Infected Calcified Homograft Root: A Sutureless Solution

Revisiting the guidelines and choice the ideal substitute for aortic valve endocarditis

Aortic valve replacement is the most commonly performed cardiac surgical operation worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the treatment goals. However, no detailed guidelines on prosthesis selection and surgical strategy are available. Management should be guided by a comprehensive evaluation of infection extension and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. We conducted a literature search of the PubMed database, EMBASE and Cochrane Library (through November 2019) for studies reporting to the use of biological substitutes in aortic valve endocarditis (AVE). Studies comparing long-term outcomes in the use of allogenic and autologous with conventional prostheses were investigated. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. In cases of complex IE with the involvement of the root or the aorto-mitral continuity, the use of homografts are recommended, according to surgeon's and center experience. Homograft use needs to be balanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives. The choice of aortic valves substitute and surgical strategy in IE is multifaceted. Principles guiding the selection of prosthesis and surgical approach rely on the long-term durability and the avoidance of infection relapse. A decisional algorithm considering the extension of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence is provided. A multidisciplinary effort is required to achieve consistent outcomes.

Placement of a rapid deployment aortic valve in a patient with severely calcified aortic root homograft

Significant aortic calcification is a known sequelae of homograft aortic root replacement and creates a treatment challenge if these patients require cardiac reintervention. The standard surgical option for patients requiring an aortic valve replacement in the setting of a calcified aortic homograft has been a Bentall procedure, which is high-risk with extended cross-clamp, cardiopulmonary bypass and operative times. We present a patient with a severely calcified aortic homograft who underwent successful valve replacement using a rapid deployment aortic valve leaving the aortic root and arch intact and avoiding the more extensive redo aortic root replacement. Similar cases in the literature are rare.

Long-term outcome of cryopreserved allograft for aortic valve replacement

OBJECTIVE

The 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.

METHODS

From 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.

RESULTS

Overall 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.

CONCLUSIONS

Cryopreserved 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.

Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root

BACKGROUND

Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure.

METHODS

Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group).

RESULTS

Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death.

CONCLUSIONS

Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.