Elsevier

International Journal of Cardiology

Volume 178, 15 January 2015, Pages 117-123
International Journal of Cardiology

One-year outcome following biological or mechanical valve replacement for infective endocarditis

https://doi.org/10.1016/j.ijcard.2014.10.125Get rights and content

Highlights

  • Large, contemporary cohort of 1,467 patients.

  • With definite active infective endocarditis.

  • And undergoing biological (37%) or mechanical (63%) valve replacement surgery.

  • Biological valve independently associated with higher hospital and 1-year mortality.

  • Particularly in patients younger than 65 years of age.

Abstract

Background

Nearly half of patients require cardiac surgery during the acute phase of infective endocarditis (IE). We describe the characteristics of patients according to the type of valve replacement (mechanical or biological), and examine whether the type of prosthesis was associated with in-hospital and 1-year mortality.

Methods and results

Among 5591 patients included in the International Collaboration on Endocarditis Prospective Cohort Study, 1467 patients with definite IE were operated on during the active phase and had a biological (37%) or mechanical (63%) valve replacement.

Patients who received bioprostheses were older (62 vs 54 years), more often had a history of cancer (9% vs 6%), and had moderate or severe renal disease (9% vs 4%); proportion of health care-associated IE was higher (26% vs 17%); intracardiac abscesses were more frequent (30% vs 23%). In-hospital and 1-year death rates were higher in the bioprosthesis group, 20.5% vs 14.0% (p = 0.0009) and 25.3% vs 16.6% (p < .0001), respectively.

In multivariable analysis, mechanical prostheses were less commonly implanted in older patients (odds ratio: 0.64 for every 10 years), and in patients with a history of cancer (0.72), but were more commonly implanted in mitral position (1.60).

Bioprosthesis was independently associated with 1-year mortality (hazard ratio: 1.298).

Conclusions

Patients with IE who receive a biological valve replacement have significant differences in clinical characteristics compared to patients who receive a mechanical prosthesis. Biological valve replacement is independently associated with a higher in-hospital and 1-year mortality, a result which is possibly related to patient characteristics rather than valve dysfunction.

Introduction

Despite improvements in diagnosis, antibiotic treatment and surgery, infective endocarditis (IE) remains a serious disease, with 50% of patients requiring cardiac surgery during the acute phase of IE and a 20% in-hospital mortality [1], [2], [3]. Cardiac surgery for IE typically involves valve replacement with a mechanical or xenograft biological prosthesis, although valve repair and homograft replacements may be used. The main advantage of mechanical prostheses is their longevity, but they require lifelong treatment with anticoagulants and the subsequent bleeding risks. Bioprostheses do not require long-term anticoagulation, but have a shorter durability, particularly in the mitral position. In its 2009 guidelines on IE, the European Society of Cardiology did not favor any specific valve substitute but recommended a tailored approach for each individual patient and clinical situation [4]. The American College of Cardiology and the American Heart Association Valvular Disease Guidelines have stated that in general, a mechanical prosthesis is reasonable in patients under 65 years of age, while a bioprosthesis is favored in patients 65 years of age or older for both the aortic and the mitral positions, but do not provide specific recommendations for surgery in IE [5].

There are limited data to support the choice of either type of prosthesis in IE [6]. The characteristics of patients receiving biological or mechanical prosthesis and the association between type of valve prosthesis and outcome are not clearly defined. Thus, the objectives of this observational study were to describe the characteristics of patients according to the type of prosthesis and to examine the relationship between prosthesis type and 1-year mortality.

Section snippets

International Collaboration On Endocarditis — Prospective Cohort Study

Data from the International Collaboration on Endocarditis — Prospective Cohort Study (ICE-PCS) were used for this study. Methods of this prospective, multicenter, international registry of IE have been previously reported [7], [8]. Between January 2000 and December 2006, 5668 patients from 64 centers in 28 countries were enrolled. The ICE-PCS database is maintained at the Duke Clinical Research Institute, which serves as the coordinating center for ICE studies, with institutional review board

Results

There were 5668 patients with definite and possible IE enrolled in the ICE-PCS. Based on pre-specified inclusion and exclusion criteria for this study, 1467 patients, including 917 (63%) who received mechanical prostheses only and 550 (37%) who received bioprostheses only, were included in this study (Fig. 1).

The clinical characteristics of patients receiving biological or mechanical prostheses are presented in Table 1. Compared to patients who received mechanical prostheses, those who received

Discussion

In the present study, 1467 patients received valve prostheses during the acute phase of IE with 37% receiving biological valve replacement and 63% a mechanical prosthesis. Both in-hospital mortality and one-year mortality were higher in the bioprosthesis group. The higher mortality associated with bioprosthesis extended beyond the in-hospital acute phase of IE, and was independently associated with 1-year mortality in multivariable analysis. These results have relevance to current clinical

Conflicts of interest

Dr. Wang is supported in part by AHA Mid-Atlantic Grant-in-Aid Award #12GRNT12030071.

Dr Kanj declared honoraria for talks from Pfizer, Merck, Astra Zeneca, Astellas, Biologix and research funds from Astellas.

Other authors declared no conflict of interest.

Acknowledgments

In addition to all of the named ICE investigators at each site, we would like to acknowledge the support given to this project from all of the personnel at each site and at the coordinating center that have allowed this project to move forward.

Study investigators

Argentina: Liliana Clara, MD, Marisa Sanchez, MD (Hospital Italiano). José Casabé, MD, PhD, Claudia Cortes, MD (Hospital Universitario de la Fundaciòn Favaloro). Francisco Nacinovich, MD, Pablo Fernandez Oses, MD, Ricardo Ronderos, MD,

References (21)

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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

1

Membership of the International Collaboration on Endocarditis Prospective Cohort Study (ICE-PCS) is provided in the Acknowledgments.

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