Publications by authors named "Alberto Riberi"

62 Publications

Infective endocarditis with neurological complications: Delaying cardiac surgery is associated with worse outcome.

Arch Cardiovasc Dis 2021 Apr 29. Epub 2021 Apr 29.

AP-HM, La Timone Hospital, Cardiology Department, 13005 Marseille, France; Aix Marseille Univ, IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, 13005 Marseille, France. Electronic address:

Background: Infective endocarditis (IE) is associated with a high mortality rate, related in part to neurological complications. Studies suggest that valvular surgery should be performed early when indicated, but is often delayed by the presence of neurological complications.

Aim: To assess the effect of delaying surgery in patients with IE and neurological complications and to identify factors predictive of death.

Methods: In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death.

Results: Between April 2014 and January 2018, 351 patients with a definite diagnosis of left-sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P=0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61-33.67; P=0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22-121.17; P=0.006).

Conclusions: Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration.
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http://dx.doi.org/10.1016/j.acvd.2021.01.004DOI Listing
April 2021

F-fluorodeoxyglucose positron emission tomography/computed tomography for the diagnosis of native valve infective endocarditis: A prospective study.

Arch Cardiovasc Dis 2021 Mar 22;114(3):211-220. Epub 2021 Jan 22.

Cardiology department, La Timone Hospital, AP-HM, 13005 Marseille, France; IHU-Méditerranée Infection, Aix-Marseille University, IRD, AP-HM, MEPHI, 13005 Marseille, France. Electronic address:

Background: F-fluorodeoxyglucose-positron emission tomography/computed tomography (F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE).

Aims: Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake).

Methods: Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected.

Results: Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P<0.001), without a change in specificity. Diffuse splenic uptake was observed in 39 (52.0%) patients, including 37 (58.7%) with a final diagnosis of NVE (specificity 83.3%).

Conclusions: F-FDG PET/CT has poor sensitivity but high specificity in the diagnosis of NVE. The usefulness of F-FDG PET/CT is high for embolic detection. Diffuse splenic uptake represents a possible new diagnostic criterion for NVE.
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http://dx.doi.org/10.1016/j.acvd.2020.10.005DOI Listing
March 2021

FDG-PET/CT Incidental Detection of Cancer in Patients Investigated for Infective Endocarditis.

Front Med (Lausanne) 2020 10;7:535. Epub 2020 Sep 10.

Aix Marseille Univ, IRD, AP-HM, MEPHI, Marseille, France.

Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) is an imaging technique largely used in the management of infective endocarditis and in the detection and staging of cancer. We evaluate our experience of incidental cancer detection by PET/CT during IE investigations and follow-up. Between 2009 and 2018, our center, which includes an "endocarditis team," managed 750 patients with IE in a prospective cohort. PET/CT became available in 2011 and was performed in 451 patients. Incidental diagnosis of cancer by PET/CT was observed in 36 patients and confirmed in 34 of them (7.5%) (colorectal = 17; lung = 7; lymphoma = 2; melanoma = 2; ovarian = 2; prostate = 1; bladder = 1; ear, nose, and throat = 1; brain = 1). A significant association has been found between colorectal cancer and and/or [12/26 vs. 6/33 for other cancers, = 0.025, odds ratio = 3.86 (1.19-12.47)]. Two patients had a negative PET/CT (a colon cancer and a bladder cancer), and two patients, with positive PET/CT, had a benign colorectal tumor. PET/CT had a sensitivity of 94-100% for the diagnosis of cancer in this patient. Whole-body PET/CT confirmed the high incidence of cancer in patients with IE and could now be proposed in these cases.
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http://dx.doi.org/10.3389/fmed.2020.00535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533668PMC
September 2020

STABILISE Technique for a Non-A Non-B Acute Aortic Dissection in Marfan Syndrome.

Ann Vasc Surg 2021 Jan 11;70:569.e5-569.e10. Epub 2020 Sep 11.

Aix-Marseille Université, APHM, Hôpital de la Timone, Service de Chirurgie Vasculaire, Marseille, France.

A 35-year-old man, with a deep pectus excavatum due to a Marfan syndrome treated 9 years before for an acute type A dissection involving only the aortic arch, by a Bentall surgery, was admitted for acute chest pain. Computed tomography (CT) scan showed an acute type non-A non-B dissection extending to the iliac. After 5 days with strict arterial blood pressure management, the patient had recurrent refractory chest pain and a hybrid technique associating full supra-aortic vessels debranching and STABILISE technique during the same procedure was performed. The patient had an uneventful recovery with CT scan showing complete aortic arch aneurysm exclusion.
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http://dx.doi.org/10.1016/j.avsg.2020.08.132DOI Listing
January 2021

Comparison Between ESC and Duke Criteria for the Diagnosis of Prosthetic Valve Infective Endocarditis.

JACC Cardiovasc Imaging 2020 12 17;13(12):2605-2615. Epub 2020 Jun 17.

APHM, La Timone Hospital, Cardiology Department, Marseille, France; Aix Marseille University, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France. Electronic address:

Objectives: The primary objective was to assess the value of the European Society of Cardiology (ESC) criteria, including F-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG-PET/CT) in prosthetic valve infective endocarditis (PVE). Secondary objectives were: 1) to assess the reproducibility of F-FDG-PET/CT; 2) to compare its diagnostic value with that of echocardiography; and 3) to assess the diagnostic value of the presence of a diffuse splenic uptake BACKGROUND: F-FDG PET/CT has been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the benefit of the ESC criteria has not been prospectively compared with the conventional Duke criteria.

Methods: Between 2014 and 2017, 175 patients with suspected PVE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable F-FDG PET/CT, 115 patients were evaluated, including 91 definite and 24 rejected IE, as defined by an expert consensus.

Results: Cardiac uptake by F-FDG PET/CT was observed in 67 of 91 patients with definite PVE and 6 with rejected IE (sensitivity 73.6% [95% confidence interval (CI): 63.3% to 82.3%], specificity 75% [95% CI: 53.3% to 90.2%]). The ESC 2015 classification increased the sensitivity of Duke criteria from 57.1% (95% CI: 46.3% to 67.5%) to 83.5% (95% CI: 74.3% to 90.5%) (p < 0.001), but decreased its specificity from 95.8% (95% CI: 78.9% to 99.9%) to 70.8% (95% CI: 48.9% to 87.4%). Intraobserver reproducibility of F-FDG PET/CT was good (kappa = 0.84) but interobserver reproducibility was less satisfactory (kappa = 0.63). A diffuse splenic uptake was observed in 24 (20.3%) patients, including 23 (25.3%) of definite PVE, and only 1 (4.2%) rejected PVE (p = 0.024).

Conclusions: F-FDG PET/CT is a useful diagnostic tool in suspected PVE, and explains the greater sensitivity of ESC criteria than Duke criteria. However, F-FDG PET/CT also presents with important limitations concerning its feasibility, specificity, and reproducibility. Our study describes for the first time a new endocarditis criterion, that is, the presence of a diffuse splenic uptake on F-FDG PET/CT.
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http://dx.doi.org/10.1016/j.jcmg.2020.04.011DOI Listing
December 2020

Spondylodiscitis complicating infective endocarditis.

Heart 2020 12 28;106(24):1914-1918. Epub 2020 May 28.

Cardiology Department, APHM, La Timone Hospital, Marseille, France

Objective: The primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS.

Methods: Prospective case-control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded.

Results: Patients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without PS. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L4-L5. Neurological symptoms were observed in 59% of patients. Enterococci and were more frequent (24% vs 12% and 24% vs 11%; p<0001, respectively) in the PS group. The diagnosis of PS was based on contrast-enhanced MRI in 92 patients, bone CT in 88 patients and F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS.

Conclusions: PS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.
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http://dx.doi.org/10.1136/heartjnl-2019-316492DOI Listing
December 2020

Prognostic Value of F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Infective Endocarditis.

J Am Coll Cardiol 2019 08;74(8):1031-1040

APHM, La Timone Hospital, Cardiology Department, Marseille, France; Aix Marseille University, IRD (Institut de Recherche pour le Développement), APHM (Assistance Publique Hôpitaux de Marseille), MEPHI (Microbes, Evolution, Phylogénie et Infection), IHU (Institut Hospitalo-universitaire)-Méditerranée Infection, Marseille, France. Electronic address:

Background: F-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) is commonly used for the diagnosis of infective endocarditis (IE), but its prognostic value remains unknown.

Objectives: This study sought to assess the prognostic value of F-FDG PET/CT in prosthetic valve endocarditis (PVE) and native valve endocarditis (NVE).

Methods: This study prospectively included 173 consecutive patients (109 PVE and 64 NVE) with definite left-sided IE who had an F-FDG PET/CT and were followed-up for 1 year. The primary endpoint was a composite of major cardiac events: death, recurrence of IE, acute cardiac failure, nonscheduled hospitalization for cardiovascular indication, and new embolic event.

Results: F-FDG PET/CT was positive in 100 (58%) patients, 83% (n = 90 of 109) in the PVE, and 16% (n = 10 of 64) in the NVE group. At a mean follow-up of 225 days (interquartile range: 199 to 251 days), the primary endpoint occurred in 94 (54%) patients: 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive F-FDG PET/CT was significantly associated with a higher rate of primary endpoint (hazard ratio [HR]: 2.7; 95% confidence interval [CI]: 1.1 to 6.7; p = 0.04). Moderate to intense F-FDG valvular uptake was also associated with worse outcome (HR: 2.3; 95% CI: 1.3 to 4.5; p = 0.03) and to new embolic events in PVE (HR: 7.5; 95% CI: 1.24 to 45.2; p = 0.03) and in NVE (HR: 8.8; 95% CI: 1.1 to 69.5; p = 0.02). In the NVE group, F-FDG PET/CT was not associated with occurrence of the primary endpoint CONCLUSIONS: In addition to its good diagnostic performance, F-FDG PET/CT is predictive of major cardiac events in PVE and new embolic events within the first year following IE.
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http://dx.doi.org/10.1016/j.jacc.2019.06.050DOI Listing
August 2019

High-dose trimethoprim-sulfamethoxazole and clindamycin for Staphylococcus aureus endocarditis.

Int J Antimicrob Agents 2019 Aug 8;54(2):143-148. Epub 2019 Jun 8.

Aix Marseille Univ., IRD, AP-HM, MEPHI, IHU Méditerranée Infection, Marseille, France. Electronic address:

Objective: The mortality rate for Staphylococcus aureus endocarditis remains as high as 20-30% despite improvements in medical and surgical treatment. This study evaluated the efficiency and tolerance of a combination of intravenous trimethoprim-sulfamethoxazole and clindamycin (T&C) +/- rifampicin and gentamicin, with a rapid switch to oral administration of T&C.

Methods: This before-after intervention study compared the outcomes of 170 control patients before introduction of the T&C protocol (2001-2011) with the outcomes of 171 patients in the T&C group (2012-2016). All patients diagnosed with S. aureus infective endocarditis and referred to the study centre between 2001 and 2016 were included. Between 2001 and 2011, the patients received a standardized antibiotic treatment: oxacillin or vancomycin for 6 weeks, plus gentamicin for 5 days. Since February 2012, the antibiotic protocol has included a high dose of T&C (intravenous, switched to oral administration on day 7). Rifampicin and gentamicin are also given in cases of cardiac abscess or persistent bacteraemia.

Results: The two groups were slightly different. On intention-to-treat analysis, global mortality (19% vs 30%, P=0.024), in-hospital mortality (10% vs 18%, P=0.03) and 30-day mortality (7% vs 14%, P=0.05) were lower in the T&C group. The mean duration of hospital stay was significantly shorter in the T&C group (30 vs 39 days; P=0.005).

Conclusions: The management of S. aureus infective endocarditis using a rapid shift to oral administration of T&C reduced the length of hospital stay and the mortality rate.
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http://dx.doi.org/10.1016/j.ijantimicag.2019.06.006DOI Listing
August 2019

Open-heart transcatheter aortic valve replacement in complex aortic valve reoperation: about a case series.

Eur Heart J Case Rep 2018 Jun 24;2(2):yty064. Epub 2018 May 24.

Department of Cardiac Surgery, La Timone Hospital, Marseille, 264 rue Saint Pierre, Marseille, France.

Introduction: Aortic homograft and stentless aortic root are helpful in acute infective endocarditis of the aortic valve as biological conduit when total root replacement is required. Reoperation for failure of aortic homograft and stentless aortic root remains challenging for the surgeon as the entire root can be heavily calcified.

Case Presentation: Here, are reported, three cases of patients successfully treated with open-heart transcatheter aortic valve replacement (TAVR) whereas no other prosthesis was implantable due to a massively calcified homograft or stentless prosthesis.

Discussion: Open-heart TAVR avoided the risk of complete root replacement which is higher than redo aortic valve replacement (AVR). This rescue technique facilitated risky surgical procedure by combining the strengths of both TAVR and conventional AVR.
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http://dx.doi.org/10.1093/ehjcr/yty064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6177095PMC
June 2018

Long-term results of surgical treatment of secondary severe mitral regurgitation in patients with end-stage heart failure: Advantage of prosthesis insertion.

Arch Cardiovasc Dis 2019 Feb 29;112(2):95-103. Epub 2018 Dec 29.

Department of Cardiology, La Timone Hospital, AP-HM, 13005 Marseille, France. Electronic address:

Background: Surgical treatment of secondary mitral regurgitation (SMR) is controversial.

Aim: To analyse outcome after undersizing annuloplasty (UA) and mitral valve replacement (MVR).

Methods: Consecutive patients operated on for severe SMR, with left ventricular ejection fraction (LVEF)<40% and refractory CHF, were included. Endpoints were in-hospital mortality, mid-term cardiovascular (CV) mortality, evolution of LV variables and recurrence of mitral regurgitation (MR).

Results: 59 patients were included (mean age 65±10 years, preoperative LVEF 36±6%; effective regurgitant orifice [ERO] 41±17 mm), 41 with ischaemic disease: 12 underwent UA and 47 underwent MVR; only eight had concomitant coronary revascularization. In-hospital mortality was 3.3% (8.3% in UA group; 2.1% in MVR group). Eight-year CV mortality was 39±13% (40±18% in UA group; 27±10% in MVR group). Older age (hazard ratio 1.14, 95% confidence interval 1.07 to 1.22; P<0.001) and LV end-systolic diameter (hazard ratio 1.18, 95% confidence interval 1.09 to 1.27; P<0.001) independently predicted CV mortality. LVEF did not change between the preoperative and follow-up transthoracic echocardiograms in the MVR group (36±6% vs. 35±10%; P=0.6) or the UA group (36±5% vs. 31±12%; P=0.09). Conversely, LV end-diastolic diameter decreased significantly in the MVR group (64±8m to 59±9mm; P=0.002), but not in the UA group (61±7m to 64±10mm; P=0.2). Recurrence of significant MR occurred in 81% of patients in the UA group (mean postoperative ERO 19±6 mm) versus none in the MVR group.

Conclusions: Surgical treatment of SMR can be performed with acceptable operative risk and mid-term survival in severe heart failure, even if there is no indication for revascularization. MVR is associated with significant reverse remodelling, and UA with prohibitive risk of MR recurrence.
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http://dx.doi.org/10.1016/j.acvd.2018.09.006DOI Listing
February 2019

Intracranial haemorrhage in infective endocarditis.

Arch Cardiovasc Dis 2018 Dec 5;111(12):712-721. Epub 2018 Jun 5.

Cardiology Department, la Timone Hospital, AP-HM, boulevard Jean-Moulin, 13005 Marseille, France; MEPHI, IRD, IHU-Méditerranée Infection, Aix Marseille University, AP-HM, 13005 Marseille, France.

Background: Although intracranial cerebral haemorrhage (ICH) complicating infective endocarditis (IE) is a critical clinical issue, its characteristics, impact, and prognosis remain poorly known.

Aims: To assess the incidence, mechanisms, risk factors and prognosis of ICH complicating left-sided IE.

Methods: In this single-centre study, 963 patients with possible or definite left-sided IE were included from January 2000 to December 2015.

Results: Sixty-eight (7%) patients had an ICH (mean age 57±13 years; 75% male). ICH was classified into three groups according to mechanism: ruptured mycotic aneurysm (n=22; 32%); haemorrhage after ischaemic stroke (n=27; 40%); and undetermined aetiology (n=19; 28%). Five variables were independently associated with ICH: platelet count<150×10/L (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.01-5.4; P=0.049); severe valve regurgitation (OR 3.2, 95% CI 1.3-7.6; P=0.008); ischaemic stroke (OR 4.2, 95% CI 1.9-9.4; P<0.001); other symptomatic systemic embolism (OR 14.1, 95% CI 5.1-38.9; P<0.001); and presence of mycotic aneurysm (OR 100.2, 95% CI 29.2-343.7; P<0.001). Overall, 237 (24.6%) patients died within 2.3 (0.7-10.4) months of follow-up. ICH was not associated with increased mortality (P not significant). However, the 1-year mortality rate differed according to ICH mechanism: 14%, 15% and 45% in patients with ruptured mycotic aneurysm, haemorrhage after ischaemic stroke and undetermined aetiology, respectively (P=0.03). In patients with an ICH, mortality was higher in non-operated versus operated patients when cardiac surgery was indicated (P=0.005). No operated patient had neurological deterioration.

Conclusions: ICH is a common complication of left-sided IE. The impact on prognosis is dependent on mechanism (haemorrhage of undetermined aetiology). We observed a higher mortality rate in patients who had conservative treatment when cardiac surgery was indicated compared with in those who underwent cardiac surgery.
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http://dx.doi.org/10.1016/j.acvd.2018.03.009DOI Listing
December 2018

An Oscillating Mass Attached to a Pacemaker Lead: Thrombus or Vegetation? A Fishing Story.

JACC Clin Electrophysiol 2017 Aug 29;3(8):915-916. Epub 2017 Mar 29.

Department of Cardiology, AP-HM, La Timone Hospital, Marseille, France; URMITE, Aix-Marseille Université UM 63, CNRS 7278, IRD 198, INSERM 1095, IHU, Marseille, France.

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http://dx.doi.org/10.1016/j.jacep.2016.12.028DOI Listing
August 2017

Diagnosis of Infective Endocarditis After TAVR: Value of a Multimodality Imaging Approach.

JACC Cardiovasc Imaging 2018 01 16;11(1):143-146. Epub 2017 Aug 16.

Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, Aix-Marseille Université-UM63, Centre National de la Recherche Scientifique 7278, IRD 198, Institut National de la Santé et de la Recherche Médicale 1095-IHU-Méditerranée Infection, Marseille, France.

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http://dx.doi.org/10.1016/j.jcmg.2017.05.016DOI Listing
January 2018

Coronary events complicating infective endocarditis.

Heart 2017 12 22;103(23):1906-1910. Epub 2017 Jun 22.

Aix-Marseille Université, Marseille, France.

Objective: Acute coronary syndromes (ACS) are a rare complication of infective endocarditis (IE). Only case reports and small studies have been published to date. We report the largest series of ACS in IE. The aim of our study was to describe the incidence and mechanisms of ACS associated with IE, to assess their prognostic impact and to describe their management.

Methods: In a bicentre prospective observational cohort study, all patients with a definite diagnosis of IE were prospectively included. The incidence, mechanism and prognosis of patients with ACS were studied.

Results: Among 1210 consecutive patients with definite IE, 26 patients (2.2%) developed an ACS. Twenty-three patients (88%) had a coronary embolism. Two patients had coronary compression by an abscess or a pseudoaneurysm and one patient had an obstruction of his bioprosthesis and left coronary ostium by a large vegetation. Nineteen (73%) patients with ACS developed heart failure and this complication was 2.5 times more frequent than in patients without ACS (p<0.0001). In the ACS population, mortality rate was twice than the population without ACS.

Conclusions: ACS is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate.
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http://dx.doi.org/10.1136/heartjnl-2017-311624DOI Listing
December 2017

Infective endocarditis in octogenarians.

Heart 2017 10 21;103(20):1602-1609. Epub 2017 Apr 21.

Aix-Marseille Université, Marseille, France.

Objective: To describe the characteristics of infective endocarditis (IE) in octogenarians and assess their prognosis.

Methods: Patients with definite IE hospitalised at a referral centre between July 2008 and July 2013 were prospectively included. A total of 454 patients were divided into three groups: 230 patients under 65 years old, 173 patients between 65 and 80 years old, and 51 patients over 80 years old. The main end point was 1-year mortality.

Results: One-year mortality was higher in the ≥80 years old group (37.3%) than in the <65 years old group (13%; p<0.001) and the 65-80 years old group (19.7%; p=0.009). and were the more frequent micro-organisms. Embolism under antibiotic therapy (n=11 (21.6%), p=0.03) and renal failure (n=23 (51%), p=0.004) were more frequent in the ≥80 years old group. Among the ≥80 years old group, 38 patients had theoretical indication for surgery. Mortality was low (6.3%) in the 16 operated patients, but very high (72.7%) in the 22 patients not operated. Even if octogenarians were less often operated, their survival after surgery was excellent like younger patients (93.7%, 89.9% and 90.4%, respectively), whereas the absence of surgery was associated with very poor prognosis.

Conclusions: IE in octogenarians is a different disease, with as the most frequent micro-organisms and with higher mortality than younger patients. ESC recommendations for surgery are less implemented than in younger patients, yielding dramatic mortality in patients not operated despite a theoretical indication for surgery, while operated patients have an excellent prognosis. These results suggest that surgery is underused in octogenarians.
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http://dx.doi.org/10.1136/heartjnl-2016-310853DOI Listing
October 2017

Severe right ventricular dysfunction is an independent predictor of pre- and post-transplant mortality among candidates for heart transplantation.

Arch Cardiovasc Dis 2017 Mar 20;110(3):139-148. Epub 2017 Jan 20.

Department of Cardiac Surgery, La Timone Hospital, 13005 Marseille, France.

Background: Heart transplantation is the gold-standard treatment for end-stage heart failure. However, the shortage of grafts has led to longer waiting times and increased mortality for candidates without priority.

Aims: To study waiting-list and post-transplant mortality, and their risk factors among patients registered for heart transplantation without initial high emergency procedure.

Methods: All patients registered on the heart transplantation waiting list (2004-2015) without initial high emergency procedure were included. Clinical, biological, echocardiographic and haemodynamic data were collected. Waiting list and 1-year post-transplant survival were analysed with a Kaplan-Meier model.

Results: Of 221 patients enrolled, 168 (76.0%) were men. Mean age was 50.0±12.0 years. Forty-seven patients died on the waiting list, resulting in mortality rates of 11.2±2.7% at 1 year, 31.9±5.4% at 2 years and 49.4±7.1% at 3 years. Median survival was 36.0±4.6 months. In the multivariable analysis, left ventricular ejection fraction<30% (hazard ratio [HR]: 3.76, 95% confidence interval [CI]: 1.38-10.24; P=0.010) and severe right ventricular systolic dysfunction (HR: 2.89, 95% CI: 1.41-5.92; P=0.004) were associated with increased waiting-list mortality. The post-transplant survival rate was 73.1±4.4% at 1 year. Pretransplant severe right ventricular dysfunction and age>50 years were strong predictors of death after transplantation (HR: 5.38, 95% CI: 1.38-10.24 [P=0.020] and HR: 6.16, 95% CI: 1.62-9.32 [P=0.0130], respectively).

Conclusions: Mortality among candidates for heart transplantation remains high. Patients at highest risk of waiting-list mortality have to be promoted, but without compromising post-transplant outcomes. For this reason, candidates with severe right ventricular dysfunction are of concern, because, for them, transplantation is hazardous.
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http://dx.doi.org/10.1016/j.acvd.2016.06.002DOI Listing
March 2017

Late infectious endocarditis of surgical patch closure of atrial septal defects diagnosed by 18F-fluorodeoxyglucose gated cardiac computed tomography (18F-FDG-PET/CT): a case report.

BMC Res Notes 2016 Aug 24;9(1):416. Epub 2016 Aug 24.

Assistance Publique - Hôpitaux de Marseille (APHM), Service de Maladies Infectieuses, Hôpital de la Conception, 147, boulevard Baille, Marseille, France.

Background: In contrast to percutaneous atrial septal occluder device, surgical patch closure of atrial defects was known to be no infective endocarditis risk.

Case Presentation: We herein report the first case of late endocarditis of surgical patch closure of atrial septal defects occurred at 47-year after surgery. On September 2014, a 56-year-old immunocompetent French Caucasian man was admitted into the Emergency Department for 3-week history of headache, acute decrease of psychomotor performance and fever at 40 °C. The diagnosis has been evoked during his admission for the management of a brain abscess and confirmed using 18F-fluorodeoxyglucose gated cardiac computed tomography (18F-FDG-PET/CT). Bacterial cultures of surgical deep samples of brain abscess were positive for Streptococcus intermedius and Aggregatibacter aphrophilus as identified by the matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry and confirmed with 16S rRNA gene sequencing. The patient was treated by antibiotics for 8 weeks and surgical patch closure removal.

Conclusions: In summary, late endocarditis on surgical patch and on percutaneous atrial septal occluder device of atrial septal defects is rare. Cardiac imaging by the 18F-fluorodeoxyglucose gated cardiac computed tomography (18F-FDG-PET/CT) could improve the diagnosis and care endocarditis on surgical patch closure of atrial septal defects while transthoracic and transesophageal echocardiography remained difficult to interpret.
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http://dx.doi.org/10.1186/s13104-016-2223-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4995769PMC
August 2016

Chronic heart failure in heart transplant recipients: Presenting features and outcome.

Arch Cardiovasc Dis 2016 Apr 15;109(4):254-9. Epub 2016 Mar 15.

Department of cardiology, La Timone hospital, Aix-Marseille university, rue Saint-Pierre, 13385 Marseille, France.

Background: The ageing graft frequently shows coronary lesions and a restrictive physiology.

Aims: To determine the presenting features and outcome of chronic heart failure in heart transplant recipients.

Methods: In this cohort study, we compared 44 consecutive heart transplant recipients who developed chronic heart failure more than 1 year after heart transplantation with 44 control heart transplant recipients who did not develop heart failure.

Results: We found that patients who developed heart failure had more frequently a history of hypertension or diabetes before transplantation. During the 12 months after transplantation, significantly more patients had moderate-to-severe acute rejections (≥ grade 2R) in the heart failure group than in the control group. At the time of heart failure diagnosis, systolic left ventricular function was preserved in 50% of patients and coronary angiography was normal or near normal in 36% of patients. Half of the 44 patients in the heart failure group died within 2 years of heart failure diagnosis. Ascites and end-stage renal failure requiring dialysis were significantly more frequent during follow-up in the heart failure group than in the control group (respectively, 10/44 vs 0/44 [P=0.001] and 18/44 vs 5/44 [P=0.003]).

Conclusion: In heart transplant recipients presenting with heart failure, systolic left ventricular function is frequently preserved and coronary angiography is frequently abnormal, but may be normal or near normal. During follow-up, the main features of these patients are a high mortality rate after heart failure diagnosis, a frequent need for renal dialysis and frequent ascites.
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http://dx.doi.org/10.1016/j.acvd.2016.01.003DOI Listing
April 2016

An uncommon cause of tricuspid regurgitation: three-dimensional echocardiographic incremental value, surgical and genetic insights.

Eur J Cardiothorac Surg 2016 Jul 15;50(1):180-2. Epub 2015 Dec 15.

Aix Marseille Université, GMGF 13385, Marseille, France Inserm, UMR_S910, 13385 Marseille, France

Congenital tricuspid valve disease is a rare defect that includes regurgitation, stenosis and Ebstein's anomaly. We report a case of severe tricuspid regurgitation associated with functional mitral regurgitation in a 47-year-old man with congestive heart failure. Transthoracic echocardiography (TTE) ruled out any Ebstein's anomaly. Three-dimensional TTE revealed a 'tricuspid hole' into the anterior leaflet that was only attached to the tricuspid annulus next to both anteroseptal and anteroposterior commissures. There was no sign of leaflet tear or perforation. The surgical repair of the tricuspid and mitral valves was performed with an optimal result. No sign of endocarditis or rheumatic disease was observed during the intervention. Sequence analysis of GATA4, HEY2 and ZFPM2 genes was performed, but no causative mutation was identified.
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http://dx.doi.org/10.1093/ejcts/ezv423DOI Listing
July 2016

Rapid Deployment of Aortic Bioprosthesis in Elderly Patients With Small Aortic Annulus.

Ann Thorac Surg 2016 Apr 18;101(4):1434-41. Epub 2015 Nov 18.

Department of Cardiac Surgery, La Timone Hospital, Marseille, France.

Background: Aortic valve replacement in elderly patients with a small aortic annulus remains challenging. Patient-prosthesis mismatch (PPM) should be prevented without impacting operative mortality. Hemodynamic benefits resulting from rapid-deployment aortic valve replacement with the Edwards Intuity bioprosthesis for this indication were evaluated.

Methods: Elective patients with severe aortic stenosis who required an Edwards Intuity bioprosthesis, size 19 mm and 21 mm, were prospectively included between July 2012 and July 2014. Transthoracic echocardiography was performed preoperatively and at 1-month follow-up.

Results: Sixty-six consecutive patients (mean age, 78 ± 6.4 years; 54.5% women) were included. The Intuity 19 mm was inserted in 29 patients, and the Intuity 21 mm was inserted in 37 patients. No deaths or aortic annulus ruptures occurred. Mean aortic cross-clamp time was 42.7 ± 18.2 minutes. At the 1-month follow-up, mean New York Heart Association classification was 1.6 ± 0.5 versus 2.2 ± 0.8 (p < 0.001). The mean gradient decreased from 59 ± 17.6 mm Hg to 13.7 ± 4.4 mm Hg (p < 0.001). Mean indexed effective orifice area was 0.77 ± 0.17 cm(2)/m(2) for the Intuity 19 mm and 1.01 ± 0.32 cm(2)/m(2) for the Intuity 21 mm. Twenty-one patients (32%) had a moderate PPM (indexed effective orifice area < 0.85 cm(2)/m(2)), and 10 patients (15%) had a severe PPM (indexed effective orifice area < 0.65 cm(2)/m(2)). The mean gradient was 15.1 ± 3.5 mm Hg and 16.9 ± 4.9 mm Hg in the moderate PPM group and severe PPM group, respectively (p = 0.3). The left ventricular mass index dramatically decreased from 153.2 ± 32.7 g/m(2) to 118.4 ± 20.2 g/m(2) (p < 0.001), and only 1 patient (1.5%) had a periprosthetic regurgitation greater than 1.

Conclusions: Regarding the low rate of severe PPM and the early regression of left ventricular mass, these preliminary studies indicate the potential benefit of the Intuity bioprosthesis in patients with a small aortic annulus. Midterm results should be evaluated.
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http://dx.doi.org/10.1016/j.athoracsur.2015.09.024DOI Listing
April 2016

Sequential management of post-myocardial infarction ventricular septal defects.

Arch Cardiovasc Dis 2015 May 6;108(5):321-30. Epub 2015 Mar 6.

Cardiologie Congénitale et Interventionelle, CHU la Timone, 13385 Marseille, France. Electronic address:

Background: Ventricular septal defect (VSD) after acute myocardial infarction is a catastrophic event.

Aims: We describe our multicentre experience of a defect closure strategy that combined surgery and transcatheter closure.

Methods: Data were obtained by retrospective chart review.

Results: Twenty patients (mean age, 67 years) from three centres were studied. Median time from myocardial infarction to VSD was 6 (range, 3-9) days. Acute cardiogenic shock occurred in 12 (60%) patients. Median defect diameter by echocardiography was 18 (range, 12-28) mm. Median time to first surgical or percutaneous closure was 18 (range, 4-96) days. Twenty-seven procedures were performed in the 20 patients. Surgical closure was undertaken in 14 patients and contraindicated in eight, six of whom underwent percutaneous closure; the other two, after reconsideration, proceeded to surgical closure. No procedural complications occurred with percutaneous closure. Percutaneous closure patients were older than surgical patients (75 vs. 64 years; P=0.01) and had a higher mean logistic EuroSCORE (87% vs. 67%; P=0.02). Rates of residual shunt and mortality did not differ between surgical and percutaneous patients (P=0.12 and 0.3, respectively). Those who underwent early VSD closure (<21 days after myocardial infarction) had higher rates of residual shunt (P=0.09) and mortality (P=0.01), irrespective of closure strategy. The mortality rate was also higher after early percutaneous closure (P=0.001), but not after early surgery. Finally, predicted mortality (logistic EuroSCORE) was higher than hospital mortality (≤30 days) in our patient population (75% vs. 30%; P=0.01).

Conclusion: Vigorous pursuit of closure of post-myocardial infarction VSD with a sequential surgical and/or percutaneous approach is recommended for improved outcomes.
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http://dx.doi.org/10.1016/j.acvd.2015.01.005DOI Listing
May 2015

Infective endocarditis: prevention, diagnosis, and management.

Can J Cardiol 2014 Sep 3;30(9):1046-57. Epub 2014 Apr 3.

Département de Cardiologie, Centre Hospitalier Universitaitre de Marseille, Hôpital de la Timone, Aix-Marseille Université, Marseille, France.

Infective endocarditis (IE) is among the most severe infectious disease, the prevention of which has not decreased its incidence. The age of patients and the rate of health care-associated IE have increased as a consequence of medical progress. The prevention strategies have been subjected to an important debate and nonspecific hygiene measures are now placed above the use of antibiotic prophylaxis. Indeed, the level of evidence of antibiotic prophylaxis efficiency is low and the indications of its prescription have been restricted in the recent international guidelines. In cases carrying a high suspicion of IE, efforts should be made to rapidly identify patients with a definite or highly probable diagnosis of IE and to find the causative pathogen to ensure that appropriate treatment, including urgent valvular surgery, begins promptly. Although echocardiography remains the main accurate imaging modality to identify endocardial lesions associated with IE, it can be negative or inconclusive especially in cases of prosthetic valve or other intracardiac devices. Recent studies demonstrated the diagnostic value of other imaging strategies including cardiac computed tomography (CT), positron emission tomography/CT, radiolabelled leukocyte single-photon emission CT/CT, and cerebral magnetic resonance imaging. Novel perspectives on the management of endocarditis are emerging and offer a hope for decreasing the rate of residual deaths by accelerating the processes of diagnosis, risk stratification, and instauration of antimicrobial therapy. Moreover, the rapid transfer of high-risk patients to specialized mediosurgical centres (IE team), the development of new surgical modalities, and close long-term follow-up are of crucial importance.
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http://dx.doi.org/10.1016/j.cjca.2014.03.042DOI Listing
September 2014

Prediction of symptomatic embolism in infective endocarditis: construction and validation of a risk calculator in a multicenter cohort.

J Am Coll Cardiol 2013 Oct 7;62(15):1384-92. Epub 2013 Aug 7.

Département de Cardiologie Hôpital Universitaire de la Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France; Service de Chirurgie Cardiaque, Hôpital Universitaire de la Timone, Assistance Publique Hôpitaux de Marseille, Aix-Marseille Université, Marseille, France.

Objectives: The aim of this study was to develop and validate a simple calculator to quantify the embolic risk (ER) at admission of patients with infective endocarditis.

Background: Early valve surgery reduces the incidence of embolism in high-risk patients with endocarditis, but the quantification of ER remains challenging.

Methods: From 1,022 consecutive patients presenting with definite diagnoses of infective endocarditis in a multicenter observational cohort study, 847 were randomized into derivation (n = 565) and validation (n = 282) samples. Clinical, microbiological, and echocardiographic data were collected at admission. The primary endpoint was symptomatic embolism that occurred during the 6-month period after the initiation of treatment. The prediction model was developed and validated accounting for competing risks.

Results: The 6-month incidence of embolism was similar in the development and validation samples (8.5% in the 2 samples). Six variables were associated with ER and were used to create the calculator: age, diabetes, atrial fibrillation, embolism before antibiotics, vegetation length, and Staphylococcus aureus infection. There was an excellent correlation between the predicted and observed ER in both the development and validation samples. The C-statistics for the development and validation samples were 0.72 and 0.65, respectively. Finally, a significantly higher cumulative incidence of embolic events was observed in patients with high predicted ER in both the development (p < 0.0001) and validation (p < 0.05) samples.

Conclusions: The risk for embolism during infective endocarditis can be quantified at admission using a simple and accurate calculator. It might be useful for facilitating therapeutic decisions.
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http://dx.doi.org/10.1016/j.jacc.2013.07.029DOI Listing
October 2013

Positron emission tomography/computed tomography for diagnosis of prosthetic valve endocarditis: increased valvular 18F-fluorodeoxyglucose uptake as a novel major criterion.

J Am Coll Cardiol 2013 Jun 10;61(23):2374-82. Epub 2013 Apr 10.

Département de Cardiologie, Hôpital de la Timone, AP-HM, Aix-Marseille Université, Marseille, France.

Objectives: This study sought to determine the value of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) for diagnosing prosthetic valve endocarditis (PVE).

Background: The diagnosis of PVE remains challenging. In PVE cases, initial echocardiography is normal or inconclusive in almost 30%, leading to a decreased diagnostic accuracy for the modified Duke criteria.

Methods: We prospectively studied 72 consecutive patients suspected of having PVE. All of the patients were subjected to clinical, microbiological, and echocardiographic evaluation. Cardiac PET/CT was performed at admission. The final diagnosis was defined according to the clinical and/or pathological modified Duke criteria determined during a 3-month follow-up.

Results: Thirty-six patients (50%) exhibited abnormal FDG uptake around the site of the prosthetic valve. The sensitivity, specificity, positive predictive value, negative predictive value, and global accuracy were as follows (95% confidence interval): 73% (54% to 87%), 80% (56% to 93%), 85% (64% to 95%), 67% (45% to 84%), and 76% (63% to 86%), respectively. Adding abnormal FDG uptake around the prosthetic valve as a new major criterion significantly increased the sensitivity of the modified Duke criteria at admission (70% [52% to 83%] vs. 97% [83% to 99%], p = 0.008). This result was due to a significant reduction (p < 0.0001) in the number of possible PVE cases from 40 (56%) to 23 (32%).

Conclusions: The use of (18)F-FDG PET/CT was helpful for diagnosing PVE. The results of this study support the addition of abnormal FDG uptake as a novel major criterion for PVE.
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http://dx.doi.org/10.1016/j.jacc.2013.01.092DOI Listing
June 2013

Three-dimensional transesophageal echocardiography assessment of a successful transcatheter mitral valve in valve implantation for degenerated bioprosthesis.

Echocardiography 2013 Jul 12;30(6):E152-5. Epub 2013 Mar 12.

Department of Cardiac Surgery, La Timone Hospital, Marseille, France.

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off-label alternative for patients contra-indicated to surgery. We report a 46-year-old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra-prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three-dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.
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http://dx.doi.org/10.1111/echo.12177DOI Listing
July 2013

Excess mortality and morbidity in patients surviving infective endocarditis.

Am Heart J 2012 Jul 13;164(1):94-101. Epub 2012 Jun 13.

Département de Cardiologie, Hôpital La Timone, Aix-Marseille Université, Marseille, France.

Background: Mortality and morbidity associated with infective endocarditis may extend beyond successful treatment. The primary objective was to analyze rates, temporal changes, and predictors of excess mortality in patients surviving the acute phase of endocarditis. The secondary objective was to determine the rate of recurrence and the need for late cardiac surgery.

Methods: An observational cohort study was conducted at a university-affiliated tertiary medical center, among 328 patients who survived the active phase of endocarditis. We used age-, sex-, and calendar year-specific mortality hazard rates of the Bouches-du-Rhone French district population to calculate expected survival and excess mortality. The risk of recurrence and late valve surgery was also assessed.

Result: Compared with expected survival, patients surviving a first episode of endocarditis had significantly worse outcomes (P = .001). The relative survival rates at 1, 3, and 5 years were 92% (95% CI, 88%-95%), 86% (95% CI, 77%-92%), and 82% (95% CI, 59%-91%), respectively. This excess mortality was observed during the entire follow-up period but was the highest during the first year after hospital discharge. Most of the recurrences and late cardiac surgeries also occurred during this period. Women exhibited a higher risk of age-adjusted excess mortality (adjusted excess hazard ratio, 2.0; 95% CI, 1.05-3.82; P = .03). Comorbidity index, recurrence of endocarditis, and history of an aortic valve endocarditis in women were independent predictors of excess mortality.

Conclusions: These results justify close monitoring of patients after successful treatment of endocarditis, at least during the first year. Special attention should be paid to women with aortic valve damage.
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http://dx.doi.org/10.1016/j.ahj.2012.04.003DOI Listing
July 2012

Risk of reoperation for mitral bioprosthesis dysfunction.

J Heart Valve Dis 2012 Jan;21(1):56-60

Service de Chirurgie Cardiaque, Hôpital de la Timone, Marseille, France.

Background And Aim Of The Study: Today, when a mitral valve replacement is required, more patients and surgeons choose a bioprosthesis. Yet, the rationale of this choice is unclear in patients in whom age represents a predicting factor for reoperation. The study aim was to define the risk factors for reoperation after mitral bioprosthesis failure.

Methods: A total of 282 consecutive patients (202 women, 80 men; mean age at surgery 61 years; range: 28-88 years) who underwent reoperation for mitral bioprosthesis failure between 1990 and 2006 was reviewed. Surgery was undertaken because of bioprosthesis degeneration (91%), prosthetic valve infective endocarditis (6%), paravalvular leak (2%), or other causes (1%). Emergency procedures were performed in 7% of cases. Associated procedures included tricuspid valve surgery in 16% of patients (tricuspid valve repair in 11%, tricuspid valve replacement in 5%) and coronary artery bypass graft in 5%. Almost one-fifth of patients (18%) had undergone more than one previous mitral valve replacement.

Results: The overall operative mortality was 7.4% (n = 21). Factors identified (by multivariate analysis) as predictors of operative death included: presence of diabetes mellitus (odds ratio (OR) = 8.69, 95% CI 2.55-29.61; p = 0.001), chronic obstructive pulmonary disease (OR = 9.01, 95% CI 1.72-47.18; p = 0.009), NYHA class III/IV (OR 5.46, 95% CI 1.41-21.16; p = 0.01), and pulmonary artery pressure > 60 mmHg (OR = 3.13, 95% CI 1.10-8.94; p = 0.03). Associated procedures were not significant risk factors for mortality. New prostheses were mechanical in 68% of cases, and bioprostheses in 32%.

Conclusion: One reoperation for mitral bioprosthesis dysfunction is acceptable if the patient can be expected to survive to reoperation while free from comorbidities and the severe effects of mitral disease. The application of strict selective criteria to recipients at the first valve replacement, combined with a close follow up, may allow this goal to be achieved.
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January 2012