Role of Early Mitral Valve Surgery in Acute Infective Endocarditis: A Case Series and Review of Literature

Abstract

Infective Endocarditis (IE) is a serious cardiac infection diagnosed with syndromic approach based on clinical, immunological, sonographic, and microbiological findings. It is highly suspected in patients with pre-existing heart disease who have bacteremia in absence of other obvious source. Due to its non-specific symptoms and delayed diagnosis causes severe septicemia, multiple organ failure, and high mortality. This case series describes three critically ill patients who were diagnosed with active IE upon admission to the Intensive Care Unit (ICU). All three patients were admitted in critical condition and were newly diagnosed with IE. They were initially stabilised with appropriate antibiotics. However, during their ICU stay, after two weeks, they experienced recurrent arrhythmias and severe Mitral Regurgitation (MR), complicating recurrent pulmonary oedema that hindered weaning from mechanical ventilation. Therefore, it was decided to perform Mitral Valve (MV) correction surgery during the acute phase of endocarditis (2 weeks after starting antibiotics). Unfortunately, all patients had in-hospital mortality. Intraoperative findings revealed extensive vegetation on the Anterior and Posterior Mitral Leaflet (AML and PML) with extension to the chordae. The high mortality was attributed to their critical pre-operative condition, septic shock, and cerebral embolism. Guidelines and task force management clearly state that early surgery plays a definitive role in acute endocarditis with complications. However, identifying the appropriate candidates for early surgery is challenging due to the associated high mortality. A database search on MV surgery in acute IE, comparing repair and replacement, has concluded that repair is safe and associated with better survival than replacement.