Mitral valve repair in native active infective endocarditis is technically challenging. The survival benefit over valve replacement is poorly established and possibly absent because of the high risk of repair failure and reoperation. In this study, we explore the results of our structured approach in these patients. Between January 2000 and January 2017, 149 patients underwent surgery for native mitral infective endocarditis. Among them, 97 (66%) patients underwent valve repair and 52 (34%) underwent valve replacement. Our structured approach consisted of early surgery, radical resection of infected tissue, liberal use of prosthetic materials and ‘patch’ repair techniques. A critical assessment of expected repair durability was made intraoperatively and repair was not performed if concerns of long-term durability existed. To study the effects of valve repair on overall survival, landmark analysis was performed. In-hospital mortality was 15.4% (14 repair vs 9 replacement patients; P = 0.642). There were no residual infective endocarditis cases or early reoperations. On Cox proportional hazards analysis, valve replacement was not inferior to repair within 1-year post-surgery [hazard ratio (HR) 1.134, 95% confidence interval (CI) 0.504–2.540; P = 0.76]. Beyond 1 year post-surgery, replacement was associated with decreased survival (HR 2.534, 95% CI 1.002–6.406; P = 0.049). There were no differences in freedom from recurrent infective endocarditis (P = 0.47) and mitral valve reintervention (P = 0.52). Active mitral valve endocarditis remains a complex disease with significant early and late morbidity and mortality. A structured approach allows valve repair in two-thirds of patients. Clinical results could be improved by focussing on early surgery, prior to extensive valve destruction, to enable durable repairs and improve late outcomes.

OBJECTIVES: Robotic-assisted mitral valve repair surgery has a steep learning curve, and it is not clear whether previous experience in minimally invasive mitral valve surgery (MIMVS) facilitates this process. We aimed to investigate the initial experience of 2 cardiac centres starting their robotic programmes, evaluating the impact of previous MIMVS experience. METHODS: Retrospective analysis was performed for the 1st consecutive cases operated due to severe degenerative mitral valve regurgitation using the robotic surgical platform in 2 European centres, 1 transitioning from conventional surgery (centre 1) and the other from mini thoracotomy MIMVS (centre 2). Cumulative sum analysis was used to evaluate the learning process using both surgical times and a combined primary outcome including relevant intra- and postoperative results. RESULTS: First 62 patients in each centre were included. All median surgical times were shorter in centre 2: cardiopulmonary bypass: 238 vs 115 min, P < 0.001; cross-clamp: 143 vs 82 min, P < 0.001; and total intervention: 313 vs 228 min, P < 0.001. The combined primary outcome showed no significant differences (9.7% vs 8%; P = 1). However, the turning point making the end of the learning phase was detected at the 60th case in centre 1 and at the 50th in centre 2. Regarding surgical time, the learning curve was steeper in centre 1 with both cardiopulmonary bypass and cross-clamp overcoming the learning phase after 32 cases, as compared to 16 cases in centre 2. CONCLUSIONS: A successful robotic-assisted mitral repair programme can be safely started coming from either conventional open approach or mini thoracotomy MIMVS. However, previous mini thoracotomy MIMVS experience had positive impact on the initial learning curve.

Native mitral valve infective endocarditis (IE) is a complicated disease with high mortality and morbidity rates. Mitral valve repair (MVRep) is feasible when limited valve destruction is present. However, recurrent valve dysfunction and reintervention are common. Between January 2000 and March 2016, 83 patients underwent surgery for isolated active native mitral valve IE. We applied an early surgery, MVRep-oriented approach with progressive utilization of patch techniques to secure a durable repair; MVRep was attempted in 67% of patients. Fifty-one (61%) patients underwent MVRep (including full-ring annuloplasty in 94%) and 32 (39%) patients underwent mitral valve replacement. Early mortality was 13%. No cases of early recurrent IE occurred. Predischarge echocardiography demonstrated good MVRep function in all, except 1 patient with residual (Grade 2+) regurgitation. The mean duration of follow-up was 3.7 years (interquartile range 1.5–8.4). For hospital survivors, 8-year overall survival rates were 92.4% (95% confidence interval 84.0–100%) and 74.2% (95% confidence interval 53.8–94.6%) for the MVRep and mitral valve replacement groups, respectively. Propensity score-adjusted Cox regression analysis revealed no significant difference in survival between the 2 groups (hazard ratio 0.359, 95% confidence interval 0.107–1.200; P = 0.096). Four reinterventions occurred, 2 in each group. Echocardiographic follow-up demonstrated excellent MVRep durability; no cases of mitral regurgitation and 1 case of mitral valve stenosis were seen. Native mitral valve IE is linked to high mortality and morbidity rates. A durable MVRep is feasible in most patients and provides excellent mid-term durability. Mitral valve replacement is a reasonable alternative when a durable repair is not likely.

OBJECTIVES: Severe cases of infective endocarditis (IE) of the aortic valve can cause aortic root destruction and affect the surrounding structures, including the aortic-mitral continuity, the anterior mitral valve leaflet and the roof of the left atrium. Reconstruction after resection of all infected tissue remains challenging. We describe our surgical approach and the mid-term results. METHODS: Between January 2004 and December 2015, 35 patients underwent surgery for extensive IE of the aortic valve with destruction of the aortic root, the aortic-mitral continuity and the mitral valve. Mean age was 60.4 ± 13.7; 26/35 (74%) patients had prosthetic valve endocarditis. Four patients were in critical preoperative state. Median EuroSCORE II was 18.0% [interquartile range (IQR) 11.0–26.7]. RESULTS: Aortic root replacement was performed in 32 (91%) patients. The remaining patients underwent aortic valve replacement. Reconstruction of the aortic-mitral continuity and the roof of the left atrium were performed using a folded pericardial patch. In 28 patients (80%), mitral valve repair was performed. Postoperative mechanical circulatory support, acute kidney failure and surgical re-exploration were seen in 5 (16%), 10 (31%) and 4 (13%) patients, respectively. Early survival rate was 77% (27 patients). During a median follow-up of 29.8 months (IQR 6.4–62.9), 7 (26%) patients required reintervention (3–42 months after surgery); 4 were due to mitral incompetence, early in our experience. CONCLUSIONS: Extensive IE of the aortic root with destruction of the surrounding tissues remains a complex disease with high morbidity and mortality rates. Our technique allows native mitral valve preservation but is technically challenging.