A standardized approach to treat complex aortic valve endocarditis: a case series

Anna Gomes,Ehsan Natour,Sandro Gelsomino,Peter Paul Van Geel,Jayant S Jainandunsing,Sander Van Assen,Bhanu Sinha,Daniel M Johnson

doi:10.1186/s13019-018-0715-8

Abstract

BackgroundSurgical treatment of complicated aortic valve endocarditis often is challenging, even for experienced surgeons. We aim at demonstrating a standardized surgical approach by stentless bioprostheses for the treatment of aortic valve endocarditis complicated by paravalvular abscess formation.MethodsSixteen patients presenting with aortic valve endocarditis (4 native and 12 prosthetic valves) and paravalvular abscess formation at various localizations and to different extents were treated by a standardized approach using stentless bioprostheses. The procedure consisted of thorough debridement, root replacement with reimplantation of the coronary arteries and correction of accompanying pathologies (aortoventricular and aortomitral dehiscence, septum derangements, Gerbode defect, total atrioventricular conduction block, mitral and tricuspid valve involvement).ResultsAll highly complex patients included (14 males and 2 females; median age 63 years [range 31–77]) could be successfully treated with stentless bioprostheses as aortic root replacement. Radical surgical debridement of infected tissue with anatomical recontruction was feasible. Although predicted operative mortality was high (median logarithmic EuroSCORE I of 40.7 [range 12.8–68.3]), in-hospital and 30-day mortality rates were favorable (18.8 and 12.5% respectively).ConclusionsRepair of active aortic valve endocarditis complicated by paravalvular abscess formation and destruction of the left ventricular outflow tract with stentless bioprosthesis is a valuable option for both native and prosthetic valves. It presents a standardized approach with a high success rate for complete debridement, is readily available, and yields comparable clinical outcomes to the historical gold standard, repair by homografts. Additionally, use of one type of prosthesis reduces logistical issues and purchasing costs.

Highlights

Surgical treatment of complicated aortic valve endocarditis often is challenging, even for experienced surgeons
Therapy of endocarditis relies on antimicrobial therapy and surgery for cardiac anatomical damage, as well as uncontrolled infection
The choice of prosthesis depends on patient characteristics, technical considerations, and surgeon preferences [8, 14]. In this illustrated series of sixteen patients with aortic valve endocarditis and complicating paravalvular abscess formation, we show that the use of stentless bioprostheses provides a more standardized surgical procedure that consists of thorough debridement, root replacement with reimplantation of the coronary arteries, and treatment of accompanying pathologies

Summary

Introduction

Surgical treatment of complicated aortic valve endocarditis often is challenging, even for experienced surgeons. Infective endocarditis causes in-hospital mortality of 20% and 40% after 1-year, rising further to 79% for aortic valve endocarditis [1, 2] This high rate is largely due to extended local destruction of heart tissue, e.g. paravalvular abscess formation, with secondary heart failure. Therapy of endocarditis relies on antimicrobial therapy and surgery for cardiac anatomical damage (vegetation, abscess, fistula, shrunken valve, valve tears or holes, prosthetic valve detachment), as well as uncontrolled infection. In this way, 25–50% of patients are operated upon in the acute phase of infection and an additional 20–40% later in the course due to haemodynamic complications [5]

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Conclusion