Long-term outcomes of mitral valve surgery in infective endocarditis: a single-centre UK experience - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Open Heart . 2026 Apr 15;13(1):e004008. doi: 10.1136/openhrt-2026-004008 Search in PMC Search in PubMed View in NLM Catalog Add to search Long-term outcomes of mitral valve surgery in infective endocarditis: a single-centre UK experience Aziz Momin Aziz Momin 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK Find articles by Aziz Momin 1 , Redoy Ranjan Redoy Ranjan 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK 2 Department of Cardiothoracic surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh Find articles by Redoy Ranjan 1, 2, ✉ , William Sowden William Sowden 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK Find articles by William Sowden 1 , Mazin Sarsam Mazin Sarsam 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK Find articles by Mazin Sarsam 1 , Venkatachalam Chandrasekaran Venkatachalam Chandrasekaran 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK Find articles by Venkatachalam Chandrasekaran 1 Author information Article notes Copyright and License information 1 1Department of Cardiac Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK 2 Department of Cardiothoracic surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh ✉ Dr Redoy Ranjan; [email protected] None declared. Received 2026 Jan 27; Accepted 2026 Mar 5; Collection date 2026. Copyright © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: https://creativecommons.org/licenses/by-nc/4.0/ . PMC Copyright notice PMCID: PMC13084839 PMID: 41985987 Abstract Background The optimal surgical strategy for mitral valve (MV) infective endocarditis (IE) remains uncertain. Although valve repair is increasingly advocated, MV replacement is frequently performed, and robust data comparing long-term outcomes between approaches are limited. We evaluated long-term survival following MV repair vs replacement in patients with IE-related mitral regurgitation. Methods We retrospectively analysed 88 consecutive patients who underwent MV surgery for IE-associated mitral regurgitation at St George’s Hospital NHS Foundation Trust, UK, between June 2011 and May 2025. Long-term all-cause mortality was assessed using Kaplan-Meier survival analysis. Multivariable logistic regression identified independent predictors of mortality, and model discrimination was evaluated using the area under the receiver operating characteristic (AUROC) curve. Results The cohort comprised 65% men with a median age of 57 years (IQR 44.0–64.8). MV replacement was performed in 51.1% of patients who were older than those undergoing repair (median age 62 vs 51 years). In-hospital mortality was 4.5% and long-term all-cause mortality was 14.8%. No in-hospital deaths occurred in the repair group. In age-adjusted and sex-adjusted analyses among replacement patients, increasing age (OR 1.1; 95% CI 1.0 to 1.1; p=0.03) and diabetes mellitus (OR 7.8; 95% CI 1.3 to 48.8; p=0.02) independently predicted long-term mortality. The model demonstrated good discrimination (AUROC 0.83; 95% CI 0.69 to 0.97). Mean survival was significantly longer following repair than replacement (161.0 vs 129.9 months; p=0.008). Conclusions MV repair for infective endocarditis is safe and associated with superior long-term survival compared with replacement. Diabetes mellitus is a strong independent predictor of mortality in the MV replacement group, highlighting the importance of risk stratification in surgical decision-making. Keywords: Mitral valve surgery, Infective endocarditis, MV repair, MV replacement, Prognosis WHAT IS ALREADY KNOWN ON THIS TOPIC Although mitral valve repair is increasingly recommended for the treatment of infective endocarditis, current evidence is constrained by small sample sizes, limited follow-up periods, and heterogeneous patient populations, particularly among UK patients. Consequently, many UK centres continue to prefer valve replacement. WHAT THIS STUDY ADDS In a contemporary UK cohort with long-term follow-up, mitral valve repair for infective endocarditis was associated with excellent survival, with no observed long-term mortality. Patients undergoing valve replacement were older and experienced significantly worse long-term outcomes. Diabetes mellitus emerged as a strong independent predictor of all-cause mortality among replacement patients, conferring an approximately eightfold increased risk. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY These findings support mitral valve repair as a safe and durable surgical strategy for infective endocarditis when technically feasible and highlight the importance of incorporating diabetes status and age into preoperative risk stratification and surgical decision-making, especially in the MV replacement population. Introduction Mitral valve (MV) infective endocarditis (IE) is a serious and potentially life-threatening condition caused by microbial infection, most commonly bacterial infection, of the endocardial surface of the heart, primarily affecting the mitral valve leaflets, resulting in mitral regurgitation (MR). 1 2 MV infective endocarditis constitutes a substantial proportion of left-sided endocarditis cases, accounting for approximately 40–50% of all native valve IE episodes. 2 3 The incidence of infective endocarditis overall is estimated at 3 to 10 cases per 100 000 population per year globally, with MV involvement remaining consistently high in both native and prosthetic valve settings. 3 , 5 Complications of MV IE are frequent and severe, contributing to its high morbidity and mortality, including acute MR leading to heart failure, systemic embolisation (particularly to the brain and kidneys), formation of annular abscesses, conduction disturbances and septic shock. 1 3 In addition, neurological complications such as stroke occur in up to 30% of cases. Persistent infection despite appropriate antimicrobial therapy and progression to heart failure are primary indications for surgical intervention. 5 , 7 MV infective endocarditis imposes a significant economic burden. 8 , 10 In the United Kingdom and across Europe, annual healthcare costs related to IE reach hundreds of millions of dollars due to the complexity of care, surgical needs, prolonged hospital stays, intensive care and reoperations. 11 12 Further, in the United States, annual treatment costs surpass $3 billion, highlighting the substantial resource demands. 8 13 Treatment of MV IE involves a combination of prolonged intravenous antibiotic therapy and timely surgical intervention. 14 15 The primary surgical options include mitral valve repair or replacement depending on the extent of valvular damage, patient stability and the surgeon’s expertise. 11 16 Valve repair is generally preferred in cases where the valve structure can be preserved, as it is associated with better postoperative valve function, lower rates of prosthesis-related complications and improved long-term survival. 16 17 However, in extensive destruction of the MV due to IE or involvement of the prosthesis, valve replacement becomes necessary. 5 14 15 Surgical prognosis in MV IE has improved over recent decades due to advancements in perioperative care, antibiotic regimens and surgical techniques. 5 , 7 In-hospital mortality rates remain ~20%, but long-term survival is influenced by patient age, comorbidities, extent of infection and surgical approach. 7 11 Studies suggest that MV repair, when feasible, is associated with superior long-term outcomes compared with replacement, including lower rates of re-infection, thromboembolism and anticoagulation-related complications. 17 18 Given the significant impact of MV IE on clinical outcomes and healthcare systems, further research into the long-term results of mitral valve surgery, especially comparing repair and replacement, is essential. There are seldom studies in the UK that are limited by small sample sizes, short follow-up and heterogeneous populations; that is why we evaluated the long-term results of MV surgery, either repair or replacement, in patients with MV infective endocarditis. Patients and methods We included 88 consecutive patients with isolated mitral valve (MV) infective endocarditis (IE) who underwent surgical intervention for mitral regurgitation at St George’s Hospital NHS Foundation Trust, UK, between June 2011 and May 2025. All procedures were performed under a single surgeon team practice. Preoperative, intraoperative and postoperative data were prospectively collected and subsequently validated. Mortality data were obtained from hospital-recorded death registries, and the accuracy of mortality status and NHS number validation was confirmed by the Information Department’s Data Quality Team. The study included patients with either active or prior isolated MV infective endocarditis. Patients with concomitant valvular disease or congenital heart defects were excluded. All categories of MV IE were incorporated to minimise selection and reporting bias. The decision to perform mitral valve repair or replacement was based on the recommendations of the American Association for Thoracic Surgery (AATS) and the European Society of Cardiology guidelines for the surgical management of infective endocarditis. 14 15 In brief, MV repair was performed in cases with limited leaflet destruction and preserved subvalvular structure, while MV replacement was indicated for extensive damage, annular abscesses or failed repairs. Early surgery was performed for severe MR with heart failure, uncontrolled infection or large vegetations (>10 mm) with embolic risk. Institutional review board approval was waived, as the audit department of St George’s Hospital approved this retrospective analysis of prospectively collected data from the UK National Institute for Cardiovascular Outcomes Research (NICOR) adult database. In accordance with UK National Research Ethics Service guidance, this retrospective study was classified as a Service Evaluation and Improvement project. The study used routinely collected clinical data and did not alter patient care; therefore, research ethics committee approval was not required. All data were encrypted to maintain confidentiality and ensure data security. The study was conducted in accordance with the principles of the Declaration of Helsinki. Data were analysed using SPSS (Statistical Package for the Social Sciences), V 28.0 software, focused on comparisons between the MV replacement and repair groups. Univariate analyses were conducted to assess associations and identify risk patterns using χ 2 tests, Fisher’s exact tests and Mann-Whitney U-tests, as appropriate for categorical and non-parametric data. Variables with a p≤0.05 in univariate analysis were included in a multivariate logistic regression model to identify independent predictors of long-term mortality. Model performance was evaluated using the area under the receiver operating characteristic (AUROC) curve to assess goodness of fit. Additionally, Kaplan-Meier survival analysis was performed to estimate long-term survival (in months) with 95% CI between clinically relevant subgroups, including MV replacement versus repair, and active versus prior IE. Furthermore, the Little’s MCAR (Missing Completely at Random) test was also performed to determine if the missing data in a dataset are missing randomly or if there’s a systematic pattern to the missingness. 19 A p value<0.05 was considered statistically significant. Results We recruited 88 patients with isolated mitral valve infective endocarditis, of whom 65% were male, with a median age of 57 years (IQR: 44.0–64.8). Of these, mitral valve replacement was performed in 45 (51.1%) of patients, who had a significantly higher median age (62 years; IQR: 47.5–70.0) compared with those who underwent repair (48.9%), with a median age of 51 years (IQR: 42.0–60.0; p=0.003). Baseline characteristics are summarised in table 1 . The median age for the bioprosthesis group was 64.5 years (IQR, 53.0–72.5), significantly older than that of the mechanical prosthesis group, which was 49 years (IQR, 42–61.5). Regarding repair techniques, repair with a ring annuloplasty was performed in 37 (42.1%) of cases, while repair without a ring accounted for 6 (6.8%). Notably, the MV annulus diameter was significantly larger in the repair group compared with the replacement group (31.9±2.7 mm vs 29.3±2.0 mm; p<0.001). In terms of long-term outcomes, all-cause mortality was significantly higher in the replacement group compared with the repair group (24.4% vs 4.7%; p=0.01), resulting in an overall rate of 14.8%. We found that the median overall survival was 96 months (IQR: 43.0–128.0), with survival of 83 months (IQR: 32.0–126.0) in the replacement group and 107 months (IQR: 51.0–130.0) in the repair group. Stratified analysis showed median survival of 51 months (IQR: 29.5–66.5) for mechanical prostheses, 16.5 months (IQR: 2.5–46.0) for bioprostheses, 108 months (IQR: 59.0–133.5) for repair with ring, and 69.5 months (IQR: 20.0–107.0) for repair without ring. Table 1. Basic and long-term outcome data (n=88). Variable Total sample (n=88) Replacement (n=45) Repair (n=43) P value Age (median; IQR) years 57 (44.0–64.8) 62 (47.5–70.0) 51 (42–60) 0.003 Male sex 57 (64.8%) 27 (60.0%) 30 (69.8%) 0.37 Active IE 66 (75.0%) 36 (80.0%) 30 (69.8%) 0.26 MV annulus (Mean±SD) mm 30.5±2.6 29.3±2.0 31.9±2.7 <0.001 Pulmonary HTN 19 (21.6%) 10 (22.2%) 9 (20.9%) 0.88 HTN 28 (31.8%) 18 (40.9%) 10 (23.8%) 0.15 DM 12 (13.6%) 10 (22.2%) 2 (4.7%) 0.02 COPD 6 (6.8%) 5 (11.1%) 1 (2.3%) 0.20 Stroke/TIA 23 (26.1%) 13 (31.0%) 10 (25.0%) 0.54 New onset stroke/TIA 5 (5.7%) 5 (11.1%) 0 (0.0%) 0.06 In hospital mortality 4 (4.5%) 4 (8.9%) 0 (0.0%) 0.11 Long-term all-cause mortality 13 (14.8%) 11 (24.4%) 2 (4.7%) 0.01 Survival (median; IQR) months 96 (43.0–128.0) 83 (32.0–126.0) 107 (51.0–130.0) 0.15 Open in a new tab P‐value reached from the χ2 and Fisher exact tests (when sample size ≤ 5); Mann-Whitney U‐test, as appropriate. P-value <0.05 set as significant. COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; IE, infective endocarditis; IQR, interquartile range; MV, mitral valve; TIA, transient ischaemic attack. A multivariate logistic regression model adjusted for age and sex identified age (OR: 1.1, 95% CI 1.0 to 1.1; p=0.03) and diabetes mellitus (OR: 7.8, 95% CI 1.3 to 48.8; p=0.02) as independent predictors of long-term all-cause mortality in the replacement group ( table 2 ). Notably, there were no deaths in the repair group. Model performance was supported by an AUROC of 0.830 (95% CI 0.69 to 0.97; p=0.001), with a sensitivity of 90.9% and specificity of 32.0% ( figure 1 ). Table 2. An age-adjusted and sex-adjusted multivariate LR model identified independent predictors of long-term all-cause mortality among patients undergoing mitral valve replacement following infective endocarditis. Variable P value OR 95% CI Lower Upper Age 0.03 1.08 1.0 1.2 DM 0.02 7.81 1.3 48.8 Sex 0.34 0.45 0.1 2.3 Variable(s): age, Sex, DM, New onset Stroke/TIA. Open in a new tab * Note: Only two deaths in the MV repair group, which was insufficient to permit logistic regression analysis. DM, Diabetes mellitus; TIA, Transient ischaemic attack. Figure 1. The receiver operating characteristic (ROC) curve assessed the goodness-of-fit of the model predicting long-term all-cause mortality among patients undergoing mitral valve replacement. Open in a new tab Additionally, a Kaplan-Meier analysis showed a significantly longer mean survival in the repair group (161.0±4.9 months; 95% CI: 151.4 to 170.5) compared with the replacement group (129.9±9.7 months; 95% CI: 110.9 to 149.0; p=0.008), resulting in an overall mean survival of 145.1±5.8 months (95% CI: 133.7 to 156.5) ( figure 2 ). Additionally, figure 3 presents a Kaplan-Meier curve comparing post-surgical survival in patients with previous vs active infective endocarditis, which revealed no significant difference between these groups (157.8±6.5 months [(95% CI 145.0 to 170.7) vs 141.3±7.3 months (95% CI 126.9 to 155.6); p=0.26). Additionally, Little’s MCAR test was not significant, indicating that the missing data were missing at random. Figure 2. A Kaplan-Meier survival curve assessed post-MV surgery survival rates following replacement and repair. MV, mitral valve. Open in a new tab Figure 3. A Kaplan-Meier survival curve showed post-MV surgery survival rates between active and previous infective endocarditis cases. MV, mitral valve. Open in a new tab Discussion We found that mitral valve repair for MR due to infective endocarditis is a safe and effective strategy, associated with favourable long-term survival rates. Diabetes emerged as a strong independent predictor associated with approximately eight times higher all-cause mortality in the MV replacement cohort following IE. MV repair is increasingly recognised as a safe and effective strategy for treating infective endocarditis (IE), offering several advantages over valve replacement. 616 , 18 Literature indicates that repair preserves native valve architecture, maintaining left ventricular function and reducing the need for long-term anticoagulation 5 14 15 compared with prosthetic replacement. Repair is associated with lower rates of prosthetic-related complications, such as thrombosis, structural deterioration and recurrent infection. 16 17 Studies also demonstrate superior long-term survival and reduced morbidity with MV repair, supporting current study findings. 18 20 Early surgical intervention, coupled with radical debridement and modern reconstructive techniques, contributes to favourable outcomes, making repair a preferred option when anatomically feasible. 21 22 Diabetes mellitus (DM) is associated with a significantly increased risk of long-term all-cause mortality following MV replacement for IE, as supported by several studies. 23 , 25 The chronic inflammatory and immunocompromised state in DM predisposes patients to persistent infections, impaired wound healing and prosthetic valve complications, including paravalvular leaks and reinfection. 26 27 Additionally, diabetes contributes to accelerated atherosclerosis, endothelial dysfunction and microvascular disease, which increase cardiovascular morbidity and mortality post-surgery. Moreover, hyperglycaemia-induced oxidative stress and glycation end-products may further impair myocardial recovery and valve function post-replacement. 24 28 The interaction of metabolic dysregulation, systemic inflammation and cardiac damage increases mortality risk in this population, highlighting the need for tailored perioperative management and long-term follow-up for diabetic patients undergoing MV replacement for infective endocarditis. 24 27 28 This study confirms that diabetes is linked to an approximately eightfold fold increase in all-cause mortality among patients undergoing mitral valve replacement in IE cohorts. Despite controversial findings, 29 30 we found no survival differences between the active and previous IE groups following MV surgery, which might be due to standardised perioperative care, improved antimicrobial therapy and advancements in surgical techniques that effectively address both active infection and post-infective valve damage. Therefore, the choice of surgical technique, whether repair or replacement, is often guided more by valve pathology and anatomical feasibility than by the timing of infection. 14 15 This study presents a novel perspective on the long-term follow-up of post-MV surgery in the context of IE, demonstrating that infection status alone does not significantly influence the surgical approach or outcome. Despite robust results, this study has important limitations. The small sample size may reduce statistical power and limit generalisability. The observational design introduces potential selection bias and unmeasured confounding, which could affect treatment allocation and outcomes. The limited number of events increases the risk of type II error and restricts robust multivariable adjustment. Residual confounding from incomplete clinical data may also remain. These limitations should be considered when interpreting the findings. Future studies with larger sample sizes or randomised controlled trials are needed to confirm these associations. The exclusively UK-based cohort may restrict applicability to broader, more diverse populations. Differences in healthcare facilities, accessibility and life expectancy, especially in low- and middle-income countries, may impact surgical outcomes and survival, thereby limiting the global applicability of these findings. Despite missing data in the replacement sample regarding the type of prosthesis, the Little MCAR test 19 was insignificant, indicating no impact on the study results, thereby mitigating the risk of bias. Additionally, the short survival duration of the bioprosthesis group might raise concerns; however, the bioprosthesis group was significantly older than the mechanical prosthesis group, which was reserved for the high-risk patients, minimising the risk of outcome bias. Further, the observed survival differences between mechanical and bioprosthetic valves likely result from the later adoption of bioprostheses in patients with mitral valve infective endocarditis during the last 8 years of our recruitment period. The lack of detailed data on causes of mortality limits the understanding of the higher mortality in the replacement group. Future studies should collect more comprehensive cause-specific mortality data to elucidate these findings. The study is limited by the lack of data on IE recurrence, but its robust findings on long-term survival between active and previous cases reduce the risk of outcome bias. Although diabetes mellitus was identified as a potential independent predictor of long-term mortality, further studies investigating glycaemic control parameters, such as HbA1c levels or fasting blood glucose, might shed deeper insights into the underlying pathophysiological mechanisms contributing to increased mortality following MV replacement in the context of infective endocarditis. We recommend large, multicentre, randomised controlled trials to confirm the current study findings and provide more definitive guidance on the optimal surgical approach for mitral valve infective endocarditis. Conclusion Mitral valve repair is a safe and effective treatment for infective endocarditis, offering favourable long-term survival. Additionally, diabetes independently predicts all-cause mortality after valve replacement, indicating the need to optimise diabetes management for improved long-term outcomes. Acknowledgements We thank the patients, their families and the hospital staff for supporting this research. Footnotes Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Data availability free text: The data is not publicly available due to privacy or ethical restrictions. The lead author, Mr. Aziz Momin, had full access to all the data in this study and took complete responsibility for the integrity and accuracy of the data analysis. Patient consent for publication: Not applicable. Provenance and peer review: Not commissioned; externally peer reviewed. Ethics approval: Institutional review board approval was waived, as the audit department of St George's Hospital approved this retrospective analysis of prospectively collected data from the UK National Institute for Cardiovascular Outcomes Research (NICOR) adult database. 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