Surgical Options for Aortic Root Replacement in Destructive Endocarditis.

Marcin Szczechowicz,Sabreen Mkalaluh,Alexander Weymann,Ahmed Mashhour,Konstantin Zhigalov

doi:10.21470/1678-9741-2020-0020

Abstract

ObjectiveTo analyze patients’ preoperative characteristics, surgical data, postoperative courses, and short- and long-term outcomes after implantation of different full-root prostheses for destructive aortic valve endocarditis.MethodsBetween 1999 and 2018, 80 patients underwent aortic root replacement due to infective endocarditis in our institution. We analyzed the abovementioned data with standard statistical methods.ResultsThe Freestyle stentless porcine prostheses were implanted in 53 (66.25%) patients, biological valve conduits in 13 (16.25%), aortic root homografts in nine (11.25%), and mechanical valve conduits in five (6.25%). There were no significant preoperative differences between the groups. The incidence of postoperative complications and intensive care unit length of stay did not differ significantly between the groups. The 30-day mortality rate was low among Freestyle patients (n=8, 15.1%) and high in the mechanical conduit cohort (n=3, 60%), though with borderline statistical significance (P=0.055). The best mean survival rates were observed after homograft (13.7 years) and stentless prosthesis (8.1 years) implantation, followed by biological (2.8 years) and mechanical (1.4 years) conduits (P=0.014). The incidence of reoperations was low in the mechanical conduit group (0) and stentless bioroot group (n=1, 1.9%), but two (15.4%) patients with biological conduits and three (33.3%) patients with homografts required reoperations in the investigated follow-up period (P=0.005).ConclusionIn patients with the destructive form of aortic valve endocarditis, homografts and stentless porcine xenografts offer better survival rates than stented valve conduits; however, the reoperation rate among patients who received homograft valves is high.

Highlights

Infective endocarditis (IE), if left untreated, is almost always lethal
In the pre-antibiotic era, most IE patients died due to sepsis, often before congestive heart failure caused by valve destruction could occur[1]
The prevalence of prosthetic valve endocarditis (PVE) grows steadily and the prognosis is worse than in cases of native valve endocarditis (NVE) due to the excavating destruction of periannular structures, which occurs in most cases (56% to 100%)[7,8]

Summary

Introduction

Infective endocarditis (IE), if left untreated, is almost always lethal. In the pre-antibiotic era, most IE patients died due to sepsis, often before congestive heart failure caused by valve destruction could occur[1]. The incidence of IE remains unchanged and amounts to 30 to 100 per million patient-years[2]. Even in these times of prophylactic treatment, modern antimicrobial therapy, advanced surgical methods, and structured guidelines, up to 30% of IE patients still die within the first year after the diagnosis[3]. A further high-risk cohort of patients are the 20% IE cases with prosthetic valve endocarditis (PVE). The prevalence of PVE grows steadily and the prognosis is worse than in cases of native valve endocarditis (NVE) due to the excavating destruction of periannular structures, which occurs in most cases (56% to 100%)[7,8]. The infection of the valve prosthesis often leads to abscess formation or detachment of the valvular ring and is associated with increased mortality[8]

Results

Discussion

Conclusion