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Ann Thorac Surg 2003;75:808
© 2003 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, The Cleveland Clinic Foundation, Kaufman Center for Heart Failure, 9500 Euclid Ave, Desk F-25, Cleveland, OH 44195, USA
e-mail: mccartp{at}ccf.org
Three principles are important for successful aortic root surgery in patients with endocarditis complicated by abscess formation. First, the surgeon must aggressively and extensively debride all infected tissue. Second, defects may need to be reconstructed, sometimes including pericardial patch closure of fistulas or holes into other cardiac chambers. Finally, aortic valve (and root) replacement with the least amount of foreign body possible (ideally no foreign body) should be performed. Previous reports described the use of prosthetic valves or the preferred option for most experienced surgeons: homograft aortic root replacement. This paper not only addresses the first two principles but reports the use of a stentless aortic valve that is "devoid of fabric material" for aortic valve replacement. Their results are good with an acceptable mortality, good hemodynamic and quality of life outcomes, and, most importantly, a low rate of reinfection (4% in patients treated with stentless valves and 4% for a similar group of patients previously treated with an aortic valve homograft).
Recent U.S. reports show similar early and late results [1, 2], but one paper reported reinfection results similar to the Berlin and Cleveland Clinic experience with the use of nonhomograft prosthetic valves [2]. Therefore, the extensive debridement is probably more important than the choice of prosthesis. However, if a prosthesis free of fabric were more readily available than homografts, most surgeons would likely prefer this to the use of prosthetic valves with extensive fabric.
Use of a stentless aortic valve in lieu of a homograft in this clinical situation has advantages, including ready availability of the stentless valve, access to a variety of different valve sizes, and cost of the prosthesis. Furthermore, at least in the U.S., there has been a chill surrounding the implantation of cryopreserved human tissue because of the risk of transmitting infection.
Unfortunately, the stentless aortic valves approved for use in the United States (Medtronic Freestyle, St. Jude TorontoTM SPV, and Edwards Prima Plus) include fabric material, which therefore violates the principle of minimizing foreign material in an infected field. The approach in this report from Berlin intuitively makes sense, and fits these three principles. Surgeons should look forward to further confirmation from other centers with a low rate of reinfection with this stentless aortic prosthesis.
References
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