Are valve repairs associated with better outcomes than replacements in patients with native active valve endocarditis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether valve replacement was associated with higher morbidity and mortality rates than valve repair in patients with native active valve endocarditis. Altogether 662 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Traditionally, valve replacement has been the standard therapy for valve endocarditis when surgical treatment is indicated. But now valve repair is increasingly used as an alternative, which may avoid disadvantages of anticoagulation, lower the risk of prosthetic infection and improve postoperative survival. To compare outcomes of these two treatments between studies can be difficult because most of related papers contain raw data on prosthetic valve endocarditis or healed endocarditis, which were excluded from our manuscript. Studies only analysing the outcomes of either of these treatments without the comparison of valve repair and replacement were also excluded. Finally, seven papers were identified. The American Heart Association/American College of Cardiology 2006 valvular guidelines recommended that mitral valve repair should be performed instead of replacement when at all possible. In three of the seven studies, there were significant differences between valve repair and replacement in long-term survival. One study found that aortic valve repair offered better outcomes in freedom from reoperation at 5 years (P = 0.021) and in survival at 4 years (repair vs replacement 88 vs 65%; P = 0.047). One study reported that there was improved event-free survival at 10 years in the mitral valve repair group (P = 0.015), although there was more previous septic embolization in this group. In one study, early and late mortality and event-free survival were better in patients undergoing mitral valve repair compared with replacement (P <0.05), and mitral valve replacement was an independent risk factor for early and late death (P <0.05). In another study, patients having mitral valve repair rather than replacement for acute endocarditis demonstrated improved event-free survival and lower in-hospital mortality, but this failed to reach significance. The remaining two studies showed similar overall survival for both repair and replacement patients. With regard to native active mitral or aortic valve endocarditis, valve repair seems to offer better outcomes in morbidity and long-term survival compared with valve replacement. Whenever it is possible according to the preoperative conditions and intraoperative findings, valve repair should be preferred.