Endocarditis - Surgery / Valve Replacement - ESRD

8/17/2005

Question:  Is end-stage renal disease a contraindication for surgery for infective endocarditis?

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14718325.ui or 12118800.ui or 12053054.ui or 9236348.ui or 3524487.ui

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14718325[PMID] OR 12118800[PMID] OR 12053054[PMID] OR 9236348[PMID] OR 3524487[PMID]

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Unique Identifier [PMID]: 14718325

Authors: Spies C. Madison JR. Schatz IJ.

Institution: Department of Internal Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu. c.spies@gmx.net

Title: Infective endocarditis in patients with end-stage renal disease: clinical presentation and outcome.

Source: Archives of Internal Medicine. 164(1):71-5, 2004 Jan 12.

Abstract: BACKGROUND: Infective endocarditis is a common complication of vascular access in patients undergoing long-term hemodialysis. However, available data are either dated or gathered from small samples. The goal of this study was to investigate the clinical characteristics and outcome of infective endocarditis occurring in patients with end-stage renal disease. METHODS: Patients were identified by computerized discharge diagnosis and manual chart review at 3 major hospitals in Honolulu, Hawaii. The search covered an 11-year period, through December 2001. Modified Duke criteria were retrospectively applied. Patients fulfilling criteria for definite endocarditis were included in this study. RESULTS: Forty patients were identified. Average age was 59.4 years, and average duration of hemodialysis before endocarditis was 3.3 years; arteriovenous fistulas were the most commonly used access sites. Predominant organism was Staphylococcus aureus in 20 (50%) of the 40 cases. The mitral valve was affected in 29 cases (73%); aortic and mitral valve endocarditis was seen in 8 cases (20%). Overall in-hospital mortality was 52% (21/40). Patients with an unfavorable outcome more often had fever on admission, fewer negative blood cultures, and bivalvular infective endocarditis, and more often underwent valve replacement surgery. The perioperative mortality in patients undergoing valve replacement was 73% (11/15). CONCLUSIONS: Mortality of infective endocarditis in patients with end-stage renal disease remains high and has been essentially unchanged during the past decade. If patients require valve replacement surgery, mortality is even higher. A randomized, controlled trial is needed to clarify whether the increased mortality is due solely to more severe disease in patients requiring valve replacement surgery.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 12118800

Authors: Brinkman WT. Williams WH. Guyton RA. Jones EL. Craver JM.

Institution: Joseph B Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA.

Title: Valve replacement in patients on chronic renal dialysis: implications for valve prosthesis selection.

Source: Annals of Thoracic Surgery. 74(1):37-42; discussion 42, 2002 Jul.

Abstract: BACKGROUND: Reports are sparse describing heart valve replacement in patients with end-stage renal disease. This review assesses a 15-year experience and outcomes after valve replacement in patients on chronic preoperative renal dialysis. METHODS: A computerized database, hospital records, and telephone contact provided outcome data for patients on chronic dialysis undergoing valve replacement between March 22, 1985, and October 13, 2000, in two hospitals. RESULTS: Seventy-two patients underwent 95 valve procedures (74 operations). Ages ranged from 23 years to 84 years (mean, 57 years). Fifty-five aortic, 30 mitral, and 3 tricuspid valve replacements and 7 valvuloplasties were performed. Six of the 74 procedures were reoperative valve replacements. In the 46 patients with reliable long-term (greater than 30 days) follow-up data, significant bleeding or stroke was documented in 17 of 34 patients with a mechanical valve and 1 of 12 patients with a bioprosthetic valve. Overall survival (including two operative deaths) was 72.8% at 3 months, 65.4% at 6 months, 60.5% at 1 year, 39.8% at 2 years, 28.5% at 3 years, and 15.9% at 6 years (Kaplan-Meier). Type of valve implanted did not influence early and late survival. CONCLUSIONS: In this series of patients on chronic dialysis, survival appears to justify valve replacement. However, the sixfold higher incidence of late bleeding or stroke in patients on dialysis with a mechanical valve requiring warfarin suggests that bioprosthetic valves are the valve substitute of choice in patients on chronic dialysis.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 12053054

Authors: Abbott KC. Agodoa LY.

Institution: Nephrology Service, Walter Reed Army Medical Center, Washington, DC 20307-5001, USA. kevin.abbott@na.amedd.army.mil

Title: Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States.

Source: Nephron. 91(2):203-9, 2002 Jun.

Abstract: AIMS: Bacterial endocarditis is a significant cause of morbidity and mortality but has not been studied in a national population of end-stage renal disease patients. METHODS: 327,993 dialysis patients in the United States Renal Data System initiated from 1 January 1992 to 30 June 1997 were analyzed in a historical cohort study of hospitalized bacterial endocarditis (ENDO, ICD9 Code 421.x). Renal transplant recipients were excluded. RESULTS: Hemodialysis patients had an age-adjusted incidence ratio for ENDO of 17.86 (95% confidence interval, 6.62-48.90) and peritoneal dialysis patients 10.54 (95% CI, 0.71- 158.13, not statistically significant) compared to the general population in 1996 (the National Hospital Discharge Survey). 6.1% of patients with ENDO underwent valve replacement surgery. In multivariate analysis, hemodialysis (vs. peritoneal dialysis), earlier year of dialysis, cardiac disease, and lower serum creatinine and albumin were associated with increased risk of ENDO. In Cox regression analysis, patients with ENDO had increased mortality, relative risk 1.48 (95% CI 1.45-1.73). CONCLUSIONS: Patients on chronic dialysis were at increased risk for ENDO compared to the general population. The risk for peritoneal dialysis patients was not statistically significant, possibly due to the smaller numbers of patients on this modality. Hemodialysis (vs. peritoneal dialysis) and comorbidities were the strongest risk factors for ENDO identified. Copyright 2002 S. Karger AG, Basel

Publication Type: Journal Article.

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Unique Identifier [PMID]: 9236348

Authors: Lucke JC. Samy RN. Atkins BZ. Silvestry SC. Douglas JM Jr. Schwab SJ. Wolfe WG. Glower DD.

Institution: Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA.

Title: Results of valve replacement with mechanical and biological prostheses in chronic renal dialysis patients.

Source: Annals of Thoracic Surgery. 64(1):129-32; discussion 132-3, 1997 Jul.

Abstract: BACKGROUND: Whether biological or mechanical valves should be used in patients on chronic dialysis therapy remains to be clearly defined. METHODS: A retrospective review was performed on 19 consecutive patients from our institution with end-stage renal disease on chronic peritoneal or hemodialysis undergoing aortic (n = 12), mitral (n = 5), or aortic-mitral (n = 2) valve replacement. RESULTS: The 9 biological and 10 mechanical valve patients had similar ages (56.5 versus 56.6 years) and cardiovascular risk factors. The overall estimated Kaplan-Meier survival was 60% +/- 12% at 12 months and 42% +/- 14% at 60 months. Mechanical valve patients had a significantly higher rate of postoperative cerebrovascular accidents or bleeding complications (10/10 versus 0/9; chi 2 = 17.0; p < 0.001). No subsequent reoperations were required for biological valve failure at a mean follow-up of 32 +/- 53 months. CONCLUSIONS: These results demonstrate that in patients with end-stage renal disease, use of mechanical valves is associated with significant risk of complications, whereas biological valve failure from prosthetic dysfunction is unusual. Overall survival is poor in both groups of patients. Therefore, preference should be given to biological valve instead of mechanical valve prostheses in patients on chronic renal dialysis.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 3524487

Authors: Zamora JL. Burdine JT. Karlberg H. Shenaq SM. Noon GP.

Title: Cardiac surgery in patients with end-stage renal disease. [Review] [49 refs]

Source: Annals of Thoracic Surgery. 42(1):113-7, 1986 Jul.

Abstract: In a retrospective study we analyzed the clinical features of 85 patients with end-stage renal disease who underwent cardiac operation. Seventy-eight patients were from reports in the literature, and 7 were from our experience. The cardiac procedures were primarily valve replacements and aortocoronary bypass (ACB) operations. The indication for valve replacement was most commonly infective endocarditis (73%), affecting most frequently the aortic valve (68%). The most common organism was Staphylococcus aureus, and there was a recent episode of angioaccess site infection in at least 17.5% of patients with documented endocarditis. The 30-day mortality was 57% for patients undergoing emergency valve replacement and only 3% for similar elective operations. Cumulative survival at 48 months was equal to that of the overall hemodialysis population not having cardiac operations. The mean age (50 years), male to female ratio (9:1), number of vessels bypassed per patient (2.4), and operative mortality for ACB were equal to those reported in comparable series of patients with normal renal function. Cumulative survival at 48 months for ACB patients was similar (60% versus 56%) to that of the overall hemodialysis population. Cardiac operations can be performed safely in patients with end-stage renal disease; the morbidity and mortality are similar to those encountered in patients with normal renal function. The long-term survival after cardiac procedures in patients with end-stage renal disease is similar to that reported for the overall hemodialysis population not having cardiac operations. [References: 49]

Publication Type: Journal Article. Review.