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Letters to the Editor |
Chirurgie Cardiovasculaire Institut de Cardiologie, Hôpital de la Salpétrière, 50-52 Bd Vincent, Auriol 75013 Paris, France
Received 26 June 2007; accepted 24 August 2007.
* Corresponding author. Tel.: +33 142 16 56 85; fax: +33 42 16 56 78.
Key Words: Endocarditis • Mitral repair • Mitral replacement
The recent article published by de Kerchove et al. [1] beautifully depicted the possibilities of early mitral repair in acute infective endocarditis. Several years ago [2], our group also recommended broadening the indications and to operate sooner in the course of mitral endocarditis.
Two epidemiologic studies [3] conducted in France at a time lapse of 8 years (in 1991 and 1999, respectively) on a large scale (over 400 cases, 80% of them being left-sided endocarditis) have attempted to assess the changes in clinical practice. A major finding was a reduction in mortality of endocarditis (from 22% to 17%, p = 0.08) together with an increasing number of referrals to surgery (from 31% to 50%, p < 0.005), additional evidence that extending the indications for surgery had been beneficial for many patients.
In this study [3], surgery was performed after a mean period of 28 days. In our own experience the mean duration of antibiotics before surgery nowadays is 20 days in mitral valve endocarditis [4]. de Kerchove et al. [1] pushed the controversy of the optimal timing of surgery one step further as the operation was carried out after durations of antibiotic therapy decreasing from 17 days to only 6 days throughout the study period.
Their arguments for shortening the preoperative antibiotic period were that: (1) the mitral repair feasibility was higher when the patient was operated sooner and (2) early mitral repair would prevent any impairment of the left ventricular function. We believe that emergency or very early surgery should be commanded by the clinical situation such as cardiogenic shock or emboli with very large (>15 mm) and threatening vegetations rather than by the concern of achieving a mitral repair.
Indeed in our view, the chances of repair are not better when facing fresh bulky vegetations and abscesses which often require large tissue resection and complex reconstruction techniques. It is usually easier to deal with healed vegetations, isolated chordal rupture or perforated leaflet with sharp clean edges. In addition, the deterioration of left ventricular function is a slowly evolving process and the haemodynamic condition most frequently allows some delay. Is there any advantage in waiting? The answer is ‘yes’ for two good reasons: (1) as mentioned above in case of a severe mitral insufficiency, a repair can be attempted in the best possible anatomical conditions after a few weeks of antibiotics and (2) because an operation can sometimes be completely avoided and it would be unfair to subject the patient to an unnecessary open heart procedure.
Many isolated vegetations of reasonable size (<15 mm) with no or mild mitral insufficiency will never require surgery. It is well known that most emboli reveal the endocarditis and that the embolic risk rapidly drops within the first week of antibiotics. In recent series [5], the group undergoing medical treatment alone even had a lower mortality rate than the surgical group provided that the patients with a contraindication to surgery (major stroke, advanced age, comorbid disease) were excluded. Certainly, this group included mainly uncomplicated cases, but we fear that an excessive shortening of the time lapse between the diagnosis and a surgical decision may compromise the chances of success of a medical treatment alone.
References
This article has been cited by other articles:
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  L. de Kerchove, A. Poncelet, and G. El Khoury Reply to Acar Early surgery in active valve endocarditis. Eur. J. Cardiothorac. Surg., December 1, 2007; 32(6): 948 - 948. [Full Text] [PDF]
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