Surgical treatment of active native mitral infective endocarditis: A meta-analysis of current evidence

Abstract Background The native mitral lesion of active infective endocarditis implies a poor prognosis and is associated with adverse short- or long-term results without surgical treatment. Both mitral valvuloplasty (MVP) and mitral valve replacement (MVR) have been performed in the treatment of active native mitral infective endocarditis (ANMIE). However, the outcomes of the two approaches remain unclear. The aim of this study was to systematically review the two procedures with mortality and survival as the primary endpoints. Methods A systematic review of the literature was conducted to identify all relevant studies with comparative data on MVP versus MVR for the treatment of ANMIE. Information on baseline characteristics of patients, operation method, quality of literature, follow-up, and so forth was abstracted using standardized protocols. Pooled odds ratio (OR) or hazard ratio (HR) was calculated and possible publication bias was tested. Results Nine comparative observational studies with a total of 633 patients (MVP = 265, MVR = 368) were identified for qualitative assessment, data extraction, and analysis. The summary OR for operative mortality, comparing repair with replacement, was 0.37 (95% CI 0.0.18–0.80; p  = 0.0005). Summary 1- and 5-year HRs for event-free survival were 0.43 (95% CI 0.20–0.92; p  = 0.03) and 0.44 (95% CI 0.25–0.77, p  = 0.004), respectively (repair vs. replacement). Summary 1- and 5-year survival HRs were 0.51 (95% CI 0.24–1.08; p  = 0.08) and 0.55 (95% CI 0.32–0.96; p  = 0.004), respectively (repair vs. replacement). No heterogeneity was revealed between studies, and possible publication bias was insignificant. Conclusions This meta-analysis suggests that MVP may be associated with superior postoperative survival outcomes compared with MVR. MVP is desirable, if possible, as a durable alternative to replacement. However, we must consider the influence of different patient characteristics and surgeons' preferences on the choice of surgical approach, and additional powered clinical trials will be required to confirm these findings.