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Ann Thorac Surg 1997;63:1644-1649
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Allograft Aortic Root Replacement in Prosthetic Aortic Valve Endocarditis: A Review of 32 Patients

Department of Cardiothoracic Surgery, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands

Accepted for publication December 7, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Background. This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction.

Methods. From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 ± 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 ± 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 ± 11.8 days.

Results. There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 ± 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%)

Conclusions. Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Prosthetic valve endocarditis (PVE) is a serious and potentially fatal complication after valve replacement. The overall incidence of PVE ranges from 0.32% to 1.20% per patient-year [1, 2]. The cumulative risk of PVE, based on actuarial data derived from a study of 1,598 patients by Rutledge and colleagues [3], was 3.2% at 5 years and 5% at 10 years. The reported mortality associated with PVE has varied considerably but is frequently in the range of 10% to 30%, underscoring the lethal potential of this condition [4–8].

Antibiotic treatment alone can be successful for late infections that involve the prosthesis only (particularly for patients with bioprostheses), but it rarely cures infections involving the valve–native annulus interface [9]. In the setting of extensive destruction of the aortic root and the presence of periannular abscesses, simple debridement and valve replacement are not possible. Among the surgical options, various techniques using prosthetic material have been described to treat such patients [4, 5, 8–11]; we evaluated allograft aortic root replacement. To date, only two series with a similar patient group reported the use of an allograft aortic root replacement in the complex setting of prosthetic aortic valve endocarditis [6, 12].

During the past 6 years, we have treated 32 consecutive patients with prosthetic aortic valve endocarditis and aortic root abscesses by aggressive debridement of the abscess cavity and surrounding tissue. The left ventricular outflow tract was then reconstructed by allograft root replacement. The aim of the study was to evaluate early and late postoperative mortality, freedom from recurrent endocarditis, and echocardiographic performance of the allograft root on midterm follow-up.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Patient Population
Between January 1990 and March 1996, 32 consecutive patients (23 men and 9 women) diagnosed with complicated PVE underwent allograft aortic root replacement. Mean age was 58.3 ± 13.2 years (range, 23 to 76 years). Concomitant procedures included coronary artery bypass grafting in 2 patients and mitral annuloplasty in 1 patient. The diagnosis of PVE was definite in 27 patients and possible in 5, according to the Duke University criteria for infective endocarditis [13].

Complicated PVE has been defined as involving one or more of the following: (1) new or worsening murmur of prosthetic valve dysfunction, (2) progressive congestive heart failure related to prosthetic valve dysfunction in the setting of endocarditis, (3) persistent fever for 10 or more days during antibiotic therapy, and (4) new or worsening abnormality of cardiac conduction.

Prosthetic valve endocarditis has been defined as early when it appeared within 1 year of valve insertion (18 patients) and late when it occurred after more than 1 year (14 patients), as suggested by Calderwood and colleagues [14].

All patients had evidence of clinical deterioration or ongoing sepsis. Fever was present in 28 patients (87.5%), newly developed aortic regurgitation in 20 (62.5%), worsening congestive heart failure in 10 (31%), complete heart block in 4 (12.5%), and peripheral embolization in 2 patients (6%). Ten operations were considered urgent. The total number of previous aortic valve replacements was 38 (for details, see Table 1).

	Operative Technique

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

The distal allograft was trimmed and sewn to the transsected aorta with continuous 5–0 polypropylene sutures. Mean perfusion time was 207 ± 47 minutes (range, 138 to 364 minutes), mean aortic cross-clamp time was 150 ± 29 minutes (range, 92 to 257 minutes).

	Operative Findings

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Periannular abscesses, most of which were extensive, were found in 26 patients (81%); mitral-aortic discontinuity in 14 patients (43%), left ventricular-aortic discontinuity in 11 patients (34%). Partial valve dehiscence was reported in 21 patients (66%), vegetations covered the prosthetic valve in 3 patients (9%). For details, see Table 2.

	Microbiology

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

	Patient Follow-up

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Patients surviving operation for PVE were followed up by telephone survey to ascertain long-term outcome. A specific inquiry was made for patient survival, recurrence of infection, or subsequent cardiac operation in the interim since initial operation for PVE. All data were obtained either from the patient or a close relative between February and March 1996. In addition, clinical examination data were collected from the patient's cardiologist. A transthoracic two-dimensional Doppler echocardiographic study was performed in all patients between November 1995 and July 1996.

	Statistical Analysis

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Life-table analysis and standard errors were calculated using the actuarial method [16].

	Results

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Operative Mortality
All patients survived the operation. There were three operative deaths, accounting for a hospital mortality rate of 9.4% (1 patient with early PVE, 2 with late PVE). Two patients died of multiorgan failure on the seventh and tenth postoperative day. In 1 patient, who underwent a third intervention, a technical failure was the cause of death. The patient could not be weaned from cardiopulmonary bypass because of massive aortic regurgitation after an allograft root replacement. The valve was replaced by a mechanical device, but the patient died 24 hours later of low cardiac output.

	In-Hospital Morbidity

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Eleven patients (37%) needed a reoperation for extensive postoperative bleeding. Six patients (18%) required insertion of a permanent pacemaker for complete heart block (4 patients already had complete heart block preoperatively). Other complications were temporary respiratory insufficiency in 3 patients (9.5%), permanent otovestibular disturbances attributable to the prolonged antibiotic treatment in 3 patients (9.5%), and temporary renal insufficiency in 1 patient (3.2%).

	Follow-up

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
A 100% follow-up of the 29 hospital survivors was obtained; mean follow-up was 37.5 ± 22.4 months (range, 4 to 82 months). Two late deaths occurred: 1 patient died of lung cancer 6 years after the intervention, and a second patient died during a reoperation (fourth intervention) for a mycotic aneurysm at the proximal suture line 6 months after previous allograft root replacement. He underwent a redo allograft root replacement but did not survive this intervention. Cause of the mycotic aneurysm formation was an iatrogenic infection in the early postoperative period. To date, this is the only patient who needed a reoperation for a recurrence of endocarditis. The 5-year survival rate (actuarial life-table analysis) including operative deaths is 87.3% (70% confidence interval, 76.8% to 97.8%) (Fig 1); the 5-year actuarial freedom from recurrent endocarditis is 96.5% (70% confidence interval, 90.0% to 100%) (Fig 2).

View larger version (10K): [in this window] [in a new window]   Fig 1. . Five-year actuarial survival, expressed as mean value with 70% confidence interval (CI).

View larger version (13K): [in this window] [in a new window]   Fig 2. . Five-year actuarial freedom from recurrent endocarditis, expressed as mean value with 70% confidence interval (CI).

	Comment

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
In this study of surgical patients, "early" PVE has been defined as PVE occurring within 12 months of operation, and "late" PVE as occurring more than 1 year after operation. This definition extends the time period during which PVE is considered "early" beyond that used in many previous studies, but seems reasonable based on microbiologic findings by Calderwood and colleagues [14]. They found that PVE occurring within the first postoperative year is often due to coagulase-negative staphylococci and other organisms indicative of hospital-acquired infection. Further evidence of nosocomial origin of PVE within 1 year after valve replacement was that 84% of coagulase-negative staphylococci causing PVE within 12 months after initial operation were methicillin resistant, suggesting a nosocomial source for the subsequent infection [17]. In the present study, 18 patients were considered to have "early" PVE; causative microorganisms were coagulase-negative staphylococci in 15 of these 18 patients (83%).

The results of treatment for complicated PVE have steadily improved with the acceptance of the role of early operation in patients presenting with heart failure, ongoing sepsis, valve destruction, or prosthesis dehiscence. When valve replacement is clinically indicated, there is little to be gained by delaying operation despite an incomplete course of antibiotic therapy [18, 19].

All patients included in these series presented with one or more of the above-mentioned conditions. The duration of the preoperative antibiotic course was highly variable. Urgent operation was required in some patients, inevitably causing an interruption of the antibiotic treatment; availability of suitable allografts was another important factor influencing the duration of the preoperative antibiotic treatment.

The general principles of operation for PVE consist in removal of the infected prosthesis from the infected site, complete excision of necrotic tissue and debridement of nonviable tissues, and adequate antibiotic coverage [9]. For extensive destruction of the aortic root, including left aortoventricular discontinuity, a number of surgical techniques have been described using prosthetic material and patch closure of abscesses. Satisfactory results have been obtained with these methods, but there is understandable concern regarding the risk of recurrent endocarditis because of the use of prosthetic material [4, 5, 8, 10, 11].

In the setting of PVE, allografts offer distinct anatomic advantages. They are uniquely flexible and can be implanted in such a way as to exclude abscess cavities and replace the aortic root despite extensive destruction. Abscess cavities in the left ventricular outflow tract can be managed by suturing the leading edge of the allograft annulus to the inferior border of the abscess cavity. The abscessed cavity is not covered over, thus leaving a packet of infected tissue that can lead to recurrent infection or paraprosthetic leak.

Haydock and colleagues [20] published a series of 108 patients with active aortic valve endocarditis (66 native valve endocarditis, 42 PVE) and compared results of freehand allograft valves with mechanical prostheses and bioprostheses. It was concluded that the allograft valve was the valve of choice for aortic valve replacement in active endocarditis. This was confirmed by McGiffin and associates [21]. Up to this date, only two reports with a similar number of patients have used the technique of allograft aortic root replacement for the treatment of complicated aortic PVE [6, 12]. In the present study, all patients underwent allograft root replacement. We consider this the appropriate technique in conditions with extensive annular destruction compared to the freehand implantation technique. Moreover, we believe that the geometry of the allograft is best respected using it as a complete root. This might be illustrated by the excellent echocardiographic findings obtained in all 27 patients alive: 80% are free of aortic regurgitation at a mean follow-up of 37.4 months.

In a number of patients, operation was delayed because of shortage of suitable allografts. D'Udekem and colleagues from Toronto [4] published recently an article suggesting that radical resection of the abscess and reconstruction of the heart with glutaraldehyde-fixed bovine pericardium yields good early results as with allografts. However, the risk of late recurrence of endocarditis was higher than in our study. This supports our philosophy of implanting an allograft whenever possible, although in some instances it may delay operation for some days.

Operative mortality (9.4%) was acceptable; the patient who died of technical failure was operated on at the beginning of our allograft experience. Overall results are comparable with those of Glazier [6] and Camacho [12] and their colleagues in an identical patient group. Other reports on PVE are often a mixture of mitral and aortic PVE. In Table 5, we selected patients with aortic PVE from different studies and compared some of the variables. In our series, it was particularly interesting to find an almost complete absence of recurrence of endocarditis. In only 1 patient, a mycotic aneurysm developed at the proximal suture line and required a reoperation. It was provoked by inadvertent handling of intravenous lines causing a postoperative period of septicemia and subsequent recurrence of endocarditis.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 
Address reprint requests to Dr Dossche, Department of Cardiothoracic Surgery, St. Antonius Ziekenhuis, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands.

	References

Top Footnotes Abstract Introduction Material and Methods Operative Technique Operative Findings Microbiology Patient Follow-up Statistical Analysis Results In-Hospital Morbidity Follow-up Comment References

 

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