Outcome of Infective Endocarditis and Concomitant Procedures in Patients Undergoing Mitral Valve Surgery

Outcome of Infective Endocarditis and Concomitant Procedures in Patients Undergoing Mitral Valve Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Outcome of Infective Endocarditis and Concomitant Procedures in Patients Undergoing Mitral Valve Surgery Basel Jobeir, Abdelkarim De Vol, Ziyad Alanazi, Domenico Galzerano, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4536435/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Oct, 2024 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 29 You are reading this latest preprint version Abstract Background The incidence of infective endocarditis (IE) in patients undergoing redo mitral valve (MV) surgery was evaluated, and the outcomes of all patients who underwent redo MV surgery were analyzed. Method This was a retrospective review with prospective follow-up of electronic medical records from patients admitted for redo MV surgery at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, from 2009 to 2019. Result A total of 211 patients underwent redo MV surgery, 41 of whom (19.4%) had IE. In 51% of patients, IE developed after the initial MV surgery. MV stenosis was moderate/severe in 50 patients, while moderate/severe MV regurgitation was present in 89 patients. Factors influencing mortality included age, peripheral vascular disease, concomitant PVD procedures, red blood cell transfusions, preoperative mechanical valves, and active IE. Cardiac events were the leading cause of mortality (69.4%), followed by sepsis and brain-related causes. Conclusion While redo MV surgery has acceptable outcomes, the presence of IE, PVD, and concomitant procedures is a significant complication in these patients. Our study highlights the need for careful patient management and more in-depth research in this area. Redo Mitral Valve Surgery Infective Endocarditis Concomitant Procedures Outcome Cardiac Reoperative Outcomes High Risk Patients Figures Figure 1 Figure 2 Introduction Redo Mitral Valve (MV) surgery is the standard of care for patients with history of MV diseases, such as bioprosthetic dysfunction and failed MV repair, after their initial cardiac surgery ( 1 , 2 ). Common complications of redo MV replacement include increased risk for major adverse events, 30-day mortality, and an independent predictor in the STS risk models is active infective endocarditis (IE), particularly in patients with prosthetic valve endocarditis (PVE) ( 3 , 4 ). For patients presenting with IE, cardiac surgery is indicated when presenting with congestive heart failure, prevention of systemic embolization, or uncontrolled infection ( 5 , 6 ). Patients with IE undergoing MV surgery experience worse immediate and midterm morbidity and mortality compared to those undergoing other MV surgeries ( 3 , 7 – 9 ); in particular, when patients develop PVE which has a 24–35% mortality rate in cardiac surgery patients ( 10 ). Prevalence of IE is 2–8 cases per 100,000, and it is expected to rise due to more prosthetic cardiac procedures ( 7 ); PVE constitutes 10–30% of IE cases and affects 6% in patients with prosthetic valve ( 10 ). The cardiac valves commonly affected in PVE include the aortic, mitral, and multiple valves with varying frequency of 66.5%, 40.7%, and 7.2%, respectively ( 11 ). The current literature for MV redo surgery presents a wide range of outcomes for the 30-day mortality rates, ranging from 1.3–17.4% ( 12 , 13 ), and reaching 22.4% when all patients, especially those undergoing concomitant procedures, are included without exclusions ( 1 ). We hypothesized the factors that predict mortality are IE (especially active IE) and the presence of any concomitant procedure. We investigated the outcomes and prevalence of IE, as well as the quality of life among all patients undergoing redo MV replacement at our institute. Material and Methods Study Population The study retrospectively reviewed and prospectively followed up on the electronic medical records (EMR) of all 211 qualified patients admitted for redo MV surgery at King Faisal Specialist Hospital and Research center (KFSHRC), Riyadh, Saudi Arabia. IRB approval number 2191219 was obtained on 06/Aug/2019 by KFSHRC and the consent was waived from the patients by the research ethics committee. The EMR documented the valvular procedures, the type of procedure on the last intervened valve, the prosthesis/intervention type, EuroSCORE-II, STS score, and relevant data from patients with surgery between 2009–2019. Outcomes The primary endpoint was factors affecting mortality. Secondary endpoints included IE incidence across MV types, MACE freedom (the absence of cardiac death, myocardial infarction, stroke, and major bleeding), and quality of life assessed using the New York Heart Association (NYHA) score. The NYHA score ranges from I to IV; I indicates no shortness of breath or limitations to ordinary physical activity, while IV indicates shortness of breath at rest. Statistical Analysis Descriptive analysis for all patients including demographics, comorbidities, and clinical data from pre- intra-, and post-operative stages, along with adverse clinical events were analyzed. Continuous variables were reported as mean ± standard deviation, and categorical variables as frequencies and percentages. Comparisons were made using chi-square tests, Student's t-test, ANOVA, and McNemar’s with statistical significance set at p < 0.05. Statistically significant variables were included in the multivariate logistic regression, data analysis was conducted on STATA (version 16) and R package using rBiostatistics.com. Results Among the 211 patients, 121 patients had concomitant procedures and 41 patients had IE. None of the patients had carotid. Surgery for active IE was indicated in 21 patients at the time of surgery, while 20 patients had previously treated IE before their MV redo. all preoperative variables are listed in Table 1 . Table 1 Preoperative variables (n = 211) Variable Result Male Female 33.2% (n = 70) 66.8% (n = 141) Age (Years) 46 ± 13 (Range 15–85) Height (CM) 160 ± 9.4 (Range 137–189) Weight (KG) 70.5 ± 17.6 (Range 36–134) BSA (M 2 ) 1.73 ± 0.23 (Range 1.2–2.4) BMI (KG/M 2 ) 27.5 ± 6.6 (Range 15.5–53) EuroSCORE-II 22.5 ± 14.7 (Range 4–79.3) STS score 3.6 ± 3.1 (Range 0.5–21.5) NYHA-i NYHA-ii NYHA-iii NYHA-iv 7% (N = 15) 27.5% (N = 56) 39.3% (N = 83) 27% (N = 57) Hypertension 22.3% (N = 47) Diabetes 17.1% (N = 36) Dyslipidemia 9.5% (N = 20) H/O lung disease 9.5% (N = 20) Syncope 1.9% (N = 4) Stroke 10% (N = 21) PVD 2.8% (N = 6) Neurological disorder 3.8% (N = 8) H/O Dialysis 8.5% (N = 18) Chemo and radio therapy 0.5% (N = 1) CTD SLE 2.4% (N = 5) 80% (N = 4) Cancer Metastasis 0.5% (N = 1) Atrial fibrillation Chronic Paroxysmal 49.8% (N = 105) 88.6% (N = 93) 11.4% (N = 12) RHD 84.8% (N = 179) H/O MI MI 90 days 1.9% (N = 4) 25% (N = 1) 75% (N = 3) Number of redos First redo Second redo Third redo Fourth redo Fifth redo Sixth redo 65.9% (N = 139) 7.6% (N = 16) 16.1% (N = 34) 8.5% (N = 18) 1.4% (N = 3) 0.5% (N = 1) IE emerged after the initial MV surgery in 20 patients (49%) and after the second redo in 8 patients (20%). Each of mechanical and bioprosthetic MVs had 18 patients with IE, 4 patients had IE on the native MV, and 1 patient on the repaired MV. IE recurred in 3 patients (7%); two had mechanical MV affected post-surgery (one each after the first and second surgeries), and 1 case had a bioprosthetic MV affected after the first surgery. From the 41 IE patients, 61% had positive IE cultures predominantly with staphylococcal species (56%). Laboratory Tests and Echocardiography Renal and liver function tests were performed at three intervals: one week before surgery, immediately before surgery, and immediately after surgery ( Table 2 ) . There was a significant difference in INR values between the tests conducted one week prior to surgery vs. immediately post-surgery (p-value < 0.0001). Table 2 Renal and liver function tests Type of Test 1-week preOP Immediately preOP Immediately postOP Urea (mmol/L) 6.4 ± 4.9 (Range 1.6–40.9) 6.6 ± 4.7 (Range 1.4–34.2) 6.3 ± 4.1 (Range 1.5–25) AST (U/L) 121 ± 693 (Range 1.6–7000) 93.9 ± 504 (Range 0–7000) 111.6 ± 499.5 (Range 5.9–7000) ALT (U/L) 71.4 ± 289.8 (Range 5–2583) 35.4 ± 94.6 (Range 1.9–1241.7) 41.7 ± 168.7 (Range 1.6–2320.9) INR 1.8 ± 0.8 (Range 0.9–4.6) 1.7 ± 0.74 (Range 0.9–5.1) 1.5 ± 0.5 (Range 0.8–4) Total bilirubin (umol/L) 26 ± 40.8 (Range 2.4–375.1) 21.5 ± 37.4 (Range 0–322.7) 2.2 ± 141 (Range 2.2–141.3) Creatinine (mmol/L) 85.3 ± 63.9 (Range 5.8–681) 82.7 ± 45.4 (Range 34–433) 90.9 ± 83.7 (Range 7.4–967) GFR (mL/min/1.73m2) 55.8 ± 10.2 (Range 8–60) 56.7 ± 8.9 (Range 11–60) 55.8 ± 10.9 (Range 0–60) Echocardiography results, when comparing preoperative data to the first follow-up (averaging 27 ± 116 days), revealed significant improvement in all valvular and cardiac parameters, with the exceptions of pulmonary valve stenosis, Left Ventricular Internal Diameter in diastole (LVIDd), and Left Ventricular Internal Diameter in systole (LVIDs) ( Table 3 ) . MV stenosis fully improved from 23.7% preoperatively to 0% postoperatively on first follow-up (p-value < 0.0001). Interestingly, LV function showed a marked decline, with the percentage of patients having moderately to severely reduced LVEF increasing from 9% preoperatively to 15.8% at the first postoperative follow-up. In contrast, Pulmonary hypertension improved significantly from 47.4% preoperatively to 37.3% postoperatively upon first follow-up (p-value = 0.0004). McNemar’s analysis of LVEF and RVEF is shown in Table 4 . Table 3 Echocardiography Results Pre and Post Operative Timing Immediately Preop (N = 211) Postop (N = 209) Mean Days = 27 Postop (N = 198) Mean Days = 776 Preop Vs. First F/U T-Test P-Value Preop Vs. Last F/U T-Test P-Value First F/U Vs. Last F/U P-Value MR No/Trace Mild Moderate Severe 44.1% (N = 93) 13.7% (N = 29) 16.1% (N = 34) 26.1% (N = 55) 89% (N = 186) 6.2% (N = 13) 1% (N = 2) 3.8% (N = 8) 82.8% (N = 113) 11.1% (N = 22) 2.5% (N = 5) 3.5% (N = 7) < 0.0001 < 0.0001 0.3173 MS No Mild Moderate Severe 73.9% (N = 156) 2.4% (N = 5) 3.3% (N = 7) 20.4% (N = 43) 99.5% (N = 208) 0.5% (N = 1) - - 98.5% (N = 195) 1.5% (N = 3) - - < 0.0001 < 0.0001 - TR No/Trace Mild Moderate Severe 24.7% (N = 52) 25.6% (N = 54) 28.4% (N = 60) 21.3% (N = 45) 47.4% (N = 99) 26.8% (N = 56) 20.1% (N = 42) 5.7% (N = 12) 38.9% (N = 77) 24.8% (N = 49) 25.8% (N = 51) 10.6% (N = 21) < 0.0001 0.0009 0.029 TS No/Trace Mild Moderate Severe 96.7% (N = 204) 1% (N = 2) 1.4% (N = 3) 1% (N = 2) 99.5% (N = 208) 0.5% (N = 1) 99% (N = 196) 0.5% (N = 1) 0.5% (N = 1) 0.0253 0.1025 0.3173 AR No/Trace Mild Moderate Severe 63.5% (N = 134) 16.6% (N = 35) 13.3% (N = 28) 6.6% (N = 14) 74.2% (N = 155) 17.2% (N = 36) 6.7% (N = 14) 1.9% (N = 4) 70.2% (N = 139) 15.7% (N = 31) 12.1% (N = 24) 2% (N = 4) 0.0003 0.0833 0.0499 AS No Mild Moderate Severe 88.6% (N = 187) 5.7% (N = 12) 2.4% (N = 5) 3.3% (N = 7) 95.2% (N = 199) 3.4% (N = 7) 1.4% (N = 3) 92.4% (N = 183) 4.6% (N = 9) 2% (N = 4) 1% (N = 2) 0.0225 0.1967 0.3173 LV Function Normal Mild Moderate Severe 58.3% (N = 123) 32.7% (N = 69) 7.1% (N = 15) 1.9% (N = 4) 52.2% (N = 109) 32.1% (n = 67) 6.2% (N = 13) 9.6% (N = 20) 49% (N = 97) 32.8% (N = 65) 15.2% (N = 30) 8.1% (N = 16) 0.0053 0.0000 00027 RV Function Normal Mild Moderate Severe 48.8% (N = 103) 32.2% (N = 68) 15.6% (N = 33) 3.3% (N = 7) 34.5% (N = 72) 30.1% (N = 63) 22% (n = 46) 13.4% (N = 28) 49% (N = 97) 26.8% (N = 53) 17.2% (N = 34) 7.1% (N = 14) < 0.0001 0.0113 0.0039 Pulmonary HTN 47.4% (N = 100) 43 ± 19.6 (Range 25–115) 37.3% (N = 78) 37.4 ± 15.7 (Range 25–75) 34.7% (N = 69) 36.1 ± 14.5 (Range 25–75) 0.0004 < 0.0001 0.3173 (0.2343) Table 4 Results of McNemar’s analysis. LVEF Pre-op 40% p-value post-op < 40% 11 22 40% 7 169 RVEF Pre-op 40% p-value Post-op 40% 8 127 Control is the preOP value. Case is postOP value. Exposed is “Severe/Moderate”. Unexposed is “Mild/Normal”. Operative characteristics The preoperative MV composition was as follows: bioprosthetic in 79 patients (37.4%), mechanical in 63 patients (29.9%), repaired in 60 patients (28.4%), and native in 9 patients (4.3%). Majority of patients underwent a redo MV replacement (98.9%) with a mechanical (59.7%) or bioprosthetic (38.4%) valves, while only 1.9% had a redo valve repair. McNemar test showed there was a significant change from tissue valve preop to mechanical postoperative in 40 patients (P = 0.009). The tricuspid valve was the most frequently involved in concomitant or previous surgeries, accounting for 38.9%. Post-surgery, 14.2% of the aortic valves and 14.6% of the pulmonary valves were non-native. The most common observed concomitant and/or previous procedure was valve replacement occurring in 188 of patients (89.3%). Majority had one redo in 139 patients (65.9%), while 16.1% required 3 cardiac surgeries redo. The average time to last redo was 14.2 years (Range 0.2–53). Intraoperative and postoperative characteristics are summarized in Table 5 . Table 5 Intraoperative and postoperative characteristics variable Result Mitral valve Repaired Mechanical Bioprosthetic 1.9% (N = 4) 59.7% (N = 126) 38.4% (N = 81) Tricuspid valve Native Repaired Mechanical Bioprosthetic 61.1% (N = 129) 19.9% (N = 42) 6.2% (N = 13) 12.8% (N = 27) Aortic valve Native Repaired Mechanical Bioprosthetic 75.8% (N = 160) 0.5% (N = 1) 15.6% (N = 33) 8% (N = 17) Pulmonary valve Native Repaired Mechanical Bioprosthetic 75.4% (N = 159) 0.5% (N = 1) 17.5% (N = 37) 6.6% (N = 14) Bentall procedure 5.2% (N = 11) Time to last redo (years) For all patients For IE patients For non-IE patients 14.2 ± 9.2 (Range 0.2–53) RBC (units) 4.2 ± 3.4 (Range 0–30) Platelets (units) 6.3 ± 4.8 (Range 0–30) FFP (units) 4 ± 5.1 (Range 0–60) Cardiopulmonary bypass time (min) 150.2 ± 75.9 (Range 39–460), N = 151 Aortic cross clamp time (min) 105.1 ± 56.8 (Range 27–285), N = 152 Intraoperative IABP Postoperative IABP 2.8% (N = 6) 2.4% (N = 5) Intraoperatively ECMO Duration (days) Postoperatively ECMO Duration (days) 2.8% (N = 6) 6.5 ± 7.9 (Range 1–22) 3.3% (N = 7) 5.3 ± 3.8 (Range 1–10) Circulatory arrest time (mins) 36.7 ± 8.5 (Range 27–43) Perioperative MI 1% (N = 2) ICU LOS (days) 10 ± 20.5 (Range 0-192) reintubation 3.8% (N = 8) ICU tracheostomy 5.7% (N = 12) Cardiac arrest postoperatively Resuscitated Failed resuscitation 7.6% (n = 16) 56.3% (N = 9) 43.7 (N = 7) Stroke 5.2% (N = 11) Severe bleeding Re-intervention for bleeding 10.4% (N = 22) 68.2% (N = 15) Infection Patients with multiple infections* UTI Wound infection Pneumonia BSI 18.5% (N = 39) 5.7% (N = 12) 10.3% (N = 4) 25.6% (N = 10) 59% (N = 23) 43.6% (N = 17) Arrythmia Atrial fibrillation/flutter Permanent pacemaker 46% (N = 97) 17.5% (N = 17) 46.4% (N = 44) Other cardiac problems 25.6% (N = 54) Noncardiac problems 6.6% (N = 14) Pulmonary embolism 1% (N = 2) Acute limb ischemia 1% (N = 2) Dialysis 5.7% (N = 12) Hospital LOS (days) 21 ± 24.1 (Range 0-192) NYHA-I NYHA-II NYHA-III NYHA-IV 7% (N = 15) 27.5% (N = 56) 39.3% (N = 83) 27% (N = 57) The average transfusion products required during surgery were 4.2 units of red blood cells (RBC), 6.3 units of platelets, and 4 units of fresh frozen plasma (FFP). Preoperative mechanical valves were associated with more bleeding (mean 4.73 units) compared to other MV types (mean 3.54 units) with a p-value of 0.0017. Patients with preoperative native valve repair had significantly fewer bleeding events (mean 2.11 units, p-value 0.006) than all other valves (mean 3.85 units). The average cardiopulmonary bypass and aortic cross clamp time during surgery were 150.2 minutes and 105.1 minutes, respectively. There was a significant shift from New York Heart Association (NYHA) class III and IV to class I and II, (p-value < 0.001). The Kaplan-Meier Curve for Survival estimates is shown in Fig. 1 . Patients with concomitant procedures had significant survival between the groups (P = 0.003), with a hazard ratio of 3.246 (95% CI: 1.417 to 7.434, p = 0.00535). In contrast, the hazard ratio for all IE patients showed an increased risk (HR = 1.84, 95% CI 0.88–3.84), however, it was not statistically significant (P = 0.1). Univariate Regression Analysis The primary objective of this study was to identify factors influencing mortality utilizing Cox regression model. For every 1-year increase in age, there was a 4.1% rise in mortality risk (P = 0.002, CI 1.02–1.07). Specifically, conditions like diabetes mellitus and stroke presented hazard ratios (HR) of 2.5 (P = 0.0185, CI 1.23–5.12) and 3.1 (P = 0.009, CI 1.33–7.12), respectively, while peripheral vascular disease (PVD) had the highest HR at 6.1 (P = 0.0065, CI 2.14–17.45). Significant determinants encompassed a history of dialysis (HR 3.4, P = 0.004, CI 1.47–7.78), the presence of a preoperative mechanical valve (HR 2.3, P = 0.014, CI 1.19–4.48), undergoing concomitant procedures (HR 3.2, P = 0.0021, CI 1.41–7.42), and having active IE (HR 3.8, P = 0.001, CI 1.78–8.15). Preoperative left and right ventricular ejection fractions were linked to heightened mortality risks, with HRs of 2.6 (P = 0.034, CI 1.07–6.23) and 3.8 (P < 0.001, CI 1.95–7.45), respectively. Elevated levels of creatinine (P = 0.007), urea (P < 0.001), total bilirubin (P < 0.001), ALT (P < 0.001), and AST (P < 0.001) were also associated with a rise in mortality. Redo cardiac surgery was associated with a significant 44.3% increase in mortality risk (P = 0.0063, CI 1.13–1.84). During surgery, PCC and FFP administrations were associated with increased mortality risks of 11.9% (P = 0.004, CI 1.04–1.21) and 5.2% (P < = 0.001, CI 1.04–1.21), respectively. Cardiac events were the leading cause of death (69.4%), followed by sepsis (11.1%), brain-related causes (5.6%), and other factors (13.9%). Most patients (89.1%) were discharged from the hospital. There was a significant association (P < 0.001) between patients who used Extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP). Multivariate Regression Analysis The Cox proportional-hazards regression analysis for the 211 cardiac surgery patients, with a mean follow-up of 2.9 years, showed a significant correlation between the evaluated variables and postoperative mortality ( Fig. 2 ) . In contrast, regression analysis on 24 patients, all of whom passed away within 25 days post-surgery revealed no significant associations Comment Our study's primary focus was to identify factors affecting mortality in high-risk patients undergoing redo MV surgery. The results showed each yearly increase in age had a 4.1% and each redo surgery had a 44.3% increase in mortality risk. While medical conditions like diabetes mellitus and stroke were significant determinants, with hazard ratios (HRs) of 2.5 and 3.1, respectively. Peripheral vascular disease (PVD) stood out as a significant risk factor with the highest HR at 6.1. However, it is crucial to highlight that only 2.8% of our patient cohort had PVD, which could introduce a potential bias in our finding. Other significant preoperative factors included a history of dialysis, presence of a preoperative mechanical valve, and active IE, with HRs of 3.4, 2.3, and 3.8, respectively. Kaplan-Meier curve showed a noticeable trend for IE patients to die postoperatively compared to non-IE patients ( Fig. 1 ) . Future research should address whether this trend is evident on the long term follow up. The adoption of biologic valve prostheses for MV replacement is on the rise increasing from 16.8% in 1993 to 53.7% in 2013 ( 14 ). However, our study showed significant change (P = 0.009) in patients who had bioprosthetic (37.4%) or mechanical (29.7%) valves preoperatively compared to the postoperative composition which was mainly mechanical (59.7%) and bioprosthetic (38.4%). This may suggest more careful selection for bioprosthetic MV in patients is required to lessen the need for redo cardiac surgeries. High-risk patients face greater risks when undergoing redo MV surgery, particularly those with IE or needing concomitant procedures. Our results showed a heightened IE risk in patients with mechanical MVs compared to bioprosthetic. However, Rutledge et al. noted equal IE susceptibility across valve types in the first post-replacement year ( 15 ). The MitraClip procedure, a type of percutaneous edge-to-edge MV repair, presents a low IE risk ( 16 ). In our cohort, IE occurred in patients with bioprosthetic (44%) and mechanical valves (44%), followed by native (10%) and repaired MV (2%), with MV recurrence occuring in 2 mechanical and 1 bioprosthetic. This may suggest patients undergoing redo mechanical MV surgery require careful follow-up and prophylaxis for IE. Our cohort showed an overestimation with EUROSCORE-II (22.5 ± 15), and an underestimation with STS score (3.6 ± 3.2). This is contrary to Keenan et al. where EUROSCORE-II underestimated mortality ( 17 ). Onorati et al. reported that EuroSCORE-II and STS-score effectively predict hospital mortality when EuroSCORE-II is > 13 or STS-score is > 7.4. However, lower score values lacked accuracy, especially in redo-patients. Intrestingly, STS-score was more predictive than EuroSCORE-II for mitral patients, emphasizing the importance of using both scoring systems ( 13 ). we need to have both scoring system and these mandates we need to have a specific scoring system that is more accurate and involves the elements of patient demographics and rheumatic heart disease. cardiac events emerged as the primary cause of mortality, accounting for 69.4% of deaths, followed by sepsis, brain-related complications, and other factors. Fortunately, the majority (89.1%) of our high-risk cohort were successfully discharged from the hospital. A significant association was identified between the intraoperative use of ECMO and IABP, emphasizing the importance of these interventions in the surgical setting. Utilizing the Cox proportional hazards model, we found age to be a crucial determinant in the risk of MACE post-cardiac surgery, with other significant contributors being diabetes mellitus and tracheostomy. Interestingly, Sex did not play a significant role in influencing this risk. Further analysis involving 211 cardiac surgery patients, with an average follow-up of 2.9 years, revealed associations between several parameters and postoperative mortality. These included age, peripheral vascular disease, concomitant surgical procedures, and preoperative left ventricular function, among others. However, a focused study on a subset of 24 patients that passed away within 25 days post-operatively, did not show significant correlations with postoperative MACE events. In conclusion, several factors were significantly associated with increased mortality risk in redo MV surgery patients. Identifying and addressing these factors can help improve patient outcomes in cardiac surgery. These results highlight the importance of close follow-up and vigorous complication prevention after MV replacement in patients with native valve IE. Limitations The study was conducted at a single tertiary hospital, predominantly involving patients with rheumatic heart disease. This specific patient demographic may introduce potential bias in the observed outcomes. Declarations Ethics approval and consent to participate IRB approval number 2191219; the consent was waived from by the research ethics committee. Consent for publication Not applicable Availability of data and materials Datasets generated and/or analysed during the current study are not publicly available due to hospital regulations but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding none References Zubarevich A, Szczechowicz M, Zhigalov K, Rad AA, Vardanyan R, Easo J, et al. Surgical redo mitral valve replacement in high-risk patients: The real-world experience. J Card Surg. 2021;36(9):3195–204. 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Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve in Valve From the National Inpatient Sample. J Am Heart Assoc. 2021;10(17):e020948. Rutledge R, Kim BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg. 1985;120(4):469–72. Boeder NF, Dorr O, Rixe J, Weipert K, Bauer T, Bayer M, et al. Endocarditis after interventional repair of the mitral valve: Review of a dilemma. Cardiovasc Revasc Med. 2017;18(2):141–4. Keenan NM, Newland RF, Baker RA, Rice GD, Bennetts JS. Outcomes of Redo Valve Surgery in Indigenous Australians. Heart Lung Circ. 2019;28(7):1102–11. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4536435","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318969154,"identity":"12787894-604f-4340-884e-6d1642007b1e","order_by":0,"name":"Basel Jobeir","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Basel","middleName":"","lastName":"Jobeir","suffix":""},{"id":318969156,"identity":"bdd1469d-6557-43f9-be3c-d05244320b2b","order_by":1,"name":"Abdelkarim De Vol","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Abdelkarim","middleName":"","lastName":"De Vol","suffix":""},{"id":318969157,"identity":"ae35ee7f-7540-49b5-9558-5cb66e88630e","order_by":2,"name":"Ziyad Alanazi","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Ziyad","middleName":"","lastName":"Alanazi","suffix":""},{"id":318969158,"identity":"c883d792-b445-4a71-8128-ba1a047cb2ea","order_by":3,"name":"Domenico Galzerano","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Domenico","middleName":"","lastName":"Galzerano","suffix":""},{"id":318969160,"identity":"777130d2-1463-4b66-8648-1c1344fef22d","order_by":4,"name":"Anas Jobeir","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Anas","middleName":"","lastName":"Jobeir","suffix":""},{"id":318969162,"identity":"9744d189-1ec3-4aaf-b8c2-ba20c99569cd","order_by":5,"name":"Aly Alsanei","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Aly","middleName":"","lastName":"Alsanei","suffix":""},{"id":318969166,"identity":"02665dde-c84c-4ac9-8209-c9b0c0a92629","order_by":6,"name":"Bahaa Fadel","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Bahaa","middleName":"","lastName":"Fadel","suffix":""},{"id":318969169,"identity":"4c623b0e-3b89-4ae1-9709-cd3a93627c96","order_by":7,"name":"Mohammed Alamri","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Alamri","suffix":""},{"id":318969172,"identity":"6f2d0166-2258-404c-bcdd-bdb4ee5f3eae","order_by":8,"name":"Zohair AlHalees","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":false,"prefix":"","firstName":"Zohair","middleName":"","lastName":"AlHalees","suffix":""},{"id":318969174,"identity":"89dba3c6-7082-41f2-8f5a-e4dfb2b2bdb9","order_by":9,"name":"Feras Khaliel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIie2PMQrCQBBFB4TdZmLaCSt6hQlCUAh4lbXZSlCwsdJUW+Uw5gZCMJUHsAzYeoAIFq6tRbKlxb5iGIZ5fD5AIPCHrC6YAewIxrJgP4UBjZsEAi9O0X5K850gSHsrkW07XkxF8qjaV5dvQdbXc5+yglimJdNcKLNPS22WBRpz70+JBSHT2qpNpkDXDITZgBLZ5M10ssnNW8FGuRTtsnyVERo1YUotfrsYw2Kwiyyz5Hk4zmJZV22X5+yWpleB0e9B9L4HAoFAwIsPIwQ4jyoARGYAAAAASUVORK5CYII=","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Center (KFSHRC)","correspondingAuthor":true,"prefix":"","firstName":"Feras","middleName":"","lastName":"Khaliel","suffix":""}],"badges":[],"createdAt":"2024-06-05 23:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4536435/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4536435/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-024-03063-5","type":"published","date":"2024-10-01T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59524990,"identity":"4e833128-efdf-441c-835b-e9b8b263e3a2","added_by":"auto","created_at":"2024-07-02 20:50:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":265075,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"OrderofFiguresforredoMVmanuscript1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4536435/v1/91f3006121eb8c870d59450f.jpg"},{"id":59524991,"identity":"88cae532-4ce6-4a5f-9f73-54004af8c1fa","added_by":"auto","created_at":"2024-07-02 20:50:09","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":247825,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend.\u003c/p\u003e","description":"","filename":"OrderofFiguresforredoMVmanuscript2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4536435/v1/26b2e4ed17357d1547f53d76.jpg"},{"id":66097483,"identity":"e89d5f00-9bc8-4b1c-982a-ca6abe20084b","added_by":"auto","created_at":"2024-10-07 16:14:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1199485,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4536435/v1/f0bef598-79ca-4d1d-97a3-1fcc62d9dd1b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outcome of Infective Endocarditis and Concomitant Procedures in Patients Undergoing Mitral Valve Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRedo Mitral Valve (MV) surgery is the standard of care for patients with history of MV diseases, such as bioprosthetic dysfunction and failed MV repair, after their initial cardiac surgery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Common complications of redo MV replacement include increased risk for major adverse events, 30-day mortality, and an independent predictor in the STS risk models is active infective endocarditis (IE), particularly in patients with prosthetic valve endocarditis (PVE) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). For patients presenting with IE, cardiac surgery is indicated when presenting with congestive heart failure, prevention of systemic embolization, or uncontrolled infection (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients with IE undergoing MV surgery experience worse immediate and midterm morbidity and mortality compared to those undergoing other MV surgeries (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e); in particular, when patients develop PVE which has a 24\u0026ndash;35% mortality rate in cardiac surgery patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Prevalence of IE is 2\u0026ndash;8 cases per 100,000, and it is expected to rise due to more prosthetic cardiac procedures (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e); PVE constitutes 10\u0026ndash;30% of IE cases and affects 6% in patients with prosthetic valve (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The cardiac valves commonly affected in PVE include the aortic, mitral, and multiple valves with varying frequency of 66.5%, 40.7%, and 7.2%, respectively (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The current literature for MV redo surgery presents a wide range of outcomes for the 30-day mortality rates, ranging from 1.3\u0026ndash;17.4% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and reaching 22.4% when all patients, especially those undergoing concomitant procedures, are included without exclusions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe hypothesized the factors that predict mortality are IE (especially active IE) and the presence of any concomitant procedure. We investigated the outcomes and prevalence of IE, as well as the quality of life among all patients undergoing redo MV replacement at our institute.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eStudy Population\u003c/p\u003e \u003cp\u003e The study retrospectively reviewed and prospectively followed up on the electronic medical records (EMR) of all 211 qualified patients admitted for redo MV surgery at King Faisal Specialist Hospital and Research center (KFSHRC), Riyadh, Saudi Arabia. IRB approval number 2191219 was obtained on 06/Aug/2019 by KFSHRC and the consent was waived from the patients by the research ethics committee. The EMR documented the valvular procedures, the type of procedure on the last intervened valve, the prosthesis/intervention type, EuroSCORE-II, STS score, and relevant data from patients with surgery between 2009\u0026ndash;2019.\u003c/p\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003cp\u003eThe primary endpoint was factors affecting mortality. Secondary endpoints included IE incidence across MV types, MACE freedom (the absence of cardiac death, myocardial infarction, stroke, and major bleeding), and quality of life assessed using the New York Heart Association (NYHA) score. The NYHA score ranges from I to IV; I indicates no shortness of breath or limitations to ordinary physical activity, while IV indicates shortness of breath at rest.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive analysis for all patients including demographics, comorbidities, and clinical data from pre- intra-, and post-operative stages, along with adverse clinical events were analyzed. Continuous variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables as frequencies and percentages. Comparisons were made using chi-square tests, Student's t-test, ANOVA, and McNemar\u0026rsquo;s with statistical significance set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Statistically significant variables were included in the multivariate logistic regression, data analysis was conducted on STATA (version 16) and R package using rBiostatistics.com.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAmong the 211 patients, 121 patients had concomitant procedures and 41 patients had IE. None of the patients had carotid. Surgery for active IE was indicated in 21 patients at the time of surgery, while 20 patients had previously treated IE before their MV redo. all preoperative variables are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePreoperative variables (n\u0026thinsp;=\u0026thinsp;211)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.2% (n\u0026thinsp;=\u0026thinsp;70)\u003c/p\u003e \u003cp\u003e66.8% (n\u0026thinsp;=\u0026thinsp;141)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 \u0026plusmn; 13 (Range 15\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (CM)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e160 \u0026plusmn; 9.4 (Range 137\u0026ndash;189)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (KG)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.5 \u0026plusmn; 17.6 (Range 36\u0026ndash;134)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSA (M\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.73 \u0026plusmn; 0.23 (Range 1.2\u0026ndash;2.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (KG/M\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.5 \u0026plusmn; 6.6 (Range 15.5\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEuroSCORE-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5 \u0026plusmn; 14.7 (Range 4\u0026ndash;79.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6 \u0026plusmn; 3.1 (Range 0.5\u0026ndash;21.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA-i\u003c/p\u003e \u003cp\u003eNYHA-ii\u003c/p\u003e \u003cp\u003eNYHA-iii\u003c/p\u003e \u003cp\u003eNYHA-iv\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7% (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003e27.5% (N\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003cp\u003e39.3% (N\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003cp\u003e27% (N\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.3% (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.1% (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyslipidemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5% (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH/O lung disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5% (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSyncope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10% (N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH/O Dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.5% (N\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemo and radio therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCTD\u003c/p\u003e \u003cp\u003eSLE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.4% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003e80% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer Metastasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003cp\u003eChronic\u003c/p\u003e \u003cp\u003eParoxysmal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.8% (N\u0026thinsp;=\u0026thinsp;105)\u003c/p\u003e \u003cp\u003e88.6% (N\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003cp\u003e11.4% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRHD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.8% (N\u0026thinsp;=\u0026thinsp;179)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eH/O MI\u003c/p\u003e \u003cp\u003eMI\u0026thinsp;\u0026lt;\u0026thinsp;21 days\u003c/p\u003e \u003cp\u003eMI\u0026thinsp;\u0026gt;\u0026thinsp;90 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003e25% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003e75% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of redos\u003c/p\u003e \u003cp\u003eFirst redo\u003c/p\u003e \u003cp\u003eSecond redo\u003c/p\u003e \u003cp\u003eThird redo\u003c/p\u003e \u003cp\u003eFourth redo\u003c/p\u003e \u003cp\u003eFifth redo\u003c/p\u003e \u003cp\u003eSixth redo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.9% (N\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003cp\u003e7.6% (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e16.1% (N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003cp\u003e8.5% (N\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003cp\u003e1.4% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIE emerged after the initial MV surgery in 20 patients (49%) and after the second redo in 8 patients (20%). Each of mechanical and bioprosthetic MVs had 18 patients with IE, 4 patients had IE on the native MV, and 1 patient on the repaired MV. IE recurred in 3 patients (7%); two had mechanical MV affected post-surgery (one each after the first and second surgeries), and 1 case had a bioprosthetic MV affected after the first surgery. From the 41 IE patients, 61% had positive IE cultures predominantly with staphylococcal species (56%).\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eLaboratory Tests and Echocardiography\u003c/h2\u003e \u003cp\u003eRenal and liver function tests were performed at three intervals: one week before surgery, immediately before surgery, and immediately after surgery \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. There was a significant difference in INR values between the tests conducted one week prior to surgery vs. immediately post-surgery (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRenal and liver function tests\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eType of Test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1-week preOP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eImmediately preOP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eImmediately postOP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrea (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9 (Range 1.6\u0026ndash;40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 (Range 1.4\u0026ndash;34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1 (Range 1.5\u0026ndash;25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAST (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e121\u0026thinsp;\u0026plusmn;\u0026thinsp;693 (Range 1.6\u0026ndash;7000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;504 (Range 0\u0026ndash;7000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e111.6\u0026thinsp;\u0026plusmn;\u0026thinsp;499.5 (Range 5.9\u0026ndash;7000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eALT (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e71.4\u0026thinsp;\u0026plusmn;\u0026thinsp;289.8 (Range 5\u0026ndash;2583)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e35.4\u0026thinsp;\u0026plusmn;\u0026thinsp;94.6 (Range 1.9\u0026ndash;1241.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e41.7\u0026thinsp;\u0026plusmn;\u0026thinsp;168.7 (Range 1.6\u0026ndash;2320.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eINR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 (Range 0.9\u0026ndash;4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.74 (Range 0.9\u0026ndash;5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 (Range 0.8\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal bilirubin (umol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e26\u0026thinsp;\u0026plusmn;\u0026thinsp;40.8 (Range 2.4\u0026ndash;375.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;37.4 (Range 0\u0026ndash;322.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;141 (Range 2.2\u0026ndash;141.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreatinine (mmol/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e85.3\u0026thinsp;\u0026plusmn;\u0026thinsp;63.9 (Range 5.8\u0026ndash;681)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e82.7\u0026thinsp;\u0026plusmn;\u0026thinsp;45.4 (Range 34\u0026ndash;433)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e90.9\u0026thinsp;\u0026plusmn;\u0026thinsp;83.7 (Range 7.4\u0026ndash;967)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGFR (mL/min/1.73m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e55.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2 (Range 8\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e56.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 (Range 11\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e55.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9 (Range 0\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEchocardiography results, when comparing preoperative data to the first follow-up (averaging 27\u0026thinsp;\u0026plusmn;\u0026thinsp;116 days), revealed significant improvement in all valvular and cardiac parameters, with the exceptions of pulmonary valve stenosis, Left Ventricular Internal Diameter in diastole (LVIDd), and Left Ventricular Internal Diameter in systole (LVIDs) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. MV stenosis fully improved from 23.7% preoperatively to 0% postoperatively on first follow-up (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Interestingly, LV function showed a marked decline, with the percentage of patients having moderately to severely reduced LVEF increasing from 9% preoperatively to 15.8% at the first postoperative follow-up. In contrast, Pulmonary hypertension improved significantly from 47.4% preoperatively to 37.3% postoperatively upon first follow-up (p-value\u0026thinsp;=\u0026thinsp;0.0004). McNemar\u0026rsquo;s analysis of LVEF and RVEF is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEchocardiography Results Pre and Post Operative\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTiming\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eImmediately Preop (N\u0026thinsp;=\u0026thinsp;211)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePostop (N\u0026thinsp;=\u0026thinsp;209)\u003c/p\u003e \u003cp\u003eMean Days\u0026thinsp;=\u0026thinsp;27\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePostop (N\u0026thinsp;=\u0026thinsp;198)\u003c/p\u003e \u003cp\u003eMean Days\u0026thinsp;=\u0026thinsp;776\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePreop Vs. First F/U T-Test\u003c/p\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003ePreop Vs. Last F/U T-Test\u003c/p\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFirst F/U Vs. Last F/U P-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMR\u003c/p\u003e \u003cp\u003eNo/Trace\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.1% (N\u0026thinsp;=\u0026thinsp;93)\u003c/p\u003e \u003cp\u003e13.7% (N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003cp\u003e16.1% (N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003cp\u003e26.1% (N\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e89% (N\u0026thinsp;=\u0026thinsp;186)\u003c/p\u003e \u003cp\u003e6.2% (N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003e3.8% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.8% (N\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003cp\u003e11.1% (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003cp\u003e2.5% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003e3.5% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.3173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMS\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73.9% (N\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003cp\u003e2.4% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003e3.3% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003e20.4% (N\u0026thinsp;=\u0026thinsp;43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e99.5% (N\u0026thinsp;=\u0026thinsp;208)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98.5% (N\u0026thinsp;=\u0026thinsp;195)\u003c/p\u003e \u003cp\u003e1.5% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTR\u003c/p\u003e \u003cp\u003eNo/Trace\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.7% (N\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003cp\u003e25.6% (N\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003cp\u003e28.4% (N\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e \u003cp\u003e21.3% (N\u0026thinsp;=\u0026thinsp;45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e47.4% (N\u0026thinsp;=\u0026thinsp;99)\u003c/p\u003e \u003cp\u003e26.8% (N\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003cp\u003e20.1% (N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003cp\u003e5.7% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38.9% (N\u0026thinsp;=\u0026thinsp;77)\u003c/p\u003e \u003cp\u003e24.8% (N\u0026thinsp;=\u0026thinsp;49)\u003c/p\u003e \u003cp\u003e25.8% (N\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003cp\u003e10.6% (N\u0026thinsp;=\u0026thinsp;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0009\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTS\u003c/p\u003e \u003cp\u003eNo/Trace\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7% (N\u0026thinsp;=\u0026thinsp;204)\u003c/p\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003cp\u003e1.4% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e99.5% (N\u0026thinsp;=\u0026thinsp;208)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e99% (N\u0026thinsp;=\u0026thinsp;196)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.0253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.1025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.3173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAR\u003c/p\u003e \u003cp\u003eNo/Trace\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.5% (N\u0026thinsp;=\u0026thinsp;134)\u003c/p\u003e \u003cp\u003e16.6% (N\u0026thinsp;=\u0026thinsp;35)\u003c/p\u003e \u003cp\u003e13.3% (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003cp\u003e6.6% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e74.2% (N\u0026thinsp;=\u0026thinsp;155)\u003c/p\u003e \u003cp\u003e17.2% (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003cp\u003e6.7% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003cp\u003e1.9% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.2% (N\u0026thinsp;=\u0026thinsp;139)\u003c/p\u003e \u003cp\u003e15.7% (N\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003cp\u003e12.1% (N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003cp\u003e2% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.0003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.0499\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAS\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.6% (N\u0026thinsp;=\u0026thinsp;187)\u003c/p\u003e \u003cp\u003e5.7% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003cp\u003e2.4% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003e3.3% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e95.2% (N\u0026thinsp;=\u0026thinsp;199)\u003c/p\u003e \u003cp\u003e3.4% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003e1.4% (N\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e92.4% (N\u0026thinsp;=\u0026thinsp;183)\u003c/p\u003e \u003cp\u003e4.6% (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003cp\u003e2% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.0225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.1967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.3173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLV Function\u003c/p\u003e \u003cp\u003eNormal\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.3% (N\u0026thinsp;=\u0026thinsp;123)\u003c/p\u003e \u003cp\u003e32.7% (N\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003cp\u003e7.1% (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003e1.9% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e52.2% (N\u0026thinsp;=\u0026thinsp;109)\u003c/p\u003e \u003cp\u003e32.1% (n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003cp\u003e6.2% (N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003cp\u003e9.6% (N\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49% (N\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003cp\u003e32.8% (N\u0026thinsp;=\u0026thinsp;65)\u003c/p\u003e \u003cp\u003e15.2% (N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003e8.1% (N\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.0053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e00027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRV Function\u003c/p\u003e \u003cp\u003eNormal\u003c/p\u003e \u003cp\u003eMild\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48.8% (N\u0026thinsp;=\u0026thinsp;103)\u003c/p\u003e \u003cp\u003e32.2% (N\u0026thinsp;=\u0026thinsp;68)\u003c/p\u003e \u003cp\u003e15.6% (N\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e3.3% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e34.5% (N\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e \u003cp\u003e30.1% (N\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003cp\u003e22% (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e \u003cp\u003e13.4% (N\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49% (N\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003cp\u003e26.8% (N\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003cp\u003e17.2% (N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003cp\u003e7.1% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.0113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.0039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary HTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47.4% (N\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e \u003cp\u003e43\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6 (Range 25\u0026ndash;115)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e37.3% (N\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e \u003cp\u003e37.4\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7 (Range 25\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.7% (N\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003cp\u003e36.1\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5 (Range 25\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.0004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003e0.3173\u003c/p\u003e \u003cp\u003e(0.2343)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResults of McNemar\u0026rsquo;s analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVEF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op\u0026thinsp;\u0026lt;\u0026thinsp;40%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-op\u0026thinsp;\u0026gt;\u0026thinsp;40%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epost-op\u0026thinsp;\u0026lt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epost-op\u0026thinsp;\u0026gt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e169\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRVEF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-op\u0026thinsp;\u0026lt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-op\u0026thinsp;\u0026gt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op\u0026thinsp;\u0026lt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.0081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-op\u0026thinsp;\u0026gt;\u0026thinsp;40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eControl is the preOP value. Case is postOP value.\u003c/p\u003e \u003cp\u003eExposed is \u0026ldquo;Severe/Moderate\u0026rdquo;. Unexposed is \u0026ldquo;Mild/Normal\u0026rdquo;.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOperative characteristics\u003c/h2\u003e \u003cp\u003eThe preoperative MV composition was as follows: bioprosthetic in 79 patients (37.4%), mechanical in 63 patients (29.9%), repaired in 60 patients (28.4%), and native in 9 patients (4.3%). Majority of patients underwent a redo MV replacement (98.9%) with a mechanical (59.7%) or bioprosthetic (38.4%) valves, while only 1.9% had a redo valve repair. McNemar test showed there was a significant change from tissue valve preop to mechanical postoperative in 40 patients (P\u0026thinsp;=\u0026thinsp;0.009). The tricuspid valve was the most frequently involved in concomitant or previous surgeries, accounting for 38.9%. Post-surgery, 14.2% of the aortic valves and 14.6% of the pulmonary valves were non-native. The most common observed concomitant and/or previous procedure was valve replacement occurring in 188 of patients (89.3%). Majority had one redo in 139 patients (65.9%), while 16.1% required 3 cardiac surgeries redo. The average time to last redo was 14.2 years (Range 0.2\u0026ndash;53). Intraoperative and postoperative characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative and postoperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMitral valve\u003c/p\u003e \u003cp\u003eRepaired\u003c/p\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eBioprosthetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003e59.7% (N\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e \u003cp\u003e38.4% (N\u0026thinsp;=\u0026thinsp;81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTricuspid valve\u003c/p\u003e \u003cp\u003eNative\u003c/p\u003e \u003cp\u003eRepaired\u003c/p\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eBioprosthetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.1% (N\u0026thinsp;=\u0026thinsp;129)\u003c/p\u003e \u003cp\u003e19.9% (N\u0026thinsp;=\u0026thinsp;42)\u003c/p\u003e \u003cp\u003e6.2% (N\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e \u003cp\u003e12.8% (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic valve\u003c/p\u003e \u003cp\u003eNative\u003c/p\u003e \u003cp\u003eRepaired\u003c/p\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eBioprosthetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.8% (N\u0026thinsp;=\u0026thinsp;160)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003e15.6% (N\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003cp\u003e8% (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary valve\u003c/p\u003e \u003cp\u003eNative\u003c/p\u003e \u003cp\u003eRepaired\u003c/p\u003e \u003cp\u003eMechanical\u003c/p\u003e \u003cp\u003eBioprosthetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.4% (N\u0026thinsp;=\u0026thinsp;159)\u003c/p\u003e \u003cp\u003e0.5% (N\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e \u003cp\u003e17.5% (N\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003cp\u003e6.6% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBentall procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2% (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime to last redo (years)\u003c/p\u003e \u003cp\u003eFor all patients\u003c/p\u003e \u003cp\u003eFor IE patients\u003c/p\u003e \u003cp\u003eFor non-IE patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.2 \u0026plusmn; 9.2 (Range 0.2\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRBC (units)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2 \u0026plusmn; 3.4 (Range 0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlatelets (units)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.3 \u0026plusmn; 4.8 (Range 0\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFFP (units)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 \u0026plusmn; 5.1 (Range 0\u0026ndash;60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiopulmonary bypass time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150.2 \u0026plusmn; 75.9 (Range 39\u0026ndash;460), N\u0026thinsp;=\u0026thinsp;151\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAortic cross clamp time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105.1 \u0026plusmn; 56.8 (Range 27\u0026ndash;285), N\u0026thinsp;=\u0026thinsp;152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative IABP\u003c/p\u003e \u003cp\u003ePostoperative IABP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003e2.4% (N\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperatively ECMO\u003c/p\u003e \u003cp\u003eDuration (days)\u003c/p\u003e \u003cp\u003ePostoperatively ECMO\u003c/p\u003e \u003cp\u003eDuration (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.8% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003cp\u003e6.5 \u0026plusmn; 7.9 (Range 1\u0026ndash;22)\u003c/p\u003e \u003cp\u003e3.3% (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003e5.3 \u0026plusmn; 3.8 (Range 1\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCirculatory arrest time (mins)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.7 \u0026plusmn; 8.5 (Range 27\u0026ndash;43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerioperative MI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 \u0026plusmn; 20.5 (Range 0-192)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ereintubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8% (N\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU tracheostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac arrest postoperatively\u003c/p\u003e \u003cp\u003eResuscitated\u003c/p\u003e \u003cp\u003eFailed resuscitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.6% (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003cp\u003e56.3% (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003cp\u003e43.7 (N\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.2% (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere bleeding\u003c/p\u003e \u003cp\u003eRe-intervention for bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.4% (N\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e \u003cp\u003e68.2% (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection\u003c/p\u003e \u003cp\u003ePatients with multiple infections*\u003c/p\u003e \u003cp\u003eUTI\u003c/p\u003e \u003cp\u003eWound infection\u003c/p\u003e \u003cp\u003ePneumonia\u003c/p\u003e \u003cp\u003eBSI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.5% (N\u0026thinsp;=\u0026thinsp;39)\u003c/p\u003e \u003cp\u003e5.7% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003cp\u003e10.3% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003cp\u003e25.6% (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e \u003cp\u003e59% (N\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003cp\u003e43.6% (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArrythmia\u003c/p\u003e \u003cp\u003eAtrial fibrillation/flutter\u003c/p\u003e \u003cp\u003ePermanent pacemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46% (N\u0026thinsp;=\u0026thinsp;97)\u003c/p\u003e \u003cp\u003e17.5% (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e \u003cp\u003e46.4% (N\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther cardiac problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.6% (N\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoncardiac problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.6% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePulmonary embolism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute limb ischemia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1% (N\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.7% (N\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital LOS (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 \u0026plusmn; 24.1 (Range 0-192)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNYHA-I\u003c/p\u003e \u003cp\u003eNYHA-II\u003c/p\u003e \u003cp\u003eNYHA-III\u003c/p\u003e \u003cp\u003eNYHA-IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7% (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003cp\u003e27.5% (N\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e \u003cp\u003e39.3% (N\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e \u003cp\u003e27% (N\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average transfusion products required during surgery were 4.2 units of red blood cells (RBC), 6.3 units of platelets, and 4 units of fresh frozen plasma (FFP). Preoperative mechanical valves were associated with more bleeding (mean 4.73 units) compared to other MV types (mean 3.54 units) with a p-value of 0.0017. Patients with preoperative native valve repair had significantly fewer bleeding events (mean 2.11 units, p-value 0.006) than all other valves (mean 3.85 units). The average cardiopulmonary bypass and aortic cross clamp time during surgery were 150.2 minutes and 105.1 minutes, respectively. There was a significant shift from New York Heart Association (NYHA) class III and IV to class I and II, (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe Kaplan-Meier Curve for Survival estimates is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients with concomitant procedures had significant survival between the groups (P\u0026thinsp;=\u0026thinsp;0.003), with a hazard ratio of 3.246 (95% CI: 1.417 to 7.434, p\u0026thinsp;=\u0026thinsp;0.00535). In contrast, the hazard ratio for all IE patients showed an increased risk (HR\u0026thinsp;=\u0026thinsp;1.84, 95% CI 0.88\u0026ndash;3.84), however, it was not statistically significant (P\u0026thinsp;=\u0026thinsp;0.1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eUnivariate Regression Analysis\u003c/h2\u003e \u003cp\u003eThe primary objective of this study was to identify factors influencing mortality utilizing Cox regression model. For every 1-year increase in age, there was a 4.1% rise in mortality risk (P\u0026thinsp;=\u0026thinsp;0.002, CI 1.02\u0026ndash;1.07). Specifically, conditions like diabetes mellitus and stroke presented hazard ratios (HR) of 2.5 (P\u0026thinsp;=\u0026thinsp;0.0185, CI 1.23\u0026ndash;5.12) and 3.1 (P\u0026thinsp;=\u0026thinsp;0.009, CI 1.33\u0026ndash;7.12), respectively, while peripheral vascular disease (PVD) had the highest HR at 6.1 (P\u0026thinsp;=\u0026thinsp;0.0065, CI 2.14\u0026ndash;17.45). Significant determinants encompassed a history of dialysis (HR 3.4, P\u0026thinsp;=\u0026thinsp;0.004, CI 1.47\u0026ndash;7.78), the presence of a preoperative mechanical valve (HR 2.3, P\u0026thinsp;=\u0026thinsp;0.014, CI 1.19\u0026ndash;4.48), undergoing concomitant procedures (HR 3.2, P\u0026thinsp;=\u0026thinsp;0.0021, CI 1.41\u0026ndash;7.42), and having active IE (HR 3.8, P\u0026thinsp;=\u0026thinsp;0.001, CI 1.78\u0026ndash;8.15).\u003c/p\u003e \u003cp\u003ePreoperative left and right ventricular ejection fractions were linked to heightened mortality risks, with HRs of 2.6 (P\u0026thinsp;=\u0026thinsp;0.034, CI 1.07\u0026ndash;6.23) and 3.8 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, CI 1.95\u0026ndash;7.45), respectively. Elevated levels of creatinine (P\u0026thinsp;=\u0026thinsp;0.007), urea (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), total bilirubin (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), ALT (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and AST (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were also associated with a rise in mortality. Redo cardiac surgery was associated with a significant 44.3% increase in mortality risk (P\u0026thinsp;=\u0026thinsp;0.0063, CI 1.13\u0026ndash;1.84). During surgery, PCC and FFP administrations were associated with increased mortality risks of 11.9% (P\u0026thinsp;=\u0026thinsp;0.004, CI 1.04\u0026ndash;1.21) and 5.2% (P\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.001, CI 1.04\u0026ndash;1.21), respectively.\u003c/p\u003e \u003cp\u003eCardiac events were the leading cause of death (69.4%), followed by sepsis (11.1%), brain-related causes (5.6%), and other factors (13.9%). Most patients (89.1%) were discharged from the hospital. There was a significant association (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between patients who used Extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMultivariate Regression Analysis\u003c/h2\u003e \u003cp\u003eThe Cox proportional-hazards regression analysis for the 211 cardiac surgery patients, with a mean follow-up of 2.9 years, showed a significant correlation between the evaluated variables and postoperative mortality \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig10\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. In contrast, regression analysis on 24 patients, all of whom passed away within 25 days post-surgery revealed no significant associations\u003c/p\u003e \u003c/div\u003e"},{"header":"Comment","content":"\u003cp\u003eOur study's primary focus was to identify factors affecting mortality in high-risk patients undergoing redo MV surgery. The results showed each yearly increase in age had a 4.1% and each redo surgery had a 44.3% increase in mortality risk. While medical conditions like diabetes mellitus and stroke were significant determinants, with hazard ratios (HRs) of 2.5 and 3.1, respectively. Peripheral vascular disease (PVD) stood out as a significant risk factor with the highest HR at 6.1. However, it is crucial to highlight that only 2.8% of our patient cohort had PVD, which could introduce a potential bias in our finding. Other significant preoperative factors included a history of dialysis, presence of a preoperative mechanical valve, and active IE, with HRs of 3.4, 2.3, and 3.8, respectively. Kaplan-Meier curve showed a noticeable trend for IE patients to die postoperatively compared to non-IE patients \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig9\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Future research should address whether this trend is evident on the long term follow up.\u003c/p\u003e \u003cp\u003eThe adoption of biologic valve prostheses for MV replacement is on the rise increasing from 16.8% in 1993 to 53.7% in 2013 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, our study showed significant change (P\u0026thinsp;=\u0026thinsp;0.009) in patients who had bioprosthetic (37.4%) or mechanical (29.7%) valves preoperatively compared to the postoperative composition which was mainly mechanical (59.7%) and bioprosthetic (38.4%). This may suggest more careful selection for bioprosthetic MV in patients is required to lessen the need for redo cardiac surgeries.\u003c/p\u003e \u003cp\u003eHigh-risk patients face greater risks when undergoing redo MV surgery, particularly those with IE or needing concomitant procedures. Our results showed a heightened IE risk in patients with mechanical MVs compared to bioprosthetic. However, Rutledge et al. noted equal IE susceptibility across valve types in the first post-replacement year (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The MitraClip procedure, a type of percutaneous edge-to-edge MV repair, presents a low IE risk (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In our cohort, IE occurred in patients with bioprosthetic (44%) and mechanical valves (44%), followed by native (10%) and repaired MV (2%), with MV recurrence occuring in 2 mechanical and 1 bioprosthetic. This may suggest patients undergoing redo mechanical MV surgery require careful follow-up and prophylaxis for IE.\u003c/p\u003e \u003cp\u003eOur cohort showed an overestimation with EUROSCORE-II (22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15), and an underestimation with STS score (3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2). This is contrary to Keenan et al. where EUROSCORE-II underestimated mortality (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Onorati et al. reported that EuroSCORE-II and STS-score effectively predict hospital mortality when EuroSCORE-II is \u0026gt;\u0026thinsp;13 or STS-score is \u0026gt;\u0026thinsp;7.4. However, lower score values lacked accuracy, especially in redo-patients. Intrestingly, STS-score was more predictive than EuroSCORE-II for mitral patients, emphasizing the importance of using both scoring systems (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). we need to have both scoring system and these mandates we need to have a specific scoring system that is more accurate and involves the elements of patient demographics and rheumatic heart disease.\u003c/p\u003e \u003cp\u003ecardiac events emerged as the primary cause of mortality, accounting for 69.4% of deaths, followed by sepsis, brain-related complications, and other factors. Fortunately, the majority (89.1%) of our high-risk cohort were successfully discharged from the hospital. A significant association was identified between the intraoperative use of ECMO and IABP, emphasizing the importance of these interventions in the surgical setting. Utilizing the Cox proportional hazards model, we found age to be a crucial determinant in the risk of MACE post-cardiac surgery, with other significant contributors being diabetes mellitus and tracheostomy. Interestingly, Sex did not play a significant role in influencing this risk.\u003c/p\u003e \u003cp\u003eFurther analysis involving 211 cardiac surgery patients, with an average follow-up of 2.9 years, revealed associations between several parameters and postoperative mortality. These included age, peripheral vascular disease, concomitant surgical procedures, and preoperative left ventricular function, among others. However, a focused study on a subset of 24 patients that passed away within 25 days post-operatively, did not show significant correlations with postoperative MACE events.\u003c/p\u003e \u003cp\u003eIn conclusion, several factors were significantly associated with increased mortality risk in redo MV surgery patients. Identifying and addressing these factors can help improve patient outcomes in cardiac surgery. These results highlight the importance of close follow-up and vigorous complication prevention after MV replacement in patients with native valve IE.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study was conducted at a single tertiary hospital, predominantly involving patients with rheumatic heart disease. This specific patient demographic may introduce potential bias in the observed outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIRB approval number 2191219; the consent was waived from by the research ethics committee.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets generated and/or analysed during the current study are not publicly available due to hospital regulations but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZubarevich A, Szczechowicz M, Zhigalov K, Rad AA, Vardanyan R, Easo J, et al. Surgical redo mitral valve replacement in high-risk patients: The real-world experience. J Card Surg. 2021;36(9):3195\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561\u0026ndash;632.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChairs ASTIECGWC, Pettersson GB, Coselli JS, Writing C, Pettersson GB, Coselli JS, et al. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: Surgical treatment of infective endocarditis: Executive summary. J Thorac Cardiovasc Surg. 2017;153(6):1241\u0026ndash;58. e29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMehaffey HJ, Hawkins RB, Schubert S, Fonner C, Yarboro LT, Quader M, et al. Contemporary outcomes in reoperative mitral valve surgery. Heart. 2018;104(8):652\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleissner F, Salman J, Naqizadah J, Avsar M, Meier J, Warnecke G, et al. Minimally Invasive Surgery in Mitral Valve Endocarditis. Thorac Cardiovasc Surg. 2019;67(8):637\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC Guidelines for the management of endocarditis: Developed by the task force on the management of endocarditis of the European Society of Cardiology (ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Nuclear Medicine (EANM). Eur Heart J. 2023;44(39):3948\u0026ndash;4042.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhtela E, Oksi J, Porela P, Ekstrom T, Rautava P, Kyto V. Trends in occurrence and 30-day mortality of infective endocarditis in adults: population-based registry study in Finland. BMJ Open. 2019;9(4):e026811.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnttila V, Malmberg M, Gunn J, Rautava P, Kyto V. Infective endocarditis and outcomes of mitral valve replacement. Eur J Clin Invest. 2021;51(9):e13577.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavid TE, Gavra G, Feindel CM, Regesta T, Armstrong S, Maganti MD. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc Surg. 2007;133(1):144\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIvanovic B, Trifunovic D, Matic S, Petrovic J, Sacic D, Tadic M. Prosthetic valve endocarditis - A trouble or a challenge? J Cardiol. 2019;73(2):126\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuciani N, Mossuto E, Ricci D, Luciani M, Russo M, Salsano A, et al. Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study. Eur J Cardiothorac Surg. 2017;52(4):768\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVohra HA, Whistance RN, Roubelakis A, Burton A, Barlow CW, Tsang GM, et al. Outcome after redo-mitral valve replacement in adult patients: a 10-year single-centre experience. Interact Cardiovasc Thorac Surg. 2012;14(5):575\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnorati F, Mariscalco G, Reichart D, Perrotti A, Gatti G, De Feo M, et al. Hospital Outcome and Risk Indices of Mortality after redo-mitral valve surgery in Potential Candidates for Transcatheter Procedures: Results From a European Registry. J Cardiothorac Vasc Anesth. 2018;32(2):646\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZia Khan M, Zahid S, Khan MU, Kichloo A, Jamal S, Mannan Khan Minhas A, et al. Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve in Valve From the National Inpatient Sample. J Am Heart Assoc. 2021;10(17):e020948.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRutledge R, Kim BJ, Applebaum RE. Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves. Arch Surg. 1985;120(4):469\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoeder NF, Dorr O, Rixe J, Weipert K, Bauer T, Bayer M, et al. Endocarditis after interventional repair of the mitral valve: Review of a dilemma. Cardiovasc Revasc Med. 2017;18(2):141\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeenan NM, Newland RF, Baker RA, Rice GD, Bennetts JS. Outcomes of Redo Valve Surgery in Indigenous Australians. Heart Lung Circ. 2019;28(7):1102\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Redo Mitral Valve Surgery, Infective Endocarditis, Concomitant Procedures, Outcome, Cardiac Reoperative Outcomes, High Risk Patients","lastPublishedDoi":"10.21203/rs.3.rs-4536435/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4536435/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe incidence of infective endocarditis (IE) in patients undergoing redo mitral valve (MV) surgery was evaluated, and the outcomes of all patients who underwent redo MV surgery were analyzed.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003e This was a retrospective review with prospective follow-up of electronic medical records from patients admitted for redo MV surgery at King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, from 2009 to 2019.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eA total of 211 patients underwent redo MV surgery, 41 of whom (19.4%) had IE. In 51% of patients, IE developed after the initial MV surgery. MV stenosis was moderate/severe in 50 patients, while moderate/severe MV regurgitation was present in 89 patients. Factors influencing mortality included age, peripheral vascular disease, concomitant PVD procedures, red blood cell transfusions, preoperative mechanical valves, and active IE. Cardiac events were the leading cause of mortality (69.4%), followed by sepsis and brain-related causes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWhile redo MV surgery has acceptable outcomes, the presence of IE, PVD, and concomitant procedures is a significant complication in these patients. Our study highlights the need for careful patient management and more in-depth research in this area.\u003c/p\u003e","manuscriptTitle":"Outcome of Infective Endocarditis and Concomitant Procedures in Patients Undergoing Mitral Valve Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-02 20:50:04","doi":"10.21203/rs.3.rs-4536435/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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