemodialysis, p = 0.03), calcified or rheumatic MV disease (p = 0.012) and MV annular abscess (p = 0.003) were significantly associated with MV reoperation. Only calcified or rheumatic MV disease (p = 0.02) and MV annular abscess (p = 0.01) were identified as independent risk factors in multivariate analyses. The patients having MV repairs using patches had a slightly higher (8% vs 13%), but not significant (p = 0.7), reoperation rate compared to the patients having repair without a patch.

During follow-up, one thromboembolic event (TIA) and one anticoagulation related bleeding occurred. Cardiac event-free survival – defined as survival without endocarditis recurrence, cardiac related death, cardiac reoperations, bleeding or thromboembolic events – was 81 ± 13% and 66 ± 23% at 5 and 10 years, respectively (Fig. 2d).

At follow-up, among the 47 patients, 33 (74%) were in NYHA class I and 14 (26%) were in class II. Among the 46 patients free from MV replacement, transthoracic echocardiograpy showed no or residual MR grade 1 in 41 patients (89%) and residual MR grade 2 in the remaining 5 patients (11%). One patient, who died from cancer, had a pericardial patch perforation (at basis of anterior leaflet) with moderate regurgitation.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
In a multicentric study conducted in North America, Gammie et al. [14] recently reported a 20% and 48% feasibility rate of MV repair in active and healed endocarditis, respectively, with a progressive increase of both rates during the last decade. However, we showed that using a wide armamentarium of repair techniques, including a liberal use of biological patches (in 50% of the patients), we could realistically achieve a 78% feasibility rate. Similar rates have been reported by other groups implementing the same or slightly different techniques for repair [1,3,11,12]. Depending on the size and location of the lesions, we relied on a large variety of patch materials, such as autologous or bovine pericardium, tricuspid autographs, transposed posterior leaflets, and mitral homografts, as leaflet substitutes. The reliability of each of these techniques has been previously demonstrated [18–21]. In our experience, the use of a patch to restore leaflet defect was not predictive for MV reoperation, and only the presence of paravalvular abscesses and calcified or rheumatic MV disease was considered significant risk factors for MV reoperation.

In 1990, Dreyfus et al. [1], who were the first to demonstrate the feasibility of MV repair in active endocarditis, introduced the concept of early surgery to prevent further destruction of the valve. We firmly believe in that concept and we observe that, during the early course of the disease, margins of infectious lesions are clearer than later on. This situation facilitates the resection of the diseased area, preserving healthy tissues in order to increase the possibilities of valve repair. In this series, in which 40% of the patients were operated within the first week after diagnosis, the short preoperative antibiotic therapy (<1 week vs >1 week) was shown to have no significant impact on either operative mortality (p = 0.8), endocarditis recurrence (p = 1) or MV reoperations (p = 0.1), as has been previously observed by Jault et al. [17] and Balasubramanian et al. [22]. However, at the current stage of our research, we are unable to evaluate any specific decrease in the rate of occurrence of postoperative complications which could be related to early surgery.

The 17.4% operative mortality rate reported in this study can be considered as high when compared to the average rate of 10% recently reported in a multicentric study by Gammie et al. [14]. However, our reported mortality rate remains within the common range of 3–21% published in other unicentric studies [1–4,6–12]. The degree of preoperative heart failure has been shown to be an important factor influencing operative mortality for degenerative MV disease. The low operative mortality rate of 4.8% in the subgroup of NYHA class I or II patients is indicative of the advantage to operate on patients with severe regurgitation before they develop severe symptomatic heart failure.

When compared to studies which primarily include remplacement in native MV endocarditis, our overall survival rates (of 73% at 5 years and 69% at 10 years) and survival rates in hospital survivors (of 88% at 5 years and 84% at 10 years) are comparable to those reported by Alexiou [23] (79% and 61%) and Aranki [15] (87% and 74%), respectively. However, the low incidence of late cardiac death in our series (93% freedom from cardiac deaths at 10 years) can support the benefits of MV repair that appear during the long-term follow-up. Excellent late survival rates after MV repair for active or healed endocarditis have also been reported by Lung [12] (93% at 7 years) and Zedgi [24] (80% at 10 years). Such results reflect the advantages of the preservation of the left ventricular function associated with MV repair.

We reported in our series 89% 5-year freedom from reoperation. In literature, such rate varies between 84% and 100% for MV repair [1,2,7,10,12] and between 76% and 94% for replacement [15,16,23]. At 10 years, this rate is reduced to 72%, which is lower [23] or equivalent [16,25] to the rates reported in patients with mechanical valve replacements in endocarditis. However, our 10-year freedom from reoperation remains higher than the reoperation rate obtained in patients with biological valve replacement [15,25]. Zedgi [24] also confirmed the excellent long term durability rate (91% at 10 years) of MV repair in acute endocarditis, which supports our results.

Our low rates of re-infection and thrombo-embolic events demonstrate the resistance and safety of MV repair. Prosthetic ring annuloplasty was never associated with high re-infection rates (even in active endocarditis); therefore, we advise its use when the annulus is dilated and to stabilize complex repairs. In addition, a pericardial band may be used as an alternative in the situation of severe contamination of the operative field by pus. Finally, our findings support the use of artificial chordae in PTFE Goretex as a safe technique that does not increase the risk of infection recurrence.

4.1 Study limitations
Our study does not include details of patients having MV replacement in order to focus on the techniques and results of MV repair in acute endocarditis. Moreover, the number of patients having replacements was small when compared to the number of those receiving MV repair (18 vs 63 patients), and these patients were significantly older with higher severity of illness compared to those having MV repair. Those differences could explain the advantage of MV repairs when compared to MV replacements: (i) 17.4% versus 44% operative mortality and (ii) 73 ± 12% versus 38 ± 23% 5-year overall survival. We are aware that the lack of comparable groups limits the conclusions of our data. However, our reconstructive approach has enabled us to show the results of complex MV repair in situations of severe endocarditis lesions.

Further studies incorporating a larger number of patients and extended follow-up period are necessary to assess the advantage of MV repair over replacement. With additional studies, we could more accurately define the best timing as well as the technical limits of MV repair in this challenging aetiology. The widespread use of reconstructive mitral surgery should provide in the future materials for large multicentric studies.

	5. Conclusions

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Diverse repair techniques are needed to overcome the heterogeneities of endocarditis lesions. We demonstrated that combining early surgery and diversity in repair techniques resulted in a reparability rate of 80%. Even in situations of complex repairs, excellent long-term outcomes of MV repair were observed. However, we also demonstrated that the risk of reoperation remains higher in patients with calcified or rheumatic disease. We suggest that patients with active endocarditis and severe MV regurgitation could benefit from early surgery to avoid development of symptomatic heart failure. Finally, we found that the completion of short preoperative antibiotics therapy after surgery does not affect the postoperative survival or endocarditis recurrence rates.

	Appendix A

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
Conference discussion

Dr H. Siniawski (Berlin, Germany): I have two questions.

First of all you reported that 33% of patients received double valve surgery, if I understood, concomitant mitral valve surgery was required to aortic replacement in these 33% of patients. My question is, was it secondary infected mitral valve disease to primary aortic endocarditis or whether there were the cases of parallel infected double valves?

The second question deals with indication for surgery in your institution. What is your policy, especially according to mitral regurgitation? Do you operate with a grade 1, 2 or 3? And is an assessment of regurgitation important in the cases when two valves are involved in a destructive form of endocarditis?

Dr de Kerchove: To answer your first question: yes, some reoperated patients already had aortic valve endocarditis before but no mitral valve endocarditis. So for all patients that was the first episode of mitral valve endocarditis.

And to your second question: yes, for sure the mitral regurgitation is very important for us. In patients who present indication of surgery like a septic emboli or an abscess or refractory sepsis, even if the patient has mitral regurgitation grade 1 or 2, we indicate surgery to resect the vegetation which provoked the embolism, or to resect the abscess, and in the case of refractory sepsis to take out infected tissues. But in patients who do not present those symptoms and without any other symptoms, we indicate surgery in presence of a mitral regurgitation grade 3.

Dr C. Mestres (Barcelona, Spain): I have a couple of questions. Number one, you have not shown data on cultures of the valves. I presume that you did culture of the tissue that you removed from the mitral valve, correct?

Dr de Kerchove: Yes.

Dr Mestres: So the question is, do you think that if cultures were positive, should this be related to the very early problems that you had in some valves, number one? And number two, in these cases that you reoperated on because of late endocarditis, was this endocarditis a relapse or a recurrence?

Dr de Kerchove: To answer to your first question, I would say that, surprisingly, even when we operate early, we observe that the valve tissue is very quickly sterilized. So we have very few positive intraoperative cultures. Majority of the positive cultures were coming from preoperative blood cultures. So even after few days of antibiotics therapy we saw that the valve was almost sterilized and the germ didn’t grow on the culture.

To your second question, all patients who had endocarditis on the aortic valve were completely cured from their endocarditis, because it was a long delay between the two operations, and I would say all the mechanical biological valves were newly infected.

Dr Mestres: Thank you, because at least in our experience, the culture positive rate of explanted second inserted valves continues to be quite high, especially in the first 2 weeks of antibiotic therapy.

Dr N. Shikhverdiev (St. Peterburg, Russian Federation): Did you have any neurological complications before the operation? If yes, what was the surgical strategy? Did you have embolic complications into the brain before the operation?

Dr de Kerchove: Yes, for sure.

Dr Shikhverdiev: You operated on 22 patients with embolic complications. I am interested – did you have embolic complications into the brain and what was the surgical strategy?

Dr de Kerchove: Of course, we had embolic stroke preoperatively, and I didn’t give the number but it was about 10 patients, and when a patient has a stroke preoperatively, the guidelines recommend that if the stroke is very recent and is hemorrhagic, you can operate. So we can go very fast. It is between 48 or 72 h after the stroke. And if the clinical situation allowed it, that is obvious. If somebody is in a coma and we are not sure about the neurological outcome of the patient, we wait. But if it is a limited stroke, we can go before hemorrhagic complications of the stroke.

Dr N. Alotti (Zalaegerszeg, Hungary): My main question is, what is your strategy in timing the operation? We have noticed in one of your data that about a quarter of your patients were operated late. Second question. What is your strategy after the operation with anticoagulant therapy?

Dr. de Kerchove: As you have seen with this approach, when indication is present, we don’t wait too much and we operate quite early. Doing so, 80% of the patients with active mitral valve endocarditis are operated during the course of the first hospitalization.

And for the second question about anticoagulant therapy, for a patient with prosthetic mitral ring annuloplasty, all patients have two months of anticoagulation, with marcoumar, and for the patient who doesn’t have a prosthetic ring, we give nothing.

Dr O. Alfieri (Milan Italy): This paper is introducing a very important change in the strategy of the treatment of endocarditis. If I understood well, even in patients who respond well to antibiotic therapy since the very beginning, you go ahead, and operate. This is an innovative concept that you introduce, but this is not acceptable, according to the guidelines.

Dr de Kerchove: In a patient who is responding to antibiotics but with severe mitral regurgitation and no other complications, the guidelines recommend to complete antibiotics therapy and to wait until the patient develops symptoms of heart failure or left ventrical dilatation. We think that it could be maybe better to operate before the patient becomes symptomatic because operative mortality is, in the present study, tightly correlated to the grade the preoperative NYHA functional class. So, the ’good responders’ with mitral regurgitation grade >2 will be operated during the same hospitalization.

Dr T. Folliguet (Paris, France): I have a technical question. When you have free edge defect on the anterior valve, I think it is very difficult to fix, and you mentioned three techniques, pericardial patch, flip-over and tricuspid transplantation. We found that sometimes when you do a pericardial patch, we have non good coaptation of the free edge, and I have seen you reoperate on three of the different techniques. But in your experience, what would be the best technique to correct someone with a large defect on the free edge, which in our hands is one of the most difficult problems we have?

Dr de Kerchove: To answer to your interesting question, I would prefer to give the words to Professor El Khoury, who is the principal investigator and surgeon in this study.

Dr M. Mahgoub (Zagazig, Egypt): Will you use any local disinfectant like glutaraldehyde or something if there is an abscess or a localized infection in the valve? And the second question is, the pericardium that you use, do you use fresh pericardium or fixed pericardium?

Dr de Kerchove: We usually use diluted Betadine to disinfect the operative field. We also impregnate prosthetic rings with ryfamicine solution before we implant it.

And about the pericardial patches, autologous pericardial patches are mostly treated.

Dr El Khoury (Bruxelles, Belgium): One answer to Dr Alfieri first about our studies in patients who had severe mitral regurgitation and do we have to go for surgery or not? We are now more and more taking the same approach as in degenerative disease. In agreement with our cardiologist, if the severity of the mitral regurgitation has to be surgically treated, we go for surgery, we don’t wait. I mean, we are not changing the indications, but when the indication is there for hemodynamics or for something else, we go for surgery. I repeat, we don’t change the indications; only the timing of surgery is shorter.

Now, concerning the second question about if you have a large destruction of the free margin, I think the best way to do it, I mean if it is only out on the free margin, not on the tissue, one is the flip-over technique, which is really very, very consistent and very durable, and the other technique is the implantation of Gore-Tex. Don’t be afraid to use it in case of endocarditis because you already remove largely the infected tissues and the antibiotics continued during postoperative period will take care of what we leave as microbes behind us.

Dr J. Pomar (Barcelona, Spain): One question is, and a short answer, how do you repair the tricuspid when you remove the posterior leaflet? Do you just make a bicuspid valve or you repair it and have another extension patch there or do you do something else?

Dr de Kerchove: It can be repaired using plication. Professor El Khoury what would you answer to this question?

Dr Pomar: Did you hear the question, Gebrine? How do you repair the tricuspid when you remove the posterior leaflet to be used as a graft on the other side?

Dr El Khoury: We have two situations. When we have enough tissue on the tricuspid valve left, I like to do a sliding plasty, slide the anterior towards the septal. Now, if we don’t have enough tissue, I put a small piece of pericardial patch with Gore-Tex suspension of the free margin.

Dr Pomar: My short comment was the last conclusion. Officially you should not say that unless you have a control group. You cannot say you do not impair that.

	Appendix B

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 
(List of variables tested in uni- and multivariate analysis)

Age >70 years, gender, history of valve disease, previous heart surgery, multiple valves endocarditis, diabetes mellitus, impaired renal function (plasma creatinine >2 mg/dl), the need for haemodialysis, septic emboli, severe congestive heart failure (NYHA 3 including cardiogenic shock), persistent sepsis, MR grade 3, Staphycoccus aureus endocarditis, <1 week of preoperative antibiotics therapy, rheumatic or calcified underlying MV disease, repair of anterior MV leaflet, presence of MV abscess, MV repair using patch, deep infection spreading, absence of annuloplasty, associated procedure, Aortic cross clamp time>120, postoperative residual MR grade 2, early MV reoperation.

	Footnotes

 
^\#9734; Presented at the joint 20th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 14th Annual Meeting of the European Society of Thoracic Surgeons, Stockholm, Sweden, September 10–13, 2006.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion 5. Conclusions Appendix A Appendix B References

 

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