Homograft aortic root replacement to correct infective endocarditis requiring seven open cardiac procedures

Early and late survival after surgical treatment of culture-positive active endocarditis

OBJECTIVE

To describe a 30-year experience with surgically treated culture-positive active endocarditis.

DESIGN

We retrospectively reviewed the microbiologic, clinical, and operative findings and the survival data in 151 patients with culture-positive active endocarditis encountered between 1961 and 1991.

RESULTS

The mean age of the 110 male and 41 female patients was 49.8 years. Native valve endocarditis was present in 86 patients, and prosthetic valve endocarditis (PVE) was diagnosed in 65. The aortic valve was involved in 62% of patients, the mitral valve in 25%, and both valves in 10%. The operative mortality was 26%. The most important univariate determinants of mortality were an abscess at operation (P = 0.01) and renal failure (P = 0.03). A trend toward a higher mortality with PVE and staphylococcal infection was noted. For hospital survivors, the 5- and 10-year survival was 71% and 60%, respectively. Univariate determinants of an adverse long-term survival were annular abscess (P = 0.01), renal impairment (P = 0.01), heart failure (P = 0.02), and aortic valve involvement (P = 0.05). On multivariate analysis, the most important adverse determinants of long-term survival were heart failure (P = 0.02), renal impairment (P = 0.02), and PVE (P = 0.03). Thirty patients required a subsequent reoperation; of these, seven required a second and two a third operation. The most common reason for reoperation was periprosthetic regurgitation without infection (N = 19). Four operations were performed for recurrent endocarditis. At 5 and 10 years, the risk of reoperation was 23% and 36%, respectively.

CONCLUSION

Although surgical treatment of culture-positive active endocarditis is still associated with substantial mortality, the long-term outcome of hospital survivors is excellent. Subsequent reoperations for periprosthetic leak are common, but recurrent infection is uncommon.

Homograft aortic root replacement for destructive prosthetic endocarditis

Prosthetic aortic valve endocarditis with extensive destruction of the aortic root, annular abscess formation, and left ventriculoaortic discontinuity was seen in 3 patients, with aorta to left atrial fistula formation in 2. Homograft aortic root replacement with use of the anterior mitral leaflet of the aortic root to repair the fistula was used successfully in all 3 patients. Their case reports are discussed to highlight the use of the homograft aortic root in these complicated cases, and to report the occurrence of aorto-left atrial fistula in prosthetic valve endocarditis.

Comparison of allografts and prosthetic valves when used for emergency aortic valve replacement for active infective endocarditis

Aortic valve replacement (AVR) using allografts is an established method of treating aortic valve disease. It is uncertain, however, whether the increased technical demands of allograft AVR can be justified in emergency operations. This study reports 15 patients treated between 1987 and 1990 for acute bacterial or fungal endocarditis involving the aortic valve. Patients underwent emergency AVR because of severe congestive failure, overwhelming sepsis or cerebral emboli. Eight patients received prosthetic valves (group I: 4 mechanical, 4 porcine) and 7 received human allografts (group II: 5 aortic and 2 pulmonary). The groups were comparable in age (group I, 55 years; group II, 51 years), intravenous drug abuse (group I, 1; group II, 3), and previous AVR (group I, 3; group II, 2). One group I and 4 group II patients had septal abscesses. Additional procedures in group I included mitral valve replacement (2), tricuspid valve replacement (1) and aortic root replacement (1). Additional procedures in group II were mitral valve repair (1), root replacement (1), atrial septal defect closure (1) and aortocoronary bypass (1). Mean bypass times (group I, 189 minutes; group II, 204 minutes) and cross-clamp times (group I; 108 minutes; group II, 121 minutes) were similar. Operative deaths occurred in 4 of 8 group I and 1 of 7 group II patients. All surviving patients have been successfully followed (group I, 28 months; group II, 18 months). No group I patient has required reoperation. One group II patients required reoperation for recurrent infection affecting the allograft, and another group II patient died 10 months postoperatively from noncardiac causes.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative echocardiography and Doppler color flow mapping in freehand allograft aortic valve and root replacement

Intraoperative epicardial echocardiography and color flow Doppler were performed before and after cardiopulmonary bypass in 17 consecutive patients undergoing 20 freehand allograft aortic valve replacements. Native aortic valves were replaced in 12, and prostheses in 8 patients. Precardiopulmonary bypass echocardiography estimates of annular diameter guided allograft selection and predicted length of allograft aortic root required, defined coronary situs, and revealed other cardiac abnormalities. These included unanticipated severe mitral regurgitation (which precluded allograft aortic valve replacements in one patient), left-to-right shunts in the membranous septum, ascending aortic dissection, and aortic root pathology requiring coronary reimplantation or bypass. Postcardiopulmonary bypass echocardiography demonstrated acceptable competency of 18/19 allograft valves (mild or no aortic insufficiency), and successful repair of 3/4 shunts. Mild mitral regurgitation was detected more often at postcardiopulmonary bypass than precardiopulmonary bypass (15 vs 11 cases) and postcardiopulmonary bypass estimates of mitral regurgitation severity corollated well with subsequent postoperative follow-up. IOE allows selection and thawing of the allograft valves prior to aortic cross clamping, minimizing cross-clamp time. It detects important concomitant cardiac abnormalities, and predicts postoperative allograft valve and mitral competency. Intraoperative echocardiography Doppler, is therefore, a useful adjunct for allograft aortic valve replacements or aortic root replacement.