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Letters to the Editor |
Division of Cardiothoracic and Vascular Surgery, Université Catholique de Louvain, Brussels, Belgium
Received 22 August 2007; accepted 24 August 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).
Key Words: Endocarditis • Surgery • Mitral repair
We thank Dr Acar for his thoughtful comments [1] on our recently published work focusing on mitral valve (MV) repair for active infective endocarditis (IE) [2]. Dr Acar has suggested that an early surgical approach could blind the potential eradication successes of medical treatment alone and believes that repair is easier during the healed phase of IE than during the active one. Effectively, our current approach is to operate on patients with active IE very early during the course of the disease, even after only a few days of antibiotic therapy.
Herein, we insist on the fact that if we had operated on the patient earlier compared to our historical controls, we have not broadened the classical indications for surgical treatment. According to the recently published ACC/AHA guidelines [3], the level of evidence for surgical exploration presented by our study population was class I in 43 patients, class IIA in 18 and class IIB in 2 patients, respectively.
During the study period, a total of 127 patients were treated for native MV IE in our institution. Eighty-one (64%) were operated on during the active phase (63 repairs = our study cohort [2] and 18 replacement) and 46 (36%) received medical treatment only. Comparing this with the recent study referenced by Dr Acar [4], and taking account of the fact that the later study combined aortic and mitral native IE, it seems that we do not over treat patients as the rate of surgery was lower in our experience (64% vs 71%).
Beside commonly accepted indications for urgent surgery, we applied early surgery in other indications for the following reasons:
Firstly, as a preventative tool for any new complicating events that may impair patients prognosis. We agree with Dr Acar that the majority of complications occur before diagnosis and that the risk of a new complication decreases with medical therapy. However, the study cited here above reported a persistent risk of complication even after initiation of medical therapy [4]. The authors showed that almost half of the heart failures and septic shocks, and two thirds of the cardiovascular collapses occurred during medical treatment.
Secondly, as a tool to improve the reparability rate of the valve. Indeed, since repair has proven to be superior to replacement in degenerative disease, we believe that surgeons should be at ease with the reconstructive approach in the setting of more difficult situations as well. In IE, destruction of the mitral valve is progressive but more rapid than in any other non-infectious disease. Since valve repair is highly dependant of the quantity and quality of residual tissues, early intervention is of interest for saving more tissues. In our opinion, fresh and bulky lesions are not too difficult to manage and at this early stage lesion margins are well circumscribed allowing easy resection and tissue preservation. Furthermore, annular abscesses, present in one third of the patients [2,4], are currently considered as a formal indication [3] because of their morbidity and the relative inefficacy of antibiotics to eradicate them [5]. Therefore, we found no reason to delay surgery when diagnostics of an abscess is suggested.
In conclusion, since a prospective randomised trial on medical versus surgical approach for NVE in unlikely to happen, no evidence will ever be undisputable, and clinician decision-making will rely on available literature. Our study shows that in an experienced centre early surgery seems to be safe and for this reason may be performed in selected patients presenting recommended indications. Obviously, other studies are necessary to define the place of early surgery in the wide spectrum of IE disease.
References
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