Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
Semin Thorac Cardiovasc Surg. 2022 Spring;34(1):67-77. doi: 10.1053/j.semtcvs.2021.03.017. Epub 2021 Apr 15.
Mitral repair (MVr) is superior to replacement for degenerative disease; however, its benefit is less established for endocarditis. We report outcomes of repair or replacement for mitral/tricuspid endocarditis and identify predictors of MVr. Patients undergoing first-time surgery for mitral (n = 260) or tricuspid (n = 71) endocarditis between 1992 to 2018 were identified. Patients with aortic endocarditis were excluded. Primary outcome was all-cause mortality and secondary outcome was MVr. Patients were stratified into active and treated endocarditis separately for mitral and tricuspid groups. Predictors of MVr were assessed through multivariable logistic regression and adjusted likelihood of MVr through marginal effects estimates. A mitral specialist was defined by performing ≥25 annual degenerative MVr. Among 331 patients, 70% (181/260) of those with mitral valve endocarditis and 52% (37/71) of those with tricuspid endocarditis underwent repair. The MVr group compared with replacement had a higher proportion of elective acuity and less diabetes, hypertension, active endocarditis, cardiogenic shock, and dialysis. Estimated 5-year survival did not differ between repair versus replacement for active mitral (68 ± 14% vs 60 ± 14%, P = 0.34) or tricuspid endocarditis (60 ± 17% vs 61 ± 19%, P = 0.67), but was superior after repair for treated mitral endocarditis (86 ± 7% vs 51 ± 24%, P = 0.014). Independent predictors of mortality included dialysis for active and treated mitral endocarditis, and mitral replacement (vs MVr) for treated mitral endocarditis. The likelihood of MVr was 82 ± 5% for mitral specialists and 47 ± 9% for non-specialists (P < 0.001). MVr for endocarditis should be pursued, if feasible. Importantly, achieving MVr was driven not only by patient factors, but also surgeon experience.
二尖瓣修复（MVr）在退行性疾病方面优于置换，但在感染性心内膜炎方面的获益尚不明确。我们报告了二尖瓣/三尖瓣感染性心内膜炎修复或置换的结果，并确定了 MVr 的预测因素。1992 年至 2018 年间，我们确定了 260 例首次行二尖瓣或 71 例三尖瓣感染性心内膜炎手术的患者。排除了主动脉瓣心内膜炎患者。主要结局是全因死亡率，次要结局是 MVr。将活跃性和治疗性心内膜炎患者分别分层为二尖瓣和三尖瓣组。通过多变量逻辑回归评估 MVr 的预测因素，并通过边缘效应估计调整 MVr 的可能性。二尖瓣专家定义为每年进行≥25 例退行性 MVr。在 331 例患者中，70%（181/260）的二尖瓣心内膜炎患者和 52%（37/71）的三尖瓣心内膜炎患者接受了修复。与置换相比，MVr 组择期急症的比例更高，糖尿病、高血压、活跃性心内膜炎、心源性休克和透析的比例更低。在活跃性二尖瓣（68 ± 14% vs 60 ± 14%，P=0.34）或三尖瓣心内膜炎（60 ± 17% vs 61 ± 19%，P=0.67）中，修复与置换的 5 年生存率无差异，但在治疗性二尖瓣心内膜炎中，修复后生存率更高（86 ± 7% vs 51 ± 24%，P=0.014）。活跃性和治疗性二尖瓣心内膜炎患者的透析以及治疗性二尖瓣心内膜炎患者的二尖瓣置换（与 MVr 相比）是死亡的独立预测因素。二尖瓣专家的 MVr 可能性为 82 ± 5%，非专家为 47 ± 9%（P<0.001）。如果可行，应考虑对心内膜炎进行 MVr。重要的是，MVr 的实现不仅取决于患者因素，还取决于外科医生的经验。
