From 1972 to 1981 40 patients have required urgent valve replacement for left-sided bacterial endocarditis. The aortic valve was replaced in 31 patients, the mitral valve in four, and both in five patients. Twenty-six patients (65.5%) were in functional class IV heart failure according to the New York Heart Association criteria, and 13 patients (32.5%) were in class III heart failure at the time of operation. One patient in class II was operated on urgently for multiple cerebral embolism but died of fatal cerebral haemorrhage. In 22 patients (55%) there were no pre-existing valvular lesions and these patients were found to be more liable to develop severe haemodynamic failure. Premature closure of the mitral valve, documented by M-mode echocardiography, was a useful diagnostic aid and successfully determined the best timing of surgery in 14 out of 20 patients with severe aortic regurgitation. Cardiac arrest before operation appeared to be a significant risk factor (p = 0.0015) unless followed by immediate cardiopulmonary bypass. There were eight operative deaths (20%). Of 26 patients who were in functional class IV heart failure, 19 were operated on within four days of their haemodynamic deterioration and all survived. The operation was delayed in the remaining seven patients and none of them survived (p = 0.000003). There were no operative deaths among the patients in class III heart failure. There was only one episode of reinfection in the 16 patients followed up for at least three years. The duration of postoperative antibiotic treatment (four to six weeks in our patients), rather than any preoperative antibiotic regimen, seems to be important for preventing reinfection. At present there are 28 survivors, of whom 24 are in functional class I and four in class II.
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