Late Endocarditis Research Articles

Valved Conduits for Right Ventricular Outflow Tract Reconstruction: A Review of Current Technologies and Future Directions.

The need for right ventricular outflow tract reconstruction is common and growing in congenital heart surgery given expanding indications for the repair of congenital as well as acquired heart disease. Various valved conduit options currently exist including homografts, xenograft pulmonary valved conduits (Contegra™), and porcine valved conduits. The major limitation for all conduits is implant durability, which requires reoperation. Currently, cryopreserved homografts are often used given their superiority shown in long-term data. Significant limitations remain in the cost and availability of the graft, particularly for smaller sizes. Contegra conduits are available in a variety of sizes. Nonetheless, the data regarding long-term durability are less robust and studies comparing durability with homografts have been conflicting. Additionally, there is concern for increased rates of late endocarditis in this conduit. Porcine valved conduits offer a reliable option but are limited by structural valve degeneration associated with all types of bioprosthetic heart valve replacements. New developments in the field of tissue engineering have produced promising bio-restorative valved conduits that may overcome many of the limitations of previous conduit technologies. These remain in the early stages of clinical testing. This review summarizes the clinical data surrounding the conduits used most commonly in clinical practice today and explores emerging technologies that may bring us closer to developing the ideal conduit.

Late Endocarditis on Aortic Prosthesis Complicated by an Infectious Aneurysm of the Right Sinus Ruptured in the Right Atrium: A Case Report

Late Endocarditis on Aortic Prosthesis Complicated by an Infectious Aneurysm of the Right Sinus Ruptured in the Right Atrium: A Case Report

Late Infective Endocarditis Associated with an Atrial Septal Defect Occluder Device.

The Amplatzer septal occluder is one of several percutaneous devices used for the closure of secundum atrial septal defects. The main complications are related to the procedure, with infection being the least common. We present the case of a 67-year-old woman with a secundum atrial septal defect, who, 3 years after repair with an Amplatzer occluder, was admitted with sepsis and bacteraemia following recent hospitalization in an intensive care unit. Transoesophageal echocardiography showed the presence of a mobile echogenic structure in the left atrium suggestive of a vegetation. Few cases of late endocarditis involving the Amplatzer device have been reported, even though partial endothelization is one of the risk factors. There are no guidelines for the prevention, diagnosis or management of this complication.LEARNING POINTSThe Amplatzer septal occluder is one of several alternatives for the closure of atrial septal defects and has few related complications, with infection being the least common.Device-related endocarditis presents either early (<6 months) or late (>6 months).In our case, transoesophageal echocardiography played a key role in the diagnosis of late endocarditis.

Is Abandonment of Failed Implanted Leads Associated with an Increased Risk of Long-Term Complications?

Background: Failure of a cardiac implantable electronic device lead can be treated by either lead abandonment or extraction. There is a paucity of long-term outcome data comparing these two management strategies. Objective: To assess the long-term outcomes of a cohort of patients with abandoned leads compared to extracted leads. Methods: We conducted a retrospective review of consecutive patients with an endocardial lead abandoned or extracted at our centre between February 2000 and 2018. Results: A total of 329 inactive leads in 282 patients were identified; 195 were abandoned, 134 extracted. Patients who underwent lead extraction were younger (58{±}16 vs. 72{±}13 years) had less hypertension (34% vs. 59%), diabetes (10% vs. 19%), coronary artery disease (26% vs. 38%), atrial fibrillation (34% vs. 56%) and were more likely to have a high voltage device (46% vs. 12%). Four of 159 patients in whom leads were initially abandoned underwent subsequent extraction, one for late endocarditis. Subsequent event rates were similar between the abandoned and extracted groups; endocarditis (0.6% vs. 0.8%), venous thrombosis (2.5% vs. 1.6%), occluded venous access at subsequent procedure (2.5% vs. 2.4%), inappropriate therapy (1.3% vs. 1.6%) and failure of therapy (0.6% vs. 1.6%). In a multivariate model there was no increase in risk of the combined endpoint of mortality and late complications in patients managed by lead abandonment (OR 1.05, CI 0.57-1.82). Conclusions: In our cohort of patients with a discretionary indication for either lead extraction or abandonment, similar outcomes were observed with either strategy.

Transillumination Rendering of a Prosthetic Mitral Valve Endocarditis

A 61-year-old man presented in mid-2019 to the emergency department complaining of high-grade fever, chills, and malaise 4 days before his visit. He had a history of hypertension and a biological mitral valve replacement in 2016 as treatment for a severe mitral regurgitation. Cardiac auscultation and physical examination were noncontributory. A late endocarditis of the prosthetic mitral valve was suspected. Hemocultures taken in the first hour were positive for Streptococcus viridans and S. pneumoniae.

Infective Endocarditis After Transcatheter Aortic Valve Replacement

BackgroundInfective endocarditis may affect patients after transcatheter aortic valve replacement (TAVR). ObjectivesThe purpose of this study was to provide detailed information on incidence rates, types of microorganisms, and outcomes of infective endocarditis after TAVR. MethodsBetween February 2011 and July 2018, consecutive patients from the SwissTAVI Registry were eligible. Infective endocarditis was classified into early (peri-procedural [<100 days] and delayed-early [100 days to 1 year]) and late (>1 year) endocarditis. Clinical events were adjudicated according to the Valve Academic Research Consortium-2 endpoint definitions. ResultsDuring the observational period, 7,203 patients underwent TAVR at 15 hospitals in Switzerland. During follow-up of 14,832 patient-years, endocarditis occurred in 149 patients. The incidence for peri-procedural, delayed-early, and late endocarditis after TAVR was 2.59, 0.71, and 0.40 events per 100 person-years, respectively. Among patients with early endocarditis, Enterococcus species were the most frequently isolated microorganisms (30.1%). Among those with peri-procedural endocarditis, 47.9% of patients had a pathogen that was not susceptible to the peri-procedural antibiotic prophylaxis. Younger age (subhazard ratio [SHR]: 0.969; 95% confidence interval [CI]: 0.944 to 0.994), male sex (SHR: 1.989; 95% CI: 1.403 to 2.818), lack of pre-dilatation (SHR: 1.485; 95% CI: 1.065 to 2.069), and treatment in a catheterization laboratory as opposed to hybrid operating room (SHR: 1.648; 95% CI: 1.187 to 2.287) were independently associated with endocarditis. In a case-control matched analysis, patients with endocarditis were at increased risk of mortality (hazard ratio: 6.55; 95% CI: 4.44 to 9.67) and stroke (hazard ratio: 4.03; 95% CI: 1.54 to 10.52). ConclusionsInfective endocarditis after TAVR most frequently occurs during the early period, is commonly caused by Enterococcus species, and results in considerable risks of mortality and stroke. (NCT01368250)

A SURPRISING CASE OF LATE-ONSET BACTERIAL ENDOCARDITIS ASSOCIATED WITH GORE HELEX SEPTAL OCCLUDER DEVICE SEVEN YEARS SINCE IMPLANTATION

Septal occluder devices are used for closure of Secundum Atrial Septal Defect (ASD) and Patent Foramen Ovale (PFO) for patients with stroke from paradoxical emboli. While several complications are reported, the least reported is late endocarditis. 65 year old Caucasian male with prior stroke and

Redo aortic root operations in late prosthetic endocarditis: clinical case series

Prosthetic aortic valve endocarditis is a severe disease that quickly leads to heart failure. Owing to microorganisms and their toxins constantly entering the bloodstream, bypassing biological barriers, and hemodynamic disturbances, systemic embolism develops quite quickly, leading to sepsis and multi-organ failure. Conservative antibiotic therapy is often not effective because the infectious focus is located in the avascular zone. The presence of an implanted foreign body promotes adhesion of bacteria on the surface of the prosthetic tissue with simultaneous isolation from the action of phagocytes. Conservative treatment of prosthetic infectious endocarditis has an extremely unfavourable prognosis. Hospital mortality without operation is approximately 80%. Operations for prosthetic infectious endocarditis of the aortic valve are technically complex and require a highly qualified operating surgeon. The most difficult operations involve extension of the abscess to the aortic root, area of mitralaortic continuity and left ventricular outflow tract. In such situations, it is necessary to perform complex reconstructive operations on the aortic root, mitral-aortic continuity and left ventricular outflow tract. This study presents an overview of a series of complex redo operations on the aortic root and the ascending aorta in late prosthetic infectious endocarditis, with an analysis of the main tactical and technical aspects of the operations. Moreover, similar operations can be performed with good results by an experienced cardiac surgeon. In this case, it is necessary that prior to operation, the surgeon develops an algorithm of actions and determines 1) optimal access to the heart, 2) perfusion scheme, 3) type of implantable conduit, 4) cardiolysis performance features, 5) myocardial protection scheme and 6) features of the treatment of the infectious focus.Received 29 October 2019. Revised 19 December 2019. Accepted 23 December 2019.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributionsDrafting the article: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. ZhangerievCritical revision of the article: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. Zhangeriev, E.V. Khasigova, L.Zh. EnokyanSurgical treatment I.I. Skopin, P.V. KakhktsyanDiagnostics: L.Zh. EnokyanTreatment: D.V. Murysova, T.A. KupriyAssistance in surgery: M.S. Latyshev, E.V. KhasigovaFinal approval of the version to be published: I.I. Skopin, P.V. Kakhktsyan, M.S. Latyshev, D.V. Murysova, T.A. Kupriy, I.A. Zhangeriev, E.V. Khasigova, L.Zh. Enokyan

Outcomes of Prosthetic Valved Conduits for Right Ventricular Outflow Tract Reconstruction.

There are limited data regarding the implantation of prosthetic valved conduits for right outflow tract reconstruction in pediatric patients in China. A retrospective review of 128 patients undergoing conduits implantation with a median follow-up of 33.3months (range, 3.3months to 10.1years) was performed between 2009 and 2018. Multivariate Cox regression model was used to analyze the risk factors for mortality, reintervention and endocarditis. Freedom from reintervention and endocarditis were plotted using the Kaplan-Meier curve. Hospital mortality was 7.8%, and the late mortality was 3.1%. Patient survival at 1, 5 and 10years was 92.2%, 87.1% and 84.3%, respectively. Freedom from reintervention at 1 and 5years was 94.1% and 60.9%. Small size conduit (p = 0.019) and previous palliation (p < 0.001) were predictive of reintervention. Ten conduits developed endocarditis at a median of 4.8years after implantation. Freedom from endocarditis at 1, 5 and 10years was 99.1%, 93.0% and 58.0%, respectively. Diffuse stenosis of the conduit (p = 0.003) was an independent risk factor for late endocarditis. Both bovine jugular venous conduits and bovine pericardial prosthetic conduits are associated with acceptable outcomes. Reintervention remains high in patients who have smaller size conduit and undergo previous palliation. It is plausible that the suboptimal flow may be one of major mechanisms involved in the development of late endocarditis.

P2471Fever within 48h after Melody implantation is a risk factor of late infective endocarditis

P2471Fever within 48h after Melody implantation is a risk factor of late infective endocarditis

Long-term outcome of cryopreserved allograft for aortic valve replacement

ObjectiveThe most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long-term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long-term results of aortic allografts and to identify factors influencing long-term durability. MethodsFrom January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free-hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow-up was updated to April 2016. ResultsOverall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free-hand technique seems to be associated with improved left ventricular remodeling compared with the root-replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow-up of the study. No differences were found in the clinical outcomes among women who had children and who did not. ConclusionsCryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.

High incidence of late infective endocarditis in bovine jugular vein valved conduits

BackgroundBovine jugular vein (BJV) grafts (Medtronic, Inc, Minneapolis, Minn) are used to restore right ventricle-to-pulmonary artery continuity. Recent studies have associated these grafts with the development of infective endocarditis. The purpose of this study was to report the incidence of endocarditis in BJV grafts. MethodsAll BJV grafts placed in the right ventricle-to-pulmonary artery position between 2001 and 2017 at our institution were included. Freedom from endocarditis was analyzed using the Kaplan–Meier method and parametric survival regression models. ResultsOverall, 228 patients underwent placement of 253 BJV grafts. The median duration of conduit follow-up was 6 years (5 months to 14 years). Twenty-five conduits developed endocarditis, yielding an incidence of 10% at a median of 7.5 years after surgery. Median duration of symptoms before the diagnosis of endocarditis was 21 days (3-180 days). The most common infectious agents were viridans streptococci (n = 13; 52%). Freedom from endocarditis at 5 and 10 years was 97% and 77%, respectively. After controlling for confounders, BJV grafts had a higher incidence of endocarditis compared with homografts (P < .001). Twenty-three (92%) of the conduits that developed endocarditis were managed surgically, with no mortality. ConclusionsThe incidence of late endocarditis affecting BJV is high. Increased surveillance and a high index of suspicion for endocarditis are warranted in patients who have undergone implantation of BJV grafts, especially if the graft has been in place for more than 7 years. When infective endocarditis has been diagnosed in these grafts, surgical replacement is recommended, with excellent outcomes.

Elective David I Procedure Has Excellent Long-Term Results: 20-Year Single-Center Experience

We present our results after elective, isolated David I procedures over the past 20 years. Between 1993 and 2015, 197 patients (mean age 46 ± 17 years, 73% men) underwent isolated aortic valve reimplantation using straight tube grafts (David I procedure). Sixty patients (31%) had Marfan syndrome, and 24 (12%) had a bicuspid aortic valve. Twenty-four patients (12%) were operated through upper mini-sternotomy. There were no perioperative deaths. Stroke rate was 1% (2 of 197). Discharge echocardiography showed none to trivial aortic regurgitation (AR) in 71% (139 of 197 patients) and mild AR in 26% (51 of 197 patients). Thirty-two patients (16%) died during follow-up (9.0 ± 5.5 years after operation). One death was aortic valve related. Twenty-six patients (13%) underwent aortic valve reoperations during follow-up (5.5 ± 5.0 years after operation). Late endocarditis occurred in 2 patients (1.0%). More than trivial AR at discharge predicted a higher reoperation rate. In 144 non-reoperated survivors, echocardiography showed none to trivial AR in 56 (39%), mild AR in 53 (37%), moderate AR in 19 (6.3%), and severe AR in 4 (2.7%) of the patients after 12 ± 5.3 years. The valve-sparing David I procedure has excellent short- and long-term results. Erosion due to supposed leaflet contact with the straight tube graft was not observed in any patient, proving that using a straight graft has no negative impact on the leaflets. The "spared valve" (being native living tissue) seems to be more resistant to infection than prosthetic valves.

Случай успешного хирургического лечения позднего протезного эндокардита у пациента 80 лет с высоким операционным риском

Случай успешного хирургического лечения позднего протезного эндокардита у пациента 80 лет с высоким операционным риском

Внезапная сердечная смерть больного с поздним инфекционным эндокардитом биопротеза аортального клапана

Внезапная сердечная смерть больного с поздним инфекционным эндокардитом биопротеза аортального клапана

Risk factors for development of endocarditis and reintervention in patients undergoing right ventricle to pulmonary artery valved conduit placement

ObjectiveTo determine the incidence and risk factors for endocarditis and reintervention in patients undergoing placement of right ventricle-to-pulmonary artery valve conduits. MethodsAll right ventricle–to–pulmonary artery valved conduits placed between 1995 and 2014 were included. Freedom from endocarditis, reintervention, and replacement were analyzed using the Kaplan-Meier method and parametric survival regression models. ResultsA total of 586 patients underwent placement of a total of 792 valved conduits, including 289 (36%) pulmonary homografts, 121 (15%) aortic homografts, 245 (31%) bovine jugular grafts, and 137 (17%) porcine heterografts. There were 474 (60%) primary placements and 318 (40%) replacements. The median duration of conduit follow-up was 7 years; 23 conduits developed endocarditis at a median of 5 years after surgery. The use of bovine jugular grafts was the sole significant risk factor associated with endocarditis (hazard ratio, 9.05; 95% confidence interval, 2.6–31.8 compared with homografts). The hazard was greater for bovine jugular grafts compared with the other conduit types and increased with time; however, bovine jugular grafts were associated with a lower risk for reintervention (P < .0001) and replacement (P = .0002). Factors associated with greater risk of both reintervention and replacement were younger age and smaller conduit size. In addition, a diagnosis of truncus arteriosus was associated with a greater risk for replacement (P = .03). ConclusionsBovine jugular grafts are associated with a significantly greater risk of late endocarditis but with lower reintervention rates compared with other valved conduits. The risk of endocarditis and durability must be balanced during conduit selection. Antibiotic prophylaxis and a high index of suspicion for endocarditis are warranted in patients with bovine jugular grafts.

Melody® transcatheter pulmonary valve implantation: Results from a French registry

Percutaneous implantation of pulmonary valves has recently been introduced into clinical practice. To analyse data of patients treated in France between April 2008 and December 2010. Prospective, observational, multi-centric survey by means of a database registry of the Filiale de cardiologie pédiatrique et congénitale. Sixty-four patients were included, with a median (range) age of 21.4 (10.5-77.3) years. The majority (60.9%) of the patients were New York Heart Association (NYHA) class II. The most common congenital heart disease was tetralogy of Fallot with or without pulmonary atresia (50%). Indication for valve implantation was stenosis in 21.9%, regurgitation in 10.9% and association of stenosis and regurgitation in 67.2%. Implantation was successful in all patients. Pre-stenting was performed in 96.9% of cases. Median (range) procedure time was 92.5 (25-250) minutes. No significant regurgitation was recorded after the procedure, and the trans-pulmonary gradient was significantly reduced. Early minor complications occurred in five cases (7.8%). Three patients died during a median follow-up of 4.6 (0.2-5.2) years, two from infectious endocarditis and one from end-stage cardiac failure. Surgical reintervention was required in three patients. Follow-up with magnetic resonance imaging demonstrated significant improvements in right ventricular volumes and pulmonary regurgitation in mixed and regurgitant lesions. Transcatheter pulmonary valve implantation is highly feasible and mid-term follow-up demonstrates sustained improvement of right ventricular function. Late endocarditis is of concern, therefore longer follow-up in more patients is urgently needed to better assess long-term outcome. NCT01250327.

Reoperation for neoaortic root pathology after the arterial switch operation

To evaluate incidence and results of surgical intervention for neoaortic root pathology following arterial switch operation (ASO) for transposition of the great arteries (TGA). Between April 1996 and August 2013, 12 patients underwent reoperation for neoaortic root dilatation (ARD) and/or neoaortic valve regurgitation (AR). Maximal aortic sinus and annulus diameter Z-scores were recorded. Original diagnoses were TGA/IVS (6), TGA/ventricular septal defect (VSD) (4) and Taussig-Bing anomaly (2) with ASO at a median age of 0.1 (range: 0-10.6) years. Age at ASO, VSD and complex TGA were reviewed as possible risk factors for reoperation. Twelve patients with tricuspid neoaortic valves underwent 15 root operations; indications were root dilatation (4) and root dilatation with AR (8). Median age was 18.0 (3.0-29.0) years at first reoperation. Median aortic root Z-score at reoperation was 6.33 (range: 3.84-12.15). Procedures were: Bentall procedure (6), aortic valve replacement (2), neoaortic valve plasty (1), supracoronary tube (1) and switch-back operation (2). Mean follow-up was 7.0 ± 5.7 years and complete. No mortality occurred. One patient had two reoperations for late endocarditis. Technical difficulties were encountered related to specific anatomy post-ASO concerning coronary anatomy, poor exposure and thin-walled aorta at the site of pulmonary artery bifurcation after Lecompte manoeuvre. Valve sparing surgery seemed not feasible due to specific anatomy of the neoaortic root and valve. No risk factors for reoperation could be identified. After ASO, surgery for neoaortic root pathology may become necessary when follow-up is long enough and regardless of primary diagnosis or other risk factors. Redo neoaortic surgery can be performed with low risk taking into account the specific technical difficulties.

Morbidity and Mortality Associated With Dental Extraction Before Cardiac Operation

Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures. A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation. Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation. Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population.

Repair versus replacement of the aortic valve for the treatment of active infective endocarditis: is Sorin Solo the aortic bioprosthesis Columbus's egg?

We read with interest the paper from Mayer et al. [1] regarding the best treatment for aortic valve endocarditis and would like to present our personal approach in such a challenging situation. Active infective endocarditis (AIE) remains a challenging situation, particularly when associated with annular infection and the presence of root abscesses [2, 3]. Such a condition, due to the fragility of the aortic annulus, is related to unfavourable postoperative mortality and high incidence of paravalvular leakage. The best treatment for abscesses is still a matter of debate, and the treatments proposed so far vary from the toilette and exclusion using mattress sutures to the more demanding technique of exclusion with a pericardium patch [4]. Mayer et al. claim better survival using valve repair compared with aortic valve replacement (AVR) particularly in patients with a tricuspid aortic valve and limited cusp defect. In his editorial comment, however, David [5] underlined the relatively poor prognosis in terms of freedom from reoperation (and from persisting endocarditis) in the group receiving valve repair. The ideal surgical procedure for AIE is still debated, and we would like to stress that a key factor for the final outcome is surely represented by the presence of a perivalvular abscess. In the Mayer experience, the presence of root abscesses (32% of patients) did not influence the choice between valve and replacement. AVR following abscess treatment, however, could cause additional technical difficulties due to the conjunction of the upper margin of the patch with the suture line of the prosthesis. We have recently considered AVR to be the treatment of choice for AIE using the Solo stentless pericardial bioprosthesis (SFS), recently introduced by Sorin, which could represent the optimal compromise between AVR and repair in AIE due to its peculiar characteristics. Our series include 5 patients with confirmed AIE and root abscess. The abscesses were excluded, after accurate debridement, using the pre-fixed patch of an autologous pericardium sutured using a running suture following antibiotics and BioGlue instillation within the cavity. The sized SFS was then sutured in place, using three running sutures above the aortic annulus according to the standard reported technique [6]. A peculiar characteristic of SFS is the supra-annular implantation within the sinuses of Valsalva, which, therefore, does not require annular sutures. This technique enables one to avoid anchoring the suture of the prosthesis on the pericardial patch used for the abscess and, therefore, the use of SFS could be the best option in case of AIE with root abscesses. In our series, perioperative mortality was 0%, with no major early complications. At cumulative follow-up of 172 months, there were no cases of late death, no persistent or recurrent endocarditis and no case of ‘failed treatment’ (i.e. sterile paravalvular leakage and/or patch dehiscence). Our preliminary results, in a cohort of haemodynamically stable patients, seem to confirm therefore that SFS is safe and effective in this clinical subset, allowing for a complete treatment of infection in all cases, without late reoperations either for sterile or for infective paravalvular leakage.