Surgical management of aortic root abscess: A 13-year experience in 172 patients with 100% follow-up

Contemporary surgical management of infective endocarditis of the aortic root

Infective endocarditis involving the aortic root is associated with a high degree of morbidity and mortality. Native aortic root infections can develop from aggressive organisms or from delays in diagnosis or definitive care, whereas prosthetic valve infections commonly result in extensive destruction of the aortic root and neighboring structures. Early detection, tailored antibiotic therapy, thoughtful pre-operative planning, and multidisciplinary heart team management are the keys to optimizing patient outcomes. Aggressive and complete surgical debridement are mandatory prior to aortic root reconstruction. Surgical experience and patient-centered decision making are critical in selecting the optimal reconstructive strategy for the aortic root and adjacent structures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01604-6.

Anomalous coronary artery masquerading as a root abscess: a case report

Congenital coronary artery anomalies are rare and most often clinically benign. We present a case of a 67-year-old male with osteomyelitis and persistent bacteremia with an anomalous left coronary artery mimicking an aortic root abscess. A transesophageal echocardiogram revealed a hypoechoic potential space around the aortic root, highly suspicious for a root abscess. Urgent cardiac surgery was performed, revealing no infection but an anomalous coronary artery arising from the right coronary sinus. This case highlights the importance of considering atypical anatomy in the diagnosis of infectious cardiac processes. While this resemblance should not delay intervention for suspected abscesses, it emphasizes the need to be aware of congenital differences in imaging for patients with known anomalies or asymptomatic patients with unknown anatomy.

Early and late outcomes of surgical repair of mycotic aortic aneurysms: A 30-year experience

OBJECTIVE

Mycotic aortic aneurysm and its associated complications are often catastrophic. In this study, we examined the early and late outcomes of surgical repair of mycotic aortic aneurysm at our center over the last 3 decades.

METHODS

We retrospectively reviewed our prospectively maintained aortic surgery database with supplemental adjudication of medical records. Aortic infection was confirmed through clinical, radiological, intraoperative, pathological, and treatment evidence.

RESULTS

Seventy-five patients (median age, 68 years; interquartile range, 62-74) who underwent surgical repair of a mycotic aortic aneurysm between 1992 and 2021 were included. Almost all patients (n = 72; 96%) presented with symptoms, including 26 patients (35%) with rupture, and many underwent urgent or emergency repair (n = 64; 85%). Sixty-one patients underwent open repair, and 14 patients underwent hybrid or endovascular repair. Infection-specific adjunct techniques included rifampin-soaked grafts (n = 16), omental pedicle flaps (n = 21), and antibiotic irrigation catheters (n = 8). There were 15 early deaths (20%), including 10 of the 26 patients (38%) who presented with rupture; however, persistent stroke, paraplegia or paraparesis, and renal failure necessitating dialysis were uncommon (each <5%). Almost all early survivors (52/60; 87%) were discharged with long-term antibiotic therapy. Estimated survival at 2, 6, and 10 years was 55.7% ± 5.8%, 39.0% ± 5.7%, and 26.9% ± 5.5%, respectively.

CONCLUSIONS

A substantial proportion of patients with mycotic aortic aneurysm present with rupture and generally require urgent or emergency repair. Operative mortality and complications are common, especially for patients who present with rupture, and late survival is poor.

Surgery for paravalvular abscess in children

Objective

To investigate the outcomes of surgery in children with paravalvular abscess at our institution.

Methods

A retrospective review of all patients who underwent surgery for paravalvular abscess was performed.

Results

Between 1989 and 2020, 30 patients underwent surgery for paravalvular abscess, of whom 5 (16.7%) had an intracardiac fistula and 6 (20.0%) had a pseudoaneurysm. Aortic annulus abscesses were most common, occurring in 23 patients (76.7%). Aortic root replacement was performed in 17 patients (56.7%), root reconstruction was performed in 4 (13.3%), and reconstruction of the central fibrous body was required in 5 (16.7%). Postoperatively, 7 patients (23.3%) required extracorporeal membrane oxygenation (ECMO) support, and 1 patient (3.3%) required permanent pacemaker insertion. There were 6 early deaths, 5 of whom were on ECMO, and no late deaths, with a 15-year survival of 79.7% (95% confidence interval [CI], 60.2%-90.3%). Deaths were from sudden cardiac arrest resulting in brain death in 3 patients, inability to wean from ECMO due to severe cardiac dysfunction in 2 patients, and cerebral mycotic aneurysm and hemorrhage in 1 patient. Freedom from reoperation was 40.0% (95% CI, 17.0%-62.3%) at 15 years Reoperation due to recurrence was rare, occurring in only 2 patients (6.7%). Streptococcus pneumoniae (hazard ratio [HR], 9.2; 95% CI, 1.6-51.7) and preoperative shock (HR, 6.4; 95% CI, 1.3-32.0) were associated with mortality. Central fibrous body reconstruction was associated with reoperation (HR, 4.4; 95% CI, 1.2-16.1).

Conclusions

Although paravalvular abscess in children is associated with high early mortality, hospital survivors have good long-term survival. Reoperation is frequent, but is rarely due to recurrence of endocarditis.

Surgical Outcomes After Reconstruction of the Aortomitral Curtain

Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.

Root-commando operation for a ruptured left ventricular outflow tract

Prosthetic valve endocarditis, especially when complicated by an aortic root abscess and a left ventricular outflow tract rupture, is a life-threatening condition. We present a case of infective prosthetic aortic valve endocarditis with a ruptured left ventricular outflow tract successfully treated with a root-commando operation using a secure anastomosis for reconstruction of the damaged aortic annulus.

Aortic root reinforcement in aortic valve endocarditis with annular abscess: The Calamari procedure

Treatment of infective endocarditis can often prove challenging due to its wide range of anatomical presentations. When complicated by an aortic root abscess, patients may require extensive root surgery, which on its own leads to a worse outcome. We present our experience with a surgical technique for reinforcing the aortic annulus with a ring from a Dacron aortic prosthesis placed in the left ventricular outflow tract to avoid the need for root replacement procedures or patch closures of the defect. The technique described in this paper provides a viable alternative to the standard techniques used for the treatment of annular abscesses in aortic valve endocarditis. Due to the relative simplicity and ease of use, this approach may present a means of reducing operation time and possibly postoperative complications of this severe condition.

Echocardiography fails to detect an extensive aortic root abscess in a patient with infective endocarditis: a case report

Background

Echocardiography plays a central role in the diagnosis of infective endocarditis (IE). In recent years, additional imaging techniques have begun to challenge the conventional approach. We present a case where the use of transthoracic/transoesophageal echocardiography (TTE/TOE) in suspected IE failed to identify an extensive periannular abscess, later identified by 18F-flurodeoxyglucose-positron emission tomography (FDG-PET), requiring urgent intervention.

Case summary

A 69-year-old man with symptomatic Streptococcus sanguinis bacteraemia and a bicuspid aortic valve was found to have new-onset left bundle branch block that progressed to complete heart block. After starting on IV Penicillin G and having a temporary pacemaker inserted, his clinical condition improved. Transthoracic echocardiography and TOE showed no evidence of abscess. However, persistent first-degree atrioventricular block raised clinical suspicion of a possible extended infection. Subsequent FDG-PET revealed focal activity around the aortic root that extended inferiorly into the interatrial septum, consistent with active infection and possible abscess. Composite aortic root replacement with insertion of a mechanical prosthesis was carried out, revealing extensive IE and multiple periannular abscesses.

Discussion

As guidelines grapple with evolving understandings of how best to define the optimal imaging approach for the management of complicated IE, the results of this case clearly show the importance of heightened clinical suspicion and need for prompt operative intervention when faced with patients who present with predisposing conditions and concern for advanced conduction disease. Clinicians and researchers are encouraged to learn from the potential near-miss of an extensive periannular abscess to help guide guideline-development of imaging in complicated IE and prevent adverse outcomes in patients with similar presentations.

Impact of aortic root repair or replacement in severe destructive aortic valve endocarditis with paravalvular abscesses on long-term survival

OBJECTIVES

Surgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis.

METHODS

A total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63).

RESULTS

Patients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39-0.95; P = 0.031).

CONCLUSIONS

Aortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis.

CLINICAL TRIAL REGISTRATION

UN4232 382/3.1 (retrospective study).

Five-year outcomes following complex reconstructive surgery for infective endocarditis involving the intervalvular fibrous body

OBJECTIVES

Destruction of the intervalvular fibrous body (IFB) due to infective endocarditis (IE) warrants a complex operation involving radical debridement of all infected tissue, followed by double valve replacement (aortic and mitral valve replacement) with patch reconstruction of the IFB. This study assesses the 5-year outcomes in patients undergoing this complex procedure for treatment of double valve IE with IFB involvement.

METHODS

A total of 127 consecutive patients underwent double valve replacement with reconstruction of the IFB for active complex IE between January 1999 and December 2018. Primary outcomes were 3-year and 5-year survival, as well as 5-year freedom from reoperation.

RESULTS

Patients' mean age was 65.3 ± 12.9 years. Preoperative cardiogenic shock and sepsis were present in 17.3% and 18.9%, respectively. The majority of patients (81.3%) had undergone previous cardiac surgery. Overall, 30-day and 90-day mortality rates were 28.3% and 37.0%, respectively. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Preoperative predictors for 30-day mortality were Staphylococcus aureus [odds ratio (OR) 1.65; P = 0.04] and left ventricular ejection fraction (LVEF) <35% (OR 12.06; P = 0.03), for 90-day mortality acute kidney injury requiring dialysis (OR 6.2; P = 0.02) and LVEF <35% (OR 9.66; P = 0.03) and for long-term mortality cardiogenic shock (hazard ratio 2.46; P = 0.01).

CONCLUSIONS

Double valve replacement with reconstruction of the IFB in patients with complex IE is a challenging operation associated with high morbidity and mortality, particularly in the first 90 days after surgery. Survival and freedom from reoperation rates are acceptable thereafter, particularly considering the severity of disease and complex surgery.

Prevalence and predictors of aortic root abscess among patients with left-sided infective endocarditis: a cross-sectional comparative study

BACKGROUND

Aortic root abscess (ARA) is a major complication of infective endocarditis that is associated with increased morbidity and mortality. Limited data are present about patient characteristics and outcomes in this lethal disease. We aimed to study the clinical and echocardiographic characteristics of patients with ARA compared to patients with left-sided infective endocarditis without ARA. We included patients with a definite diagnosis of left-sided infective endocarditis according to modified Duke's criteria. The patients were classified into two groups according to the presence of ARA (ARA and NO-ARA groups). All the patients were studied regarding their demographic data, clinical characteristics, laboratory and imaging data, and complications.

RESULTS

We included 285 patients with left-sided infective endocarditis. The incidence of ARA was 21.4% (61 patients). Underlying heart disease, mechanical prosthesis, bicuspid aortic valve, and prior IE were significantly higher in ARA. The level of CRP was higher in ARA (p = 0.03). ARA group showed more aortic valve vegetations (73.8% vs. 37.1%, p < 0.001), more aortic paravalvular leakage (26.7% vs. 4.5%, p < 0.001), and less mitral valve vegetations (21.3% vs. 68.8%, p < 0.001). Logistic regression analysis showed that the odds of ARA increased in the following conditions: aortic paravalvular leak (OR 3.9, 95% CI 1.2-13, p = 0.03), mechanical prosthesis (OR 3.6, 95% CI 1.5-8.7, p = 0.005), aortic valve vegetations (OR 3.0, 95% CI 1.2-8.0, p = 0.02), and undetected organism (OR 2.3, 95% CI 1.1-4.6, p = 0.02), while the odds of ARA decreased with mitral valve vegetations (OR 0.2, 95% CI 0.08-0.5, p = 0.001). We did not find a difference between both groups regarding the incidence of major complications, including in-hospital mortality.

CONCLUSION

In our study, ARA occurred in one fifth of patients with left-sided IE. Patients with mechanical prosthesis, aortic paravalvular leakage, aortic vegetations, and undetected organisms had higher odds of ARA, while patients with mitral vegetations had lower odds of ARA.

Comparative Effectiveness of Mechanical Valves and Homografts in Complex Aortic Endocarditis

BACKGROUND

The ideal surgical reconstruction of the aortic root in patients with complex endocarditis is controversial. We compared the short- and long-term outcomes between mechanical valves, bioprostheses, and homografts.

METHODS

We identified all patients undergoing an operation for active complex aortic endocarditis at our institution between 2003 and 2017. We grouped patients according to those who received a mechanical valve, bioprosthesis, or homograft. We used multiple logistic regression and proportional hazards models. To minimize confounding by indication, we used marginal risk adjustment to simulate that every patient would undergo (contrary to fact) all 3 operations.

RESULTS

Of 159 patients with complex active endocarditis, 48 (30.2%) had a valve plus patch reconstruction, and 85 (53.4%) had a root replacement. Of all, 50 (31.5%) had a mechanical valve, 56 (35.2%) had a bioprosthesis, and 53 (33.3%) had a homograft. The groups were similar in age, sex, body mass index, comorbid conditions, organism, abscess location, and mitral involvement (all P > .05). However, patients receiving mechanical reconstructions were more likely to have native valve endocarditis (46% vs 37.5% vs 17%; P = .005) and less likely to undergo root replacement (32% vs 28.6% vs 100%; P < .001). Marginal risk-adjusted operative mortality was lowest for mechanical valves (4.8%) and highest for homografts (16.9%; P = .041). Long-term survival after root replacement was worse with homografts than with mechanical valve conduits (adjusted hazard ratio, 2.9; P = .045).

CONCLUSIONS

In patients with complex endocarditis, mechanical valves are associated with similar, if not better, short- and long-term outcomes compared with homografts, even after adjusting for important baseline characteristics and limiting the analysis to root replacements only.

Successful treatment of left ventricular patch infection by latissimus dorsi muscle flap covering without patch removal

Removal of the infected prosthesis is considered an essential procedure in the treatment of prosthetic graft infection following cardiovascular surgery. Here, we present a case of left ventricular patch infection following repair of left ventricular rupture that was successfully treated by coverage with a latissimus dorsi muscle flap without patch removal. A 61-year-old man underwent double-patch repair for left ventricular-free wall rupture following posterior myocardial infarction. He underwent drainage and omental transposition with re-sternotomy for postoperative mediastinitis by Candida albicans, followed by pericardial fenestration via left thoracotomy for infectious pericarditis; however, left ventricular patch infection was detected. Considering the high invasiveness of a reoperation for patch removal, we preserved and covered the patch using a left pedicled latissimus dorsi muscle flap via left thoracotomy. The postoperative course was uneventful, and the patient was asymptomatic with no signs of recurrence at 30 months.

Early outcomes of native and graft-related abdominal aortic infection managed with orthotopic xenopericardial grafts

OBJECTIVE

Reconstruction of infected aortic cases has shifted from extra-anatomic to in situ. This study reports the surgical strategy and early outcomes of abdominal aortic reconstruction in both native and graft-related aortic infection with in situ xenopericardial grafts.

METHODS

Included in the analysis are 21 consecutive patients (mean age, 69 years; 20 male) who underwent abdominal xenopericardial in situ reconstruction of native aortic infection (4) and endovascular (4) or open (13) graft aortic infection between July 2017 and September 2019. All repairs were performed on an urgent basis, but none were ruptured. All patients were followed up with clinical and biologic evaluation, ultrasound at 3 months, and computed tomography scan at 6 months and 1 year.

RESULTS

Technical success was 100%; 8 patients were treated with xenopericardial tubes and 13 with bifurcated grafts. Thirty-day mortality was 4.7% (one death due to pneumonia with respiratory hypoxic failure in critical care.). Six patients (28%) developed acute kidney injury, four (19%) requiring temporary dialysis; five fully recovered and one died. Four patients (19%) required a return to the operating room. After a median follow-up of 14 months (range, 1-26 months), overall mortality was 19% (n = 4). Two patients presented with recurrent sepsis after reconstruction, leading to death due to multiorgan failure. Other patients (17/21) have discontinued antibiotics with no evidence of recurrence of infection clinically, radiologically, or on blood tests. Computed tomography scans at 1 year demonstrated no stenosis or graft dilation and one asymptomatic left graft branch thrombosis. Primary patency is 95%.

CONCLUSIONS

In situ xenopericardial aortic reconstruction is a safe and effective management strategy for both native and graft-related abdominal aortic infection with good short-term results. The graft demonstrates appropriate resistance to infection such that reliable eradication of infection in this vascular bed is possible. Longer follow-up is required in future studies to determine the durability of the reconstruction and need for reinterventions.

Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes

OBJECTIVES

To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically.

METHODS

From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data.

RESULTS

Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%).

CONCLUSIONS

Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.

Surgical treatment and long-term outcome of aortic valve endocarditis with periannular abscess

Objectives

Aortic valve endocarditis is occasionally complicated by periannular spreading of the infection and abscess formation, leading to a more aggressive course of the disease and life-threatening complications. This retrospective observational study investigated the long-term outcomes of patients with this complication, which was surgically managed with annular reconstruction and aortic valve replacement.

Methods

Between 1998 and 2018, 69 patients were identified with aortic valve endocarditis complicated by periannular abscess formation. All patients were treated with debridement of the infected tissue, gentamicin filling of abscess cavities, annulus reconstruction with bovine pericardium, and valve replacement. Long-term follow-up was performed to detect the rate of recurrence of endocarditis, aortic valve reoperation and survival.

Results

Mean age was 58 ± 15 years, 81% of patients were male, and the infected valve was native in 51% of all patients. The overall mortality was 36%, with a 30-day mortality of 13% and 120–day mortality of 16%. Five- and 10-year survival was 69.4 ± 12.0% and 55.7 ± 14.3%, respectively. Ten-year freedom from recurrent endocarditis was 83.5 ± 13.3%.

Conclusion

Endocarditis with annular abscess remains associated with high morbidity and mortality and aggressive treatment of the infected tissue and abscess cavities is crucial. Compared with earlier literature, long-term outcome of annular reconstruction in this series is comparable to that of aortic root replacement.

Local administration of the powder minocycline during surgical intervention for active infective endocarditis

OBJECTIVES

We retrospectively assessed the initial clinical impact of the locally administered bacteriostatic antibiotic, powder minocycline, during surgery for active infective endocarditis (AIE).

METHODS

Among 38 surgical AIE patients, 36 patients who underwent surgical intervention for AIE using local administration of powder minocycline between January 2008 and August 2017 in our institute were enrolled. During surgery, the local administration and dispersion of powder minocycline at not only the valvular annulus and perivalvular cavity, but also the prosthetic cuff and ring were performed following the complete resection and aggressive debridement of infectious tissues. Early clinical outcomes, including survival, postoperative co-morbidities, and freedom from re-intervention or significant paravalvular leakage (PVL), were assessed.

RESULTS

Early mortality within 30 days was 5.6% and hospital death was 13.9%. There was no reoperation within 30 days and only one patient (3.8%) developed recurrent infection, which improved with additional antibiotic treatments. More than moderate PVL within 30 days was detected in one patient only (3.8%). Over a median follow-up period of 38.3 ± 35.5 months, a Kaplan-Meier analysis revealed that 1- and 5-year survival rates were 75.7 and 66.8%, respectively, and freedom from reoperation was 100% at 5 years. Freedom from significant PVL at 5 years was 91.0%.

CONCLUSIONS

The local administration of powder minocycline may be a simple and effective manipulation during surgical intervention for AIE without extensive reconstruction; however, the surgical management of AIE remains challenging.

Systematic review and meta-analysis of surgical outcomes comparing mechanical valve replacement and bioprosthetic valve replacement in infective endocarditis

Background

Infective endocarditis (IE) is an infection involving either native or prosthetic heart valves, the endocardial surface of the heart or any implanted intracardiac devices. IE is a rare condition affecting 3-15 patients per 100,000 population. In-hospital mortality rates in patients with IE remain high at around 20% despite treatment advances. There is no consensus recommendation favoring either bioprosthetic valve or mechanical valve implantation in the setting of IE; patient age, co-morbidities and preferences should be considered selecting the replacement prosthesis.

Methods

A systematic review and meta-analysis of studies reporting the outcomes of patients undergoing bioprosthetic or mechanical valve replacement for infective endocarditis with data extracted for overall survival, valve reinfection rates and valve reoperation.

Results

Eleven relevant studies were identified, with 2,336 patients receiving a mechanical valve replacement and 2,057 patients receiving a bioprosthetic valve replacement. There was no significant difference for overall survival between patients treated with mechanical valves and those treated with bioprosthetic valves [hazard ratio (HR) 0.94, 95% confidence interval (CI): 0.73-1.21, P=0.62]. There was no significant difference in reoperation rates between patients treated with a bioprosthetic valve and those treated with a mechanical valve (HR 0.82, 95% CI: 0.34-1.98, P=0.66) and there was no significant difference in the rate of valve reinfection rates (HR 0.95, 95% CI: 0.48-1.89, P=0.89).

Conclusions

The presence of infective endocarditis alone should not influence the decision of which type of valve prosthesis that should be implanted. This decision should be based on patient age, co-morbidities and preferences.

Aortic cross-clamp time and cardiopulmonary bypass time: prognostic implications in patients operated on for infective endocarditis

OBJECTIVES

Prolonged aortic cross-clamp (XCT) and cardiopulmonary bypass time (CPBT) are associated with increased morbidity and mortality following cardiac surgery. The aim of this study was to assess the predictors of mortality and other severe postoperative complications in patients undergoing surgery for infective endocarditis (IE), focusing in particular on the role of prolonged XCT and CPBT.

METHODS

A retrospective single-centre study was conducted from January 2000 to January 2017, including all patients undergoing valvular surgery for IE. The primary end point was early postoperative mortality. The main secondary end point was a composite end point for severe postoperative complications.

RESULTS

During the study period, 264 patients were included. Early postoperative mortality was 14%. Prolonged CPBT [odds ratio (OR) 1.008, 95% confidence intervals (CIs) 1.003-1.01; P = 0.009] and increasing age (OR 1.04, 95% CI 1.01-1.07; P = 0.02) independently predicted mortality, while an inverse association was observed for left ventricular ejection fraction (OR 0.93, 95% CI 0.89-0.97; P = 0.0007). The best mortality cut-offs were >72 min for XCT and >166 min for CPBT. Prolonged CPBT also predicted severe complications, along with age, stroke, preoperative mechanical ventilation and reduced left ventricular ejection fraction. When XCT was included in the multivariable models instead of CPBT, it was associated with both mortality and severe complications.

CONCLUSIONS

Prolonged XCT and CPBT are associated with mortality and development of severe complications after valvular surgery for IE. Further validation of safe limits for XCT and CPBT might provide novel insights on how to improve intraoperative and postoperative outcomes of patients with IE.

Late Reoperation Following Ligation of the Left Main Coronary Artery in a Patient with Infective Endocarditis

We report the case of a female patient who underwent late reoperation following endocarditis surgery. The patient first underwent surgery at 22 years of age for endocarditis with aortic and tricuspid insufficiency. She underwent aortic root replacement with a homograft and tricuspid valve replacement with a tissue valve. Coronary artery bypass using the internal thoracic artery and ligation of the left main coronary artery were performed. Ten years later, failure of the homograft and the tricuspid valve developed. In the second operation, the patient underwent a successful Bentall operation and tricuspid valve replacement with a mechanical valve under deep hypothermia and retrograde cold cardioplegia without drainage.

Outcome for surgical treatment of infective endocarditis with periannular abscess

BACKGROUND

Surgical treatment of infective endocarditis (IE) with aortic periannular abscess (PA) is a challenging issue with high mortality and morbidity rate in the current era. The present study is to review the results of surgical treatment for IE-PA based on an anatomy-guided surgical procedure selection for either aortic valve replacement (AVR) or aortic root reconstruction (ARR).

METHODS

Patients with IE-PA received surgical treatment in National Taiwan University Hospital during the years 2001-2017 were retrospectively reviewed. The selection of surgical procedure was based on the intraoperative anatomical finding. The AVR group consisted of isolated AVR or AVR with patch repair if PA involved less than one cusp of the annulus. The ARR group included aortic root replacement if PA involved more than one cusp, causing commissural/sub-commissural destruction. In-hospital mortality and mid-term outcome and the risk factors were examined.

RESULTS

In-hospital mortality was 13% in the AVR group (24 patients) and 25% in the ARR group (8 patients) (p = 0.578). The composite adverse events (cardiac death, valve reoperation, or paravalvular leak) rate was 31% in the AVR group and 40% in the ARR group at one year; 48% in the AVR group and 40% in the ARR group at five years; 55% in the AVR group and 40% in the ARR group at ten years.

CONCLUSION

Anatomy-guided surgical procedure selection for IE-PA is feasible. With the appropriate selection, ARR may be associated with fewer adverse events in mid-term follow-up. Careful intraoperative judgment and management and long-term follow-up are warranted for these patients.

Hospital Results of a Single Center Database for Stentless Xenograft Use in a Full Root Technique in Over 970 Patients

Our aim was to analyse the hospital outcome for the worldwide largest series of stentless bioroot xenografts (Medtronic Freestyle) as full root replacement in a single centre over a period of 18 years. Retrospective data analysis was performed for the entire cohort of patients undergoing aortic root surgery with the Medtronic Freestyle valve prosthesis. Logistic regression analysis was performed to analyse predictors of in-hospital mortality. 971 patients underwent aortic full root replacement with the Medtronic Freestyle valve in the period from 1999–2017, with an average age of 68.8 ± 10.3y and gender distribution of 608:363 (male:female). Concomitant surgery was performed in 693 patients (71.4%). In-hospital all-comers mortality was 9.8% (95 patients), with the respective highest risk profiles including dissections (6.4%), endocarditis (5.6%) and re-do procedures (12.5%). In-hospital mortality for elective patients was 7.6% while isolated aortic root replacement demonstrated a mortality of 3.6%. Logistic regression analysis demonstrated age (OR 1.05, p = 0.005), dissection (OR 5.78, p < 0.001) and concomitant bypass surgery (OR 2.68, p < 0.001) as preoperative risk factors for the entire cohort. Postoperative analysis demonstrated myocardial infarction (OR 48.6, p < 0.001) and acute kidney injury (OR 20.2, p < 0.001) to be independent risk factors influencing mortality. This analysis presents a work-through of all patients with stentless bioroot treatment without positive selection in a high-volume clinical center with the largest experience world-wide for this form of complex surgery. Isolated aortic root replacement could be performed at acceptable operative risk for this technically-challenging procedure.

Chain pain following cardiac surgery in a 35-year-old man

CLINICAL INTRODUCTION

A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B-D and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313577.supp1Supplementary file 1 heartjnl;105/3/234/F1F1F1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography.

QUESTION

Which of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm.

Extensive infective endocarditis of the aortic root and the aortic-mitral continuity: a mitral valve sparing approach†

OBJECTIVES

Severe cases of infective endocarditis (IE) of the aortic valve can cause aortic root destruction and affect the surrounding structures, including the aortic-mitral continuity, the anterior mitral valve leaflet and the roof of the left atrium. Reconstruction after resection of all infected tissue remains challenging. We describe our surgical approach and the mid-term results.

METHODS

Between January 2004 and December 2015, 35 patients underwent surgery for extensive IE of the aortic valve with destruction of the aortic root, the aortic-mitral continuity and the mitral valve. Mean age was 60.4 ± 13.7; 26/35 (74%) patients had prosthetic valve endocarditis. Four patients were in critical preoperative state. Median EuroSCORE II was 18.0% [interquartile range (IQR) 11.0-26.7].

RESULTS

Aortic root replacement was performed in 32 (91%) patients. The remaining patients underwent aortic valve replacement. Reconstruction of the aortic-mitral continuity and the roof of the left atrium were performed using a folded pericardial patch. In 28 patients (80%), mitral valve repair was performed. Postoperative mechanical circulatory support, acute kidney failure and surgical re-exploration were seen in 5 (16%), 10 (31%) and 4 (13%) patients, respectively. Early survival rate was 77% (27 patients). During a median follow-up of 29.8 months (IQR 6.4-62.9), 7 (26%) patients required reintervention (3-42 months after surgery); 4 were due to mitral incompetence, early in our experience.

CONCLUSIONS

Extensive IE of the aortic root with destruction of the surrounding tissues remains a complex disease with high morbidity and mortality rates. Our technique allows native mitral valve preservation but is technically challenging.

Risks and Challenges of Surgery for Aortic Prosthetic Valve Endocarditis

BACKGROUND

Prosthetic valve endocarditis is the most severe form of infective endocarditis. This study assessed the risks and challenges of surgery for aortic prosthetic valve endocarditis.

METHODS

In total, 116 consecutive patients (98 males, age 65.2±12.7years), who underwent redo-surgery for active aortic prosthetic valve endocarditis between 2000 and 2014, were reviewed. Cox regression analysis was used to identify factors for aortic root destructions as well as for morbidity and mortality. Median follow-up was 3.8 years (0-13.9 years).

RESULTS

Aortic root destructions (42 limited and 29 multiple lesions) were associated with early prosthetic valve endocarditis and delayed diagnosis (≥14 d), but not with mortality. There were 16 (13.8%) early (≤30 d) and 32 (27.6%) late (>30 days) deaths. Survival at 1, 5, and 10 years was 72±4.3%, 56±5.4%, and 46±6.4%, respectively. The cumulative incidence of death, reinfection, and reoperation was 19.0% at 30days and 36.2% at 1year. Delayed diagnosis, concomitant procedures, and EuroSCORE II >20% were predictors for early mortality and need for mechanical circulatory support, age >70years, and critical preoperative state were predictors for late mortality. In their absence, survival at 10 years was 70±8.4%. Reinfections and reoperations occurred more frequently if ≥1 risk factor for endocarditis and aortic root destructions were present. At 10 years, freedom from reinfection and reoperation was 89±4.2% and 91±4.0%.

CONCLUSIONS

The risks of death, reinfection, and reoperation are significant within the first year after surgery for aortic prosthetic valve endocarditis. Early diagnosis and aortic root destructions are the most important challenges, but advanced age, critical preoperative state, and the need for mechanical circulatory support determine long-term survival.

Are Sutureless Aortic Valves Suitable for Severe High-Risk Patients Suffering from Active Infective Aortic Valve Endocarditis?

Background

Sutureless aortic valves were introduced to facilitate minimally invasive aortic valve surgery. Since sutureless aortic valves are a feasible procedure, we evaluated if any benefits could be identified in severe high-risk patients with active infective endocarditis of the aortic valve.

Material/Methods

Between April 2014 and April 2015, a total of 42 patients received a sutureless Perceval^® aortic valve (Sorin Biomedica Cardio Srl, Saluggia, Italy) for different indications. Nine of these patients (median age 71 years, range 47–83 years) suffered from active infective endocarditis, including four patients with prosthetic aortic valve endocarditis. Five patients underwent prior cardiac surgery, including transcatheter aortic valve implantation (TAVI). The median EuroSCORE II was 29.5% (range 16.8–87.7%). Post-operatively, data regarding mortality, operative results, and early operative morbidity were collected.

Results

There were no cases of 30-day mortality. Four patients needed abscess closure with pericardium. Three patients underwent left atrial appendix closure: one left ventricular thrombectomy, one bypass grafting, and one arch replacement. Median aortic cross-clamp and cardiopulmonary bypass time was 35 minutes (range 26–88 minutes) and 52 minutes (range 40–133 minutes), respectively. The median intubation time was 14 hours (range 1–9 hours). In these high-risk patients, no postoperative morbidity was found except for one re-intubation due to extensive delirium and one re-exploration. No pacemaker implantation was needed. Echocardiographic evaluation showed no central or para-valvular regurgitation, and a median discharge mean gradient of 5.5 mm Hg (range 2.5–10.0 mm Hg).

Conclusions

Sutureless aortic valve replacement in very high-risk patients suffering from active infection endocarditis seems to be an option with limited morbidity and appropriate echocardiographic results, however, further studies are needed.

Emergency cardiac double valve surgery in active infective endocarditis due to Acinetobacter baumannii with aortic root abscess in a patient with dialysis-dependent end-stage renal failure: a rare case report

We report an end-stage renal disease (ESRD) patient on regular haemodialysis awaiting renal transplant having native aortic valve endocarditis due to Acinetobacter baumannii complicated with aortic root abscess and severe mitral valve regurgitation with NYHA class IV symptoms. He underwent emergency aortic root abscess debridement, reconstruction with autologous pericardial patch and bioprosthetic aortic valve replacement along with mitral valve repair. This emergency intervention in active infective endocarditis due to A. baumannii and associated ESRD is very rare. We could not trace any case report for such combination of clinical scenario in the literature.

Bovine Pericardium as New Technical Option for In Situ Reconstruction of Aortic Graft Infection

BACKGROUND

Alloplastic aortic graft infection is a devastating complication following aortic surgery. It is associated with excessively high mortality and morbidity caused by anastomotic rupture or septicemia. Many authors consider in situ replacement after complete surgical graft removal as the method of choice. However, there is an ongoing debate about the most suitable material for reconstruction. We present our first experiences with replacing the descending and infrarenal aorta using custom-made bovine pericardium grafts.

MATERIAL AND METHODS

From January 2013 to 2015, 13 patients (10 male, median age 70 years, range 53-84) were treated for 5 early-graft infections after open reconstructions and 7 late graft infections (1 TEVAR, 2 EVAR, and 4 open reconstructions), and 1 patient was treated for mycotic aneurysm. Septicemia was evident in 8 patients, whereas 5 patients were presented with low-grade infection. In all cases, graft infection was proven by a synopsis of clinical findings, laboratory tests, imaging, and microbiologic tests (positive pathogen detection in 11 patients). Cutaneous and aortoenteric fistulae were present in 3 and 4 patients, respectively. All patients received an in situ replacement using a hand-sewn xenoprosthesis or patch made from a bovine pericardium sheet. Follow-up was routinely performed 3, 12, and 24 months after discharge.

RESULTS

For reconstruction, 4 pericardium tubes, 7 bifurcated grafts, and 2 large patches were implanted in situ. Technical success was 100%. Median length of hospital stay was 44 days (range, 20-136 days), with an in-hospital mortality rate of 7.7% (n = 1). Major procedure- and disease-related complications were temporary (n = 2) and permanent dialysis (n = 1), limb loss (n = 1), and long-term ventilation (n = 5). Complete infection control and initial healing could be achieved in 75% (n = 10). During the follow-up (median 9 months, range: 1-27 months), primary graft patency was 100%, and mortality was 41.7%. We observed 2 secondary ruptures due to reinfection at 4 and 7 months.

CONCLUSIONS

Custom-made bovine pericardium grafts provide a good option for in situ replacement following early or late aortic graft infection. Despite of its high biocompatibility, pericardium provides not an absolute protection against ongoing retroperitoneal infection. For the treatment, the principles of septic surgery need to be applied and close follow-up is mandatory.

Valve selection in aortic valve endocarditis

Aortic prosthetic valve endocarditis (PVE) is a potentially life-threatening disease. Mortality and incidence of infective endocarditis have been reduced in the past 30 years. Medical treatment of aortic PVE may be successful in patients who have a prompt response after antibiotic treatment and who do not have prosthetic dysfunction. In advanced stages, antibiotic therapy alone is insufficient to control the disease, and surgical intervention is necessary. Surgical treatment may be lifesaving, but it is still associated with considerable morbidity and mortality. The aim of surgery is to perform a radical excision of all infected and necrotic tissue, reconstruction of the left ventricle outflow tract, and replacement of the aortic valve. There is no unanimous consensus on which is the optimal prosthesis to implant in this context, and several surgical techniques have been suggested. We aim to analyze the efficacy of the surgical treatment and discuss the issue of valve selection in patients with aortic valve endocarditis.

Infective Endocarditis With Paravalvular Extension: 35-Year Experience

BACKGROUND

We investigated our surgical strategy and clinical results in patients from active infective endocarditis (AIE) complicated by paravalvular involvement to determine the risk factors of early and late death and reoperation.

METHODS

From October 1979 to December 2014, 955 patients underwent operations for AIE; among them 207 had AIE with paravalvular extension. The patients were a mean age of 59.9 ± 15.4 years, and 162 (78%) were male. Of these patients, 137 (66%) had isolated aortic valve endocarditis, and 138 (67%) had native valve endocarditis. Follow-up was 99% complete.

RESULTS

The operative mortality of the cohort was 16% (n = 34). Abnormal communication, mechanical valve implantation, and renal failure were independent predictors of 30-day death. Survival at 1, 5, 10, and 15 years was 90.3% ± 2.3%, 62.4% ± 3.7%, 49.3% ± 4.1%, and 37.9% ± 4.4%, respectively. Streptococcus endocarditis (all species), complex annular repair, and preoperative heart failure were independent predictors of long-term death. A reoperation was required in 29 patients (14%). Streptococcus pneumoniae endocarditis was the only independent predictor of early reoperation (within 30 days after the operation or during the same hospitalization). Freedom from reoperation at 1, 5, 10, and 15 years was 91.9% ± 2.2%, 89.6% ± 2.6%, 89.6% ± 2.6%, and 87.0% ± 3.5%, respectively. Independent predictors of late reoperation were urgent/emergency operation, prosthetic valve endocarditis, and complex annular repair.

CONCLUSIONS

AIE complicated by paravalvular involvement remains a surgical challenge. Valve replacement (particularly using bioprosthesis) associated with ad hoc reconstruction seems to be a reliable option and showed very encouraging results in this context.

Surgery for Aortic Root Abscess: A 15-Year Experience

Aortic root abscess is the most severe sequela of infective endocarditis, and its surgical management is a complicated procedure because of the high risk of morbidity and death. Twenty-seven patients were included in this 15-year retrospective study: 21 (77.8%) with native- and 6 (22.2%) with prosthetic-valve endocarditis. The surgical reconstruction of the aortic root consisted of aortic valve replacement in 19 patients (70.4%) with (11) or without (8) a pericardial patch, or total aortic root replacement in 7 patients (25.9%); 5 of the 27 (18.5%) underwent the modified Bentall procedure with the flanged conduit. Only one patient (3.7%) underwent subaortic pericardial patch reconstruction without valve replacement. A total of 7 patients (25.9%) underwent reoperation: 6 with prior valve surgery, and 1 with prior isolated sinus of Valsalva repair. The mean follow-up period was 6.8 ± 3.7 years. There were 6 (22.2%) in-hospital deaths, 3 (11.1%) of which were perioperative, among patients who underwent emergent surgery. Five patients (23.8%) died during follow-up, and the overall survival rates at 1, 5, and 10 years were 70.3% ± 5.8%, 62.9% ± 6.4%, and 59.2% ± 7.2%, respectively. Two of 21 patients (9.5%) underwent reoperation because of paravalvular leakage and early recurrence of infection during follow-up. After complete resection of the perianular abscess, replacement of the aortic root can be implemented for reconstruction of the aortic root, with or without left ventricular outflow tract injuries. Replacing the aortic root with a flanged composite graft might provide the best anatomic fit.

Homograft Aortic Root Replacement with Saphenous Vein Graft Hemi-Cabrol for Prosthetic Aortic Valve Endocarditis

A 44-year-old female presented with prosthetic valve endocarditis with periannular abscess involving the left coronary ostium. We describe cryopreserved aortic homograft root replacement with hemi-Cabrol reimplantation of the left coronary ostium using the long saphenous vein.

Left Main Compression by a Giant Aneurysm of the Left Sinus of Valsalva: An Extremely Rare Reason for Myocardial Infarction and Cardiogenic Shock

Aneurysms of the sinus of Valsalva are very rare and mostly located in the right coronary sinus. They might course with dyspnea, fatigue, and acute coronary syndromes. We present herein an extremely rare case report of a 61-year-old woman diagnosed with external left main coronary compression by a giant aneurysm of the left sinus of Valsalva, which was successfully managed with percutaneous coronary intervention.

Cardiothoracic surgical emergencies in the intensive care unit

Patients with cardiothoracic surgical emergencies are frequently admitted to the ICU, either prior to operative intervention or after surgery. Recognition and appropriate timing of operative intervention are key factors in improving outcomes. A collaborative team approach with the cardiothoracic service is imperative in managing this patient population.

Surgical management of destructive aortic endocarditis: left ventricular outflow reconstruction with the Sorin Pericarbon Freedom stentless bioprosthesis†

OBJECTIVES

The treatment of complicated aortic endocarditis with periannular abscesses and root disarrangement is a surgical challenge, and includes left ventricular outflow tract (LVOT) reconstruction with the patch technique or homograft implantation. The results of a simplified technique to reconstruct the LVOT in destructive endocarditis of either the aortic native valve or valve prosthesis with the Sorin Pericarbon Freedom stentless valve are reported.

METHODS

Since August 2007, 40 patients with destructive endocarditis (mean age: 69 ± 12, 75% males, European System for Cardiac Operative Risk Evaluation II (EuroSCORE II): 19 ± 13, New York Heart Association (NYHA) class: ≥3 in all cases) have undergone LVOT reconstruction with a Sorin Pericarbon Freedom stentless bioprosthesis. Seven patients (17.5%) were in septic or cardiogenic shock preoperatively, and 18 patients (45%) suffered from moderate or severe aortic regurgitation. Eleven patients (27.5%) experienced preoperative systemic embolizations. Thirty-six cases (90%) were valve redos and 9 patients (22.5%) had concomitant procedures. The mean follow-up was 26 ± 25 months.

RESULTS

One patient (2.5%) died early (<30 days) and another 3 patients never discharged died due to multiorgan failure and septic shock. Actuarial survival rate was 85 ± 6% at 1 year, and 76 ± 8% at 3 and 5 years, respectively. Twelve patients (30%) required pacemaker implantation because of atrioventricular block and 20 patients (50%) developed or showed a progression of renal failure. One patient (2.5%) had an endocarditis relapse, and 1 (2.5%) showed a mild paraprosthetic aortic leak. No patient needed reoperation. At the last echocardiographic evaluation, mean gradient, peak gradient and left ventricular ejection fraction were 7.9 ± 5.0 mmHg, 15.1 ± 7.2 mmHg and 63.3 ± 9.3%, respectively.

CONCLUSIONS

The Sorin Pericarbon Freedom stentless prosthesis, with the modified technique herein described, seems to be a good option in most of cases of destructive aortic valve endocarditis. It is promptly available in different sizes, easy to implant and, due to its pericardial inflow skirt, ideal for extensive reconstruction of the LVOT with good haemodynamic performance and low risk of relapse.

Durability of homografts used to treat complex aortic valve endocarditis

BACKGROUND

Acute bacterial endocarditis may be extremely destructive for cardiac valves and their periannular structures. It has been suggested that complex reconstruction procedures require the use of homografts because of their versatility and potency to resist repeated infection.

METHODS

We studied the long-term results of 69 patients with complex endocarditis who received homografts in the aortic position.

RESULTS

The results after a mean follow-up of 8.1 ± 5.1 years (median, 8.0 years) showed that the recurrence of endocarditis even in these complex cases is low (7%), but the incidence of structural valve degeneration (SVD) is high. Freedom from SVD at 10 years is only 60.0%. When aortic homografts degenerate, they predominantly calcify.

CONCLUSIONS

The use of homografts to reconstruct endocarditis-related aortic valve destruction is associated with a low recurrence of endocarditis but a high incidence of SVD in the long run.

Aortic valve endocarditis complicated by ST-elevation myocardial infarction

Infective endocarditis complicated by abscess formation and coronary artery compression is a rare clinical event with a high mortality rate, and diagnosis requires a heightened degree of suspicion. We present the clinical, angiographic, and echocardiographic features of a 73-year-old woman who presented with dyspnea and was found to have right coronary artery compression that was secondary to abscess formation resulting from diffuse infectious endocarditis. We discuss the patient's case and briefly review the relevant medical literature. To our knowledge, this is the first reported case of abscess formation involving a native aortic valve and the right coronary artery.

Surgical experience with infective endocarditis and aortic root abscess

PURPOSE

This study was conducted to evaluate the surgical outcomes of active infective endocarditis with aortic root abscess formation.

MATERIALS AND METHODS

Between February 1999 and June 2012, 49 patients underwent surgery for active endocarditis with aortic root abscess. The infected valve was native in 29 patients and prosthetic in 20 patients. The patients' mean age was 50±14 years, and 36 patients were male. Surgery was urgent/emergent in 15 patients (31%). The abscess involved the aortic annulus (11), left ventricular outflow tract (18), fibrous trigone (16), and mitral annulus (4). In all patients, wide debridement of abscess and aortic valve replacement with or without patch reconstruction of aortic root or annulus was performed.

RESULTS

There were 6 (12%) operative deaths. Causes of early mortality were sepsis (2) and multi-organ failure (4). On postoperative echocardiogram, there was significant improvement of left ventricular dimension (LVEDD, from 58.8±11.8 mm to 52.6±8.2 mm, p<0.001); however, LV ejection fraction was significantly decreased (from 61.4±12.0% to 49.8±16.5%, p<0.001). The mean follow-up duration was 68.7±40.4 months. There was no late death or recurrent endocarditis during follow up. New York Heart Association functional class significantly improved from 3.2±0.7 to 1.2±0.4 (p<0.001). Kaplan-Meier estimated survival at 10 years was 87.2%.

CONCLUSION

Surgical treatment for active endocarditis with aortic root abscess is still challenging, and was associated with high operative mortality. Nevertheless, long-term survival was excellent with good functional capacity after recovery from the early postoperative period.

Reconstruction of fibrous skeleton: technique, pitfalls and results

Destruction of the mitral-aortic (or mitroaortic) intervalvular fibrosa (IVF) by infective endocarditis is a marker of advanced pathology. Patients are at high risk, as they are sicker, have more comorbidities and have more advanced pathology, requiring a difficult operation that includes debriding and reconstructing the IVF. The anatomy and surgical techniques for that reconstruction are presented and discussed. Operative risk is high and remains high for the first year, before becoming equivalent to that of conventional operations for endocarditis. Current outcomes are better than in the past, but there is room for further improvement.

Valvular repair or replacement for mitral endocarditis: 7-year cohort study

Background

A few studies have compared mitral valve repair and replacement in the setting of infective endocarditis, with varying results. We compared the characteristics and outcomes of mitral repair and replacement in endocarditis patients.

Methods

All patients undergoing mitral valve repair or replacement for active mitral endocarditis during 2005–2011 were included. Operative and follow-up mortality, composite morbidity, recurrent endocarditis, and redo operations were prespecified endpoints for analyses.

Results

There were 25 and 35 patients undergoing mitral valve repair and replacement, respectively. They were followed-up for 3.9 ± 2.5 years. Valve replacement patients were older ( p = 0.029), had a higher prevalence of intracardiac abscess ( p = 0.035), previous endocarditis ( p = 0.036), atrial fibrillation ( p = 0.001), worse renal function ( p = 0.013), higher risk scores ( p = 0.004–0.020), and longer operation times ( p < 0.001). Repair and replacement had similar rates of operative mortality (4.0% vs. 8.6%, p = 0.634), composite morbidity (16.0% vs. 28.6%, p = 0.357), survival ( p = 0.564), recurrent endocarditis ( p = 0.081), and redo operations ( p = 0.813). Independent predictors of operative mortality were preoperative inotropic or intraaortic balloon pump support. The independent predictor of mortality during follow-up was dialysis. Independent predictors of composite morbidity were intracardiac abscess and hypercholesterolemia. The independent predictor of recurrent endocarditis was previous endocarditis, and the independent predictor of redo operation was previous stroke.

Conclusion

Mitral valve replacement candidates had more baseline risk factors and higher raw rates of postoperative mortality and morbidity, which did not reach statistical significance.