Jean-Paul Remadi

Prosthetic valve endocarditis: who needs surgery? A multicentre study of 104 cases

Objectives: To identify the prognostic markers of a bad outcome in a large population of 104 patients with prosthetic valve endocarditis (PVE), and to study the influence of medical versus surgical strategy on outcome in PVE and thus to identify patients for whom surgery may be beneficial. Design: Multicentre study. Methods and results: Among 104 patients, 22 (21%) died in hospital. Factors associated with in-hospital death were severe co-morbidity (6% of survivors v 41% of those who died, p  =  0.05), renal failure (28% v 45%, p  =  0.05), moderate to severe regurgitation (22% v 54%, p  =  0.006), staphylococcal infection (16% v 54%, p  =  0.001), severe heart failure (22% v 64%, p  =  0.001), and occurrence of any complication (60% v 90%, p  =  0.05). By multivariate analysis, severe heart failure (odds ratio 5.5) and Staphylococcus aureus infection (odds ratio 6.1) were the only independent predictors of in-hospital death. Among 82 in-hospital survivors, 21 (26%) died during a 32 month follow up. A Cox proportional hazards model identified early PVE, co-morbidity, severe heart failure, staphylococcus infection, and new prosthetic dehiscence as independent predictors of long term mortality. Mortality was not significantly different between surgical and non-surgical patients (17% v 25%, respectively, not significant). However, both in-hospital and long term mortality were reduced by a surgical approach in high risk subgroups of patients with staphylococcal PVE and complicated PVE. Conclusions: Firstly, PVE not only carries a high in-hospital mortality risk but also is associated with high long term mortality and needs close follow up after the initial episode. Secondly, congestive heart failure, early PVE, staphylococcal infection, and complicated PVE are associated with a bad outcome. Thirdly, subgroups of patients could be identified for whom surgery is associated with a better outcome: patients with staphylococcal and complicated PVE. Early surgery is strongly recommended for these patients.

Comparison of clinical and morphological characteristics of Staphylococcus aureus endocarditis with endocarditis caused by other pathogens

Objectives: To analyse clinical, echocardiographic, and prognostic characteristics of Staphylococcus aureus infective endocarditis (IE) compared with endocarditis caused by other pathogens. Design: Cohort study. Methods: 194 consecutive patients with definite IE according to the Duke criteria prospectively examined by transthoracic and transoesophageal echocardiography were enrolled. Patients without identified microorganisms were excluded. The S aureus IE group (n  =  61) was compared with the group with IE caused by other pathogens (n  =  133). Results: Compared with IE caused by other pathogens, S aureus IE was characterised by severe co-morbidity, a shorter duration of symptoms before diagnosis, and a higher prevalence of right sided IE, cutaneous portal of entry, and history of renal failure. Severe sepsis, major neurological events, and multiple organ failure were more frequent during the acute phase in S aureus IE. In-hospital mortality (34% v 10%, p < 0.001) was higher in patients with S aureus IE and the 36 month actuarial survival rate was lower in S aureus IE than in IE caused by other pathogens (47% v 68%, p  =  0.002). Multivariate analyses identified S aureus infection as a predictive factor for in-hospital mortality and for overall mortality. Conclusions:S aureus IE compared with IE caused by other pathogens occurs in a more debilitated clinical setting and is characterised by a higher prevalence of severe sepsis, major neurological events, and multiple organ failure leading to higher mortality.

Heart failure in left-sided native valve infective endocarditis: characteristics, prognosis, and results of surgical treatment

Although congestive heart failure (CHF) represents the most common cause of death in native valve infective endocarditis (IE), recent data on the outcome of IE complicated by CHF are lacking. We aimed to analyse the characteristics and prognosis of patients with left‐sided native valve IE complicated by CHF and to evaluate the impact of early surgery on 1 year outcome.

Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction.

AIMS Left ventricular (LV) dysfunction is the first cause of late mortality after mitral valve surgery. In this retrospective analysis, we studied the association between preoperative echocardiographic LV measures and occurrence of LV dysfunction after mitral valve repair (MVR). METHODS AND RESULTS Between 1991 and 2009, 335 consecutive patients underwent MVR for severe mitral regurgitation due to leaflet prolapse in our institution. Echocardiography was performed preoperatively and at 10.8 (9.1-12.0) months after surgery in 303 patients who represented the study population. Cardiac events were recorded during follow-up. LV ejection fraction (EF) decreased from 68 ± 9% before surgery to 59 ± 9% post-operatively (P < 0.001). Preoperative EF <64% and LV end-systolic diameter (ESD) ≥ 37 mm were the best cut-off values for the prediction of post-operative LV dysfunction (EF < 50%). On the basis of a combined analysis, the occurrence of post-operative LV dysfunction was 9% when EF was ≥ 64% and LVESD < 37 mm, 21% with EF < 64% or LVESD ≥ 37 mm, and 33% with EF < 64% and LVESD ≥ 37 mm (P for trend < 0.001). The combined variable EF < 64% and LVESD ≥ 37 mm added incremental prognostic value to the multivariable regression model (P = 0.001). CONCLUSION Simple preoperative echocardiography measures allow the prediction of LV dysfunction after MVR in patients with leaflet prolapse. Patients with preoperative EF ≥ 64% and LVESD < 37 mm incur relatively low risk of post-operative LV dysfunction.

Early hemodynamics results of aortic valve replacement with the new St Jude Trifecta bioprosthesis

Aortic stenosis is the most frequent acquired heart valve lesion in the Western countries. The aim of this prospective study was to evaluate the early clinical results and hemodynamic performance of the new St Jude Medical Trifecta stented bioprosthesis. One hundred consecutive patients were prospectively included in this study from April 2011 to December 2012. They underwent aortic valve replacement (AVR) with the St Jude Bioprosthesis Trifecta in our institution. The Trifecta valve is a tri-leaflet stented pericardial valve designed for supra-annular placement in the aortic position. A single cardiac surgeon operated on all the patients. Echocardiograms were performed pre-operatively and post-operatively, between 7 and 10 days to assess the hemodynamic performance of the prosthesis. The effective orifice area (EOA) of the aortic valve was calculated by the continuity equation and the mean transvalvular gradient at rest was derived from the simplified Bernoulli equation accounting for the flow velocity across the left ventricular outflow tract. A follow-up was performed at one year (100% complete). An informed consent form was signed by the patients before the intervention to allow data processing. Mean age at implantationwas 75.2 ± 7.5 ans (from 34.2 to 83.6 ans, median 71.7 ans). The sex ratio was 1.32 (Table 1). Fifty-five (55%) patients were octogenarians. The main AVR indication was aortic stenosis (n = 79). Preoperative New York Heart Association (NYHA) functional class was: I for 2 patients, II for 61 pts, III for 34 pts, and IV for 3 patients (Table 1). The preoperative cardiac rhythm was sinus for 94 patients, atrial fibrillation for 5 patients and one patient had a pacemaker. This study included 1 redo procedure. Ten patients (10%) had a poor left ventricular ejection fraction (LVEF b 35%). All prostheses were implanted in supra annular position using a continuous suture of polypropylene 2/0. The operation was elective in 98 patients and urgent in 2 patients. Forty one patients underwent a concomitant procedure, including 36 coronary artery bypass grafting (CABG) with an average of 1.16 grafts performed and the left internal thoracic artery was used for all patients. The prosthesis diameters were mainly 21 and 23 mm (Fig. 1). Operation times were for isolated AVR: 31 ± 20.2 mn for aortic cross-clamp and 45.5 ± 20.7 mn for cardiopulmonary bypass (Table 2). A de novo atrioventricular (AV) block occurred in 8 patients with only one pacemaker implantation. Acute atrial fibrillation was the most frequent post-operative complication (42%). Operativemortality (b30 days after the surgery ormore if the patient was not discharged) was 2%. One patient died after a redo procedure due to endocarditis and one because of respiratory failure. Therewere no valve related post-operative complications. Baseline mean pre-operative and post-operative LVEF were 60 ± 15% and 58± 18% respectively (ns). Themean transvalvular gradient improves significantly from 52.8 ± 15.4 mmHg pre-operatively to 10.4 ± 3.5 mmHg postoperatively (p= 0.001) (Table 3). The mean gradient was low for all bioprosthesis sizes (Fig. 2). The indexed effective orifice area (EOA) was for all diameters greater than 0.65 cm/m (Fig. 3). Only 3 trivial paravalvular leaks were observed. A trans-thoracic echocardiography was performed for fifty patients between 4 and 6 months and showed that mean gradients were stable (10.2 ± 2.5 mmHg). At one year, one non valve related death occurred. During this short follow-up, therewere novalve related complications.Ninetyninepercentof thepatientswere in NYHA class I (70%) or class II (29%). In Western countries, AVR has increased because of the increasing rate of octogenarians operated on. During this period the bioprosthesis has become the prosthesis most commonly used with almost 70% of the implantation rate compared to mechanical prostheses. This evolution could be explained by the aging population and the good bioprostheses durability [1,2]. Hemodynamic performance and long term durability are both crucial to get an ideal bioprosthesis. The Carpentier Edwards valve is the oldest bioprosthesis, implanted since 1969, and remains the “gold standard bioprosthesis” because of the extended durability studied in literature for more than 20 years [1–3]. Freedom from structural deterioration at 18 years for the porcine Carpentier–Edwards valve was 86.4% ± 1.2% and respectively 98.2% ± 0.6% for patients aged between 61 et 70 years and 90.5% ± 1.8% for patients older than

Long-term prognosis of left-sided native-valve Staphylococcus aureus endocarditis.

BACKGROUND Staphylococcus aureus infective endocarditis (SAIE) is a serious and common disease. AIMS To assess the clinical and echocardiographic characteristics and prognostic factors of left-sided native-valve SAIE, and to compare these characteristics between two periods (1990-2000 vs. 2001-2010). METHODS This was a retrospective analysis of 162 cases of left-sided native-valve SAIE among 1254 patients hospitalized for infective endocarditis (IE) between 1990 and 2010. RESULTS SAIE represented 18.1% of all cases of IE and 22.9% of cases of native-valve IE. Complications included heart failure in 44.7% of cases, acute renal failure in 23.3%, sepsis in 28.5%, neurological events in 35.8%, systemic embolic events in 54.9% and in-hospital mortality in 25.3%. Factors associated with in-hospital mortality were heart failure (odds ratio [OR] 2.5; P=0.04) and sepsis (OR 5.3; P=0.001). Long-term 5-year survival was 49.6±4.9%. Factors associated with long-term mortality were heart failure (OR 1.7; P=0.032), sepsis (OR 3; P=0.0001) and delayed surgery (OR 0.43; P=0.003). Comparison of the two periods revealed a significant increase in bivalvular involvement, valvular incompetence and acute renal failure from 2001 to 2010. No significant difference was observed in terms of in-hospital mortality rates (28.1% vs. 23.5%; P=0.58) and long-term 5-year survival (45.0±6.6% vs. 57.1±6.4%; P=0.33). CONCLUSION Mortality as a result of left-sided native-valve SAIE remains high. Factors associated with in-hospital mortality are heart failure and sepsis. Factors associated with long-term mortality are heart failure, sepsis and delayed surgery. Despite progress in surgical techniques, in-hospital mortality and long-term mortality have not decreased significantly between the two periods.

0031 : Left-sided native valve staphylococcus aureus infective endocarditis – evolution of prognosis

Introduction Staphylococcus Aureus infective endocarditis (SAIE) remains a serious disease. Our objective is to study the epidemiological, clinical and echographic characteristics and prognostic factors of left-sided native valve SAIE, and compare these characterisctics between 2 periods (1990-2000 vs 2001-2010). Methods It is a retrospective analysis of 162 left-sided native valve SAIE in 1254 patients hospitalized for infective endocarditis (IE) at University Hospitals in Amiens and Marseille between 1990 and 2010. Results SAIE represents 18% of IE and 22.8% of native valve IE. Complications include heart failure in 44.7% of the cases, acute renal failure in 23.3%, sepsis in 28.5%, neurological events in 35.8%, systemic embolic event in 54.9% and hospital mortality in 25.3%. Factors associated with hospital mortality are comorbidity index (OR=1.2, p=0.04), heart failure (OR=2.5, p=0.04) and sepsis (OR=5.3, p=0.001). Overall mortality is 45.4%±7.2% at 48 months. Factors associated with overall mortality are comorbidity index (OR=1.1, p=0.017), heart failure (OR=1.7, p=0.032), sepsis (OR=3, p=0.0001) and delayed surgery (OR=0.43, p=0.003). The comparison of the 2 periods shows a significant increase in acute renal failure, bivalvular involvement and valvular insufficiency from 2001 to 2010. There was also a non-significant increase in early surgery (39.1% vs 50%, p=0.2). There was no significant difference in hospital mortality rates (28.1% vs 23.5%, p=0.58), in overall mortality at 48 months (48.8% vs 42.9%, p=0.241), and in delayed mortality at 48 months (28.2% vs 23.5%, p=0.225). Conclusion The mortality due to left-sided native valve SAIE remains elevated. Factors associated with hospital mortality are comorbidity index, heart failure and sepsis. Factors associated with overall mortality are comorbidity index, heart failure, sepsis and delayed surgery. Despite surgical progress, there is no significant decrease in hospital mortality, overall mortality and delayed mortality between the 2 periods.

Valvular Heart Disease Associated with Long-term Treatment by Methysergide: a Case Report

This case report concerns a woman treated continuously since at least 10 years by methysergide for cluster headache. The echocardiographic and histological features of the severe valve fibrosis presented by this patient are very similar to those described with 5 HT(2B) receptors agonistic drugs.