Active Aortic Valve Endocarditis Research Articles

Minimally Invasive Video-Assisted Surgery for Concomitant Ascending Aorta and Aortic Valve Replacement via Right Infra-Axillary Thoracotomy.

This study aims to assess the safety, efficacy, and esthetic outcomes of an innovative 4 cm right infra-axillary incision approach for concomitant ascending aorta and aortic valve replacement (AAR and AVR), with a specific focus on achieving optimal surgical outcomes while ensuring minimal visible scarring. We retrospectively examined all elective cases of concomitant AAR and AVR surgery performed at our institution from July 2021 to June 2023. Exclusions encompassed emergency surgery, acute type A aortic dissection, active aortic valve endocarditis, redo cardiac surgery, the necessity for concurrent mitral valve replacement, or left ventricular assist device implantation. We collected and analyzed perioperative data for the patients. The study comprised 24 consecutive patients. Cardiopulmonary bypass time and aortic cross-clamp time averaged 215.0 (interquartile range [IQR], 38.0) and 158.0 (IQR, 37.0) min, respectively. No instances of reoperation due to postoperative bleeding or need for permanent pacemaker implantation were recorded. Initial 24-h postoperative drainage volume averaged 186.9 ± 76.9 mL. Average follow-up duration was 21.7 ± 6.2 months (range, 5 to 30 months). Throughout short-term follow-up, no occurrences of valve dysfunction, paravalvular leak, cardiovascular events necessitating readmission, or mortality were observed. The right infra-axillary incision approach effectively yields secure, successful, and cosmetically pleasing outcomes for concomitant AAR and AVR. Further research and comparisons are warranted to validate these findings.

Incidental Finding of Subannular Perfused Aortic Root Abscess.

An 83-year-old female presented with aortic valve stenosis requiring surgery, which was diagnosed with a transthoracic echocardiography three years ago. However, the patient declined the surgery at that time due to personal reasons. Three years later she presented again with signs of dizziness and weakness and progression of the aortic valve stenosis. Cardiac catheterization and a computed tomography scan were performed before the planned surgery. Surprisingly, a huge subannular perfused abscess hole around the aortic root companying a pericardial effusion was revealed. The patient underwent an urgent aortic root replacement with a tissue valve and an aortic ascending replacement without any complications. Intraoperative inspection confirmed an active aortic root and valve endocarditis.

Coronary angiography in patients with native or prosthetic aortic-valve endocarditis: outcomes and implications for myocardial revascularisation

Abstract Background Coronary angiography (CA) remains the cornerstone of the preoperative assessments before open-heart surgery to detect or rule out coronary artery disease (CAD). Preoperative CA is currently not recommended in patients with active infective aortic valve endocarditis, but may help to reduce the risk of perioperative myocardial infarction. Purpose This study aimed to evaluate the risks and benefits of preoperative CA in selected patients before aortic valve replacement to treat active infective endocarditis of the aortic valve and to assess the incidence and relevance of CAD. Methods Sixty-five patients with native or prosthetic aortic-valve endocarditis underwent preoperative diagnostic CA between 03/2008 and 09/2020. We collected their baseline characteristics, including the neurological status, previous cardiac surgical procedures, and reviewed the preoperative echocardiograms and the CA data. We evaluated the intraoperative data, and clinical outcomes after CA and after surgery. Patients were selected according to the site, size and mobility of vegetations of the underlying active infective process. Results CA revealed CAD in the majority of patients (n=34; 52%): one-vessel disease n=17 (26%), two-vessel disease n=6 (9%), and three-vessel disease n=11 (17%). Coronary sclerosis without hemodynamic significance were detected in 23 patients (35%). Sixteen patients had a previous history of CAD. We observed no adverse events following preoperative diagnostic CA, particularly no thromboembolic complications, including stroke, visceral, or lower body ischaemia. Surgery was performed 3 [IQR 1; 5] days after CA. During surgical aortic-valve replacement, concomitant coronary artery bypass grafting was performed in 19 patients (29%). Postoperative in-hospital mortality was 12% (n=8) and the new-onset disabling-stroke incidence was 2% (n=1). Neither stroke nor visceral or lower body ischemia due to embolism were observed in any patient after surgery. Conclusions By weighing risks and benefits of CA together as a team, no adverse clinical outcomes but significant clinical implications could be identified in patients with active infective aortic valve endocarditis. Concomitant surgical myocardial revascularization was frequent and may well have contributed to favorable clinical outcome. Therefore, active infective endocarditis of the aortic valve per se should not be regarded as an absolute contraindication for CA. Funding Acknowledgement Type of funding sources: None.

Treatment of aortic valve endocarditis with stented or stentless valve.

The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis. From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n=97, 37%) or a stentless valve (n=168, 63%) with further breakdown into inclusion technique (n=142, 85%) or total root replacement (n=26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data. The median age of patients was 53years (43-56) in the stented group and 57years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups. Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.

Active Aortic Endocarditis in Young Adults: Long-term Results of the Ross Procedure

The best valvular substitute remains controversial in young adults with active aortic valve endocarditis. The Ross procedure has gained interest because of its theoretical resistance to infection. We aimed to report our long-term outcomes of the Ross procedure in this indication. Between March 1992 and January 2019, 511 patients underwent a Ross procedure in our institution. Among them, we included 38 patients who suffered from an active aortic valve infective endocarditis. The mean age was 33.9 ± 8.1 years. Six patients had emergent procedures and 17 patients had perivalvular involvement. A pulmonary autograft was implanted using the full root technique in 78.9% of patients. Median follow-up was 12 (interquartile range, 1.75-16.25) years. The hospital mortality rate was 5.3%. Estimated overall survival was 84.2% ± 6.6% at 10 years. There were 2 cases of recurrent endocarditis, both requiring reoperation. Six other patients required reoperation on an autograft or homograft. Estimated freedom from recurrent endocarditis or reoperation was 89.4% ± 5.9% at 10 years. In experienced centers, the Ross procedure is a reliable alternative to prosthetic or homograft valve replacement in young adults experiencing active aortic valve endocarditis, with a low operative risk and good long-term results.

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

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.

Risks and Challenges of Surgery for Aortic Prosthetic Valve Endocarditis

Prosthetic valve endocarditis is the most severe form of infective endocarditis. This study assessed the risks and challenges of surgery for aortic prosthetic valve endocarditis. In total, 116 consecutive patients (98 males, age 65.2±12.7years), who underwent redo-surgery for active aortic prosthetic valve endocarditis between 2000 and 2014, were reviewed. Cox regression analysis was used to identify factors for aortic root destructions as well as for morbidity and mortality. Median follow-up was 3.8 years (0-13.9 years). Aortic root destructions (42 limited and 29 multiple lesions) were associated with early prosthetic valve endocarditis and delayed diagnosis (≥14 d), but not with mortality. There were 16 (13.8%) early (≤30 d) and 32 (27.6%) late (>30 days) deaths. Survival at 1, 5, and 10 years was 72±4.3%, 56±5.4%, and 46±6.4%, respectively. The cumulative incidence of death, reinfection, and reoperation was 19.0% at 30days and 36.2% at 1year. Delayed diagnosis, concomitant procedures, and EuroSCORE II >20% were predictors for early mortality and need for mechanical circulatory support, age >70years, and critical preoperative state were predictors for late mortality. In their absence, survival at 10 years was 70±8.4%. Reinfections and reoperations occurred more frequently if ≥1 risk factor for endocarditis and aortic root destructions were present. At 10 years, freedom from reinfection and reoperation was 89±4.2% and 91±4.0%. The risks of death, reinfection, and reoperation are significant within the first year after surgery for aortic prosthetic valve endocarditis. Early diagnosis and aortic root destructions are the most important challenges, but advanced age, critical preoperative state, and the need for mechanical circulatory support determine long-term survival.

Invited Commentary

Invited Commentary

Percutaneous temporary aortic valve: A hemodynamic support system for acute aortic insufficiency

A percutaneous temporary aortic valve hemodynamic support catheter is a device that can conceptually maintain stable hemodynamics when significant structural damage occurs to the native aortic valve ensuing acute severe aortic insufficiency. Applications may include a bridge to surgery in active aortic valve endocarditis and an option to allow for diseased valve resection prior to transcatheter aortic valve replacement. An early prototype has undergone successful fundamental mathematical, bench and animal proof-of-concept studies. Design, concept and early data are presented and discussed.

Surgical treatment of aortic valve endocarditis with left ventricular – aortic discontinuity

Background The periannular expansion of infection is a serious complication of infective endocarditis associated with high morbidity and mortality. The present study evaluates the results of aortic annular reconstruction in active infective endocarditis with left ventricular-aortic discontinuity. Methods Left ventricular-aortic discontinuity was diagnosed by echocardiography in 25 (21 men, 4 female; mean age 60.2 ± 13.2 years) of 269 patients who underwent surgery for active native or prosthetic aortic valve endocarditis between January 2001 and October 2011. Seventeen (68%) and 8 (32%) patients had native and prosthetic valve endocarditis, respectively. Aortic root abscesses were radically debrided in all patients. The aortic annulus was reconstructed using autologous pericardium in 20 patients and a Dacron patch in 2. Isolated aortic valves were replaced with a bioprosthesis in 9 (36%) patients and a mechanical prosthesis in 13 (52%). Mechanical composite grafts were implanted in 3 (12%) patients. The mean follow-up was 29.1 ± 23.6 months and complete. Results Thirty-day mortality was 20% (n = 5). Survival at 3 years was 80% ± 8% with no significant difference between native and prosthetic valve endocarditis (log-rank, p = 0.69). Endocarditis did not recur during follow-up. Conclusions Despite procedural progress, surgery for aortic valve endocarditis with left ventricular-aortic discontinuity remains associated with significant in-hospital mortality, but mid-term survival after the perioperative period is good. Annular reconstruction with a pericardial patch is technically safe.

Reply to Totaro and Zattera

We appreciate the comments of Totaro and Zattera [1]. As they correctly point out, surgical treatment of complicated active aortic valve endocarditis can be challenging, in particular, in the presence of perivalvular abscess cavities. In effect, such a scenario requires the treatment of each of the two components, i.e. valve destruction and perivalvular extension. Different surgical options exist; closure of the cavity with a patch and separate valve replacement is one, and we have used it in many patients over the past 20 years. We cannot confirm the authors’ observation that the insertion of a stented valve after closure of an abscess cavity is a relevant surgical challenge. Primary root and valve replacement with a homograft or a stentless bioprosthesis is another possibility [2, 3]. We have preferred this approach if extensive aortoventricular dehiscence was found intraoperatively and valve replacement was required. Fortunately, most of these procedures are successful if the surgical approach is adequate. Nevertheless, one has to keep in mind that active endocarditis is characterized by marked heterogeneity of patient risk profiles, details of endocarditic destruction and causative organisms. Along these lines, any interpretation of clinical results should be made carefully. The authors are to be congratulated for their success in 5 patients in whom a stentless prosthesis was used after the abscess cavity was closed with a patch. Nevertheless, the number is definitely too low to draw any conclusions; success in our mind does not warrant generalization, which the term Columbus’s egg implies. Misinterpretation can also occur in other directions; based on the treatment of 33 patients who underwent repair of active endocarditis [4], we observed that their survival was better compared with the survival of those who had replacement as the initial treatment. We pointed out that we could not determine with certainty whether this survival advantage was due to the operation, or rather, a consequence of patient characteristics. The authors also quote David in his editorial comment [5], stating that the probability of reoperation was markedly increased after repair. This statement also ignores some details, since repair stability was excellent after repair of tricuspid aortic valves, and repair failures were a point of concern only after reconstruction of bicuspid aortic valves with active endocarditis [4]. In summary, one should be careful in drawing conclusions from limited patient cohorts in such a heterogeneous disease. We will follow the activities of the authors with interest.

In patients with severe active aortic valve endocarditis, is a stentless valve as good as the homograft?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with severe active aortic valve endocarditis, is a stentless valve as good as a homograft?' The scientific literature was reviewed by searching Medline, using the OVID interface, from 1950 to March 2010. One hundred and eight papers were found. Twelve papers were used in the writing of the article, of which 10 were deemed relevant to the topic. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers were tabulated. In the homograft series, literature review reports a reinfection rate from 3.8% to 6.8%. Yankah, in studying 161 patients with endocarditis, reports 91% freedom from reinfection at 10 and 17 years and 70% survival at 17-year follow-up. Sabik, in studying 103 consecutive patients with prosthetic endocarditis, reports a 3.8% reinfection rate and 95% freedom from reinfection at 10 years, with 56% survival at 10 year. In the stentless series: Musci, in studying 255 patients with endocarditis, reports a 8.6% reinfection rate, 83% freedom from reinfection at five years and 46% five-year survival. He finds a non-significant difference between survival and freedom from reinfection in patients with native valve endocarditis compared to those with prosthetic valve endocarditis (PVE) (P=0.1371 and P=0.8356). The same author, in 221 patients treated with a homograft, reports a 5.4% reinfection rate and 10-year freedom from reoperation, with a reinfection rate in native and PVE of 92%. Ten-year survival was better in native than in PVE (P=0.029). Siniawski, comparing two groups of patients treated with stentless valves and homografts, finds an equal reinfection rate of 4% and lower mortality for the stentless group (12% vs. 16%, respectively). He finds the reinfection rate to be lower for the homograft and stentless groups than for the patients treated with standard prostheses, respectively, 5.8%, 3.7% and 33%. The stentless valve offers a reinfection rate and postoperative echocardiographic data comparable to those achieved with homografts. Further follow-up is required to determine the stentless valve durability and long-term freedom from valve-related complications.

Fibrous skeleton endocarditis causing septated aneurysm on the anterior mitral leaflet

A 26-year-old male was diagnosed to active aortic valve endocarditis extending the fibrous skeleton, caused by Streptococcus sanguinis . A transthoracic echocardiography showed multiple, highly mobile vegetations on all three cusps of the aortic valve with mild-to-moderate aortic regurgitation and a 2.7 × 1.2 cm-sized septated aneurysm on the anterior mitral leaflet with moderate-to-severe mitral regurgitation ( Panels A – C ). On emergent surgery, a septated …

Aortic valve and/or aortic root replacement using an aortic homograft

Aortic valve replacement using the homograft valve has a special place in the cardiac surgical practice although it has never been widely used, in part due to the lack of tissue donors but also due to the perceived difficulty of the procedure compared with aortic valve replacement using prosthetic devices and concerns regarding homograft valve failure. The principal indication for aortic valve replacement using a homograft aortic valve is for active aortic valve endocarditis (native or prosthetic) with or without perivalvular tissue destruction (abscess cavity, fistula, detachment of the anterior mitral valve leaflet from the aortic annulus). Since the homograft tissue is pliable and adaptable, it can be used to repair defects in complex cases with root destruction. A second interesting application of homograft aortic valve is in the treatment of small aortic root (in which replacement with a small prosthetic valve would produce an unacceptable orifice ratio and ultimately affect long-term outcome) and left ventricular outflow tract obstruction when the homograft aortic valve can be combined to the Konno procedure. Homograft aortic valve can be used in these cases without sacrifying the pulmonary valve to be used as aortic valve substitute (for instance in adolescents and young adults who do not want to undergo a 'two-valve' procedure like the Ross-Konno procedure). The most frequent operation technique is the cylindrical aortic root replacement, performed in a similar way than the classical Bentall procedure. This technique is the most easiest one and performed more frequently than the subcoronary implantation, which is substantially more demanding. Results from centres that have significant experience with homograft valve surgery report equivalent survival data. The University of Alabama had an 87% survival at 5years in a 10-year period from 1981 to 1991. Of those who underwent isolated aortic valve replacement with a homograft, there was 99% survival at 30days and 94% survival at 8years. In the Mayo Clinic series, 82% were alive at 8years. Like all tissue valves, homograft aortic valves may fail. An understanding of the mechanisms of homograft valve failure and the way in which these mechanisms interact has important surgical implications. Homograft aortic valves may develop progressive regurgitation as a result of a change in the mechanical properties of the leaflets over time.

Rare complication of dissection of valsalva sinus with aorto-left atrial fistula in active aortic valve endocarditis

We present a rare case of dissection of the sinus of Valsalva associated with an aortic annular abscess that perforated into the left atrium. A 61-year-old patient with infective endocarditis underwent emergent operation due to progressive heart failure, in whom echocardiography showed the dissection of sinus of Valsalva with aorto-left atrial communication. Procedure included autologous pericardial patch repair of the dissecting sinus of Valsalva and bioprosthetic valve replacement with a successful outcome. Microscopic examination showed excessive neutrophil infiltration in the aortic valve and annulus without involvement of the sinus of Valsalva.

Cryopreserved Aortic Viable Homograft for Active Aortic Endocarditis

To evaluate the short and long-term results of cryopreserved aortic viable homograft (CAVH) in the treatment of active aortic endocarditis. From January 1992 to December 2002, 104 patients (23 females, 81 males) with a mean age 51 +/- 13 years (from 14 to 77) underwent CAVH replacement for active aortic valve endocarditis. Seventy-six patients (73%) had endocarditis of the native aortic valve, 28 (27%) had endocarditis of prosthetic aortic valve; among them, eight had a recurrent infection. Eighty-three patients (80%) had isolated aortic endocarditis. Plurivalvular endocarditis was observed in 21 (20%) patients, (aortic and mitral in 16 patients, aortic and tricuspid in 5). Intraoperative transesophageal echocardiography was systematically used. Anatomical lesions included perforations in 89 (86%) patients, vegetations in 79 (77%) patients and periannular extensions in 60 (58%) patients. Precise bacteriologic diagnosis was available in 82 (80%) patients. Cryopreserved aortic viable homografts were inserted using the aortic root replacement technique in 93 (89%) patients and the subcoronary technique in 11 (11%) patients. Associated procedures were performed in 38 (37%) patients: mitral (n = 23) and tricuspid (n = 3) valve repair, partial homograft mitral valve replacement (n = 3), partial homograft tricuspid valve replacement (n = 3), coronary bypass graft (n = 3), and ascending aorta replacement (n = 3). Hospital mortality was 5 (5%) patients. Causes of death included: myocardial infarction (n = 2), myocardial failure (n = 2), and multiorgan failure (n = 1). During follow-up (61 +/- 36 months, from 6 months to 136 months), 9 secondary deaths occurred (2 were cardiac related), 14 aortic valvular redo surgeries were performed (2 for nonstructural failure, 6 for structural failure, and 6 for endocarditis). Actuarial survival at ten years was 83%, with 93% of the patients free from cardiac death. At ten years, actuarial rate for freedom from reoperation was 76% and freedom from recurrent endocarditis was 93%. No thromboembolic complications were observed. The CAVH has proven its effectiveness in treating the destructive lesions of active aortic endocarditis. It has provided satisfactory immediate and long-term results. Allowing the possibility to avoid a prosthetic material, CAVH could represent an option for surgically treating active aortic endocarditis more rapidly.

The subcoronary Ross procedure in patients with active endocarditis

Objectives: The Ross procedure has gained increasing interest as an attractive alternative to conventional aortic valve prostheses within the last decade. Due to a better resistance to infection as one of its advantages the pulmonary autograft is often prefered in case of active endocarditis. The 10 years' experience of the Ross procedure in the subcoronary and root inclusion technique in active aortic valve endocarditis is evaluated.

Optimal size of prostheses for functioning of the aortic prosthetic valve in aortic and mitral valve replacement with annular enlargement through Manouguian's technique.

There is not yet agreement about the optimal size of the prostheses in aortic and mitral valve replacement with Manouguian's technique. In this technique, the aortic prosthetic valve can be pushed upon the mitral prosthesis which may cause dysfunction of the aortic prosthetic valve. The aim of this study was to clarify the size of the prostheses needed to avoid dysfunction of the aortic prosthetic valve. Three patients underwent aortic and mitral valve replacement through this procedure. Two of them had active aortic and mitral valve endocarditis. Aortomitral continuity involved with abscesses could be approached and completely excised using this technique. All patients survived the operation, but 1 of them suffered aortic mechanical valve dysfunction for the reason stated. Anatomical analysis of the geometrical relation of the 2 prosthetic valves suggests that the mitral annulus should be enlarged less than 25 mm to avoid dysfunction of the aortic prosthetic valve.

Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess—11 year results

The aim of the study was to evaluate the long-term results of allograft and prosthetic valve replacement in the treatment of infective aortic valve endocarditis with periannular abscess. Between March 1988 and March 1996, 65 patients underwent surgery for active aortic valve endocarditis and paravalvular abscess. The indications for surgery were congestive heart failure, systemic emboli and atrioventricular block III. The pre-operative evaluation was performed with transoesophageal echocardiography. Aortic valve replacement was performed with allografts in 47 cases, with mechanical valves in 15, and bioprosthetic valves in three cases. All patients with total ventricular-aortic dehiscence and prosthetic valve endocarditis were treated with allografts. The 30-day mortality rate was 23.5% in the prosthetic group, when compared with 8.5% in the patients treated with allografts. The rate of recurrent valve infections during the 11-year follow-up period was 27.1% in the prosthetic group and 3.2% in the allograft group. The actuarial 11-year survival rate was 82.1% in the allograft group and 64.7% in the prosthetic group. Aortic allografts are an effective treatment for infective aortic valve endocarditis with associated periannular abscess. The operative mortality and recurrent infection rates are lower than in the prosthetic group, resulting in a significantly higher survival rate. Diagnosis and surgical management of these cases should be based on pre-operative transoesophageal echocardiography.

Long-term survival after aortic valve replacement for native active infective endocarditis

Background: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. Methods: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 ± 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were unbeatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. Results: Operative mortality was 8% in the majority of cases caused by heart failure or multiorgan failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. Conclusions: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-op-rative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.