Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology.

Marcin P Szczechowicz,Konstantin Zhigalov,Alina Zubarevich,Michel P B O Sá,Sabreen Mkalaluh,Ahmed Mashhour,Jerry Easo,Alexander Weymann

doi:10.21470/1678-9741-2020-0412

Abstract

IntroductionDestructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors.MethodsEighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality.ResultsThirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients.ConclusionIn endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Highlights

Destructive aortic root endocarditis is associated with high mortality rates
We divided our sample into three subgroups, which were considered as independent samples: patients with native valve endocarditis (NVE), patients with early-onset prosthetic valve endocarditis (PVE), and patients with late-onset PVE; and we analyzed pre, intra, postoperative, and follow-up data
Among the PVE patients, the median time from the prior aortic valve implantation to surgery for endocarditis was 4.2 (1.6 to 7.6) years

Summary

Introduction

Destructive aortic root endocarditis is associated with high mortality rates. Despite new antimicrobial agents and advancements in surgical therapy, the mortality rate of infective endocarditis (IE) remains very high[1]. The incidence of IE varies from 1.5 to 11.6 cases/100,000 person-years[2]. The IE of prosthetic aortic valves has a much higher incidence at the level of 70/10,000 person-years with a described five-year mortality of 18.3% and 10-year mortality of 43.6%. The history of prosthetic heart valve implantation increases the cumulative incidence of IE up to 5% at 10 years and is one of the major risk factors of IE[1]. The likelihood of bioprosthetic valve infection has been described as twice as high when compared to mechanical prosthetic valves[4]

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