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Ann Thorac Surg 1999;67:1603-1608
© 1999 The Society of Thoracic Surgeons

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Original Articles

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis

^a Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA
^b Section of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

Address reprint requests to Dr Knott-Craig, Section of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190

Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14, 1998.

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Methods. From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 ± 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 ± 3.4 years.

Results. Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% ± 9% in Ross-AVR, 69% ± 11% in homo-AVR, and 29% ± 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR.

Conclusions. Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
E ndocarditis involving the aortic valve remains a formidable surgical challenge. The infection is seldom eradicated medically, particularly in patients with prosthetic valve endocarditis [1]. It often progresses to involve the aortic root and interventricular septum [2], is frequently associated with systemic embolization that may result in neurologic injury [2–4], and may be associated with the early development of life-threatening arrhythmias [5].

Among the array of available aortic valve substitutes, the aortic homograft and the aortic autograft (Ross operation) have several theoretical advantages [6, 7]. Homografts mold well to the fragile infected aortic annulus [8], have good resistance to infection [6, 9], have excellent hemodynamic performance especially in small sizes [10, 11], and do not require anticoagulation. In addition, the pulmonary autograft is a viable living structure with the propensity for repair and growth [12]. It is, however, more friable than the homograft, and requires a more complicated double-valve replacement [4, 13].

To evaluate whether these theoretical advantages translated into benefit to the patient with regard to the incidence of reinfection, late mortality, and valve-related complications, we reviewed our 11-year experience of aortic valve replacement for infective endocarditis.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patient characteristics
Between January 1986 and October 1998, 81 adults diagnosed with infective endocarditis involving the aortic valve or the root, or both, underwent operation at the Oklahoma University Health Sciences Center. The hospital records and operative findings were reviewed retrospectively. Endocarditis affected the native aortic valve in 52 patients, and a previous aortic valve replacement in29 patients. The mean age of the 65 men and 16 women was 44 ± 14 years (range, 16 to 83 years). Many patients were critically ill at the time of operation: 7 were on ventilators, 10 had significant thromboembolic phenomena, 6 were in overt renal failure, 3 required pacemakers, 13 were known intravenous drug abusers, and 6 were septic. Sixty-three (78%) patients had active (culture-positive or clinical signs of sepsis) endocarditis at the time of operation, and they all received preoperative and postoperative antibiotic therapy. The causative organisms identified by blood or intraoperative culture are shown in Table 1. The infectious agent could not be isolated in 6 patients.

View larger version (32K): [in this window] [in a new window]   Fig 1. Transesophageal echocardiography. Aortic valve long axis view showing disrupted aortic cusps and aortic root abscess (arrows) extending into the base of the interventricular septum from acute endocarditis. (AO = aorta; LA = left atrium.)

View larger version (58K): [in this window] [in a new window]   Fig 2. Transesophageal echocardiography. Short axis showing complex aortic root abscess in a patient with prosthetic valve endocarditis. Arrows point to the anterior and posterior abscesses. (AO = aorta; LA = left atrium; RA = right atrium.)

View larger version (61K): [in this window] [in a new window]   Fig 3. Transesophageal echocardiography. Modified four-chamber view of the patient with prosthetic valve endocarditis showing mycotic aneurysm of the mitral aortic intervalvular fibrosa with communication between left ventricular outflow tract (LVOT), aortic root, and left atrium. (LA = left atrium; RA = right atrium; LV = left ventricle; RV = right ventricle.)

Among homo-AVR and Ross-AVR patients, 11 patients required concomitant mitral valve replacement or repair (homo-Ross-DVR). Of the 10 patients having prosth-AVR, a mechanical prosthesis was used in 5 and a bioprosthesis in 5 patients. Four patients had a double-valve replacement using prosthetic (3 mechanical, 1 bioprosthetic) valves in both aortic and mitral positions (prosth-DVR). Valve choice and operative procedure were dependent on the local anatomy, comorbidity factors, and surgeon preference.

Follow-up
The follow-up data was obtained by the most recent clinic or personal physician visit, or by telephone contact. Recent echocardiographic assessment was available on all patients undergoing either a Ross-AVR or a homo-AVR. Follow-up was 90% complete within 2 years of the cutoff date for the study with mean follow-up time of 3.7 ± 3.4 years after valve replacement. In the follow-up assessment, late death, all complications, and valve-related complications [15] were recorded.

Statistical analysis
Early mortality was defined as all deaths occurring within 30 days of operation. Valve-related late mortality and morbidity were defined using generally accepted guidelines [15]. Dichotomous variables were compared using the ² method or Fisher’s exact test. The following variables were analyzed univariately using early mortality as the end point: age, gender, date of operation, surgeon, active versus inactive endocarditis, localized versus extensive disease, prosthetic valve endocarditis, previous cardiac operation, previous aortic valve replacement, single versus multiple valves involved, preoperative status (renal failure, ventilator dependence, history of intravenous drug abuse), and homo-AVR versus prosth-AVR. For all tests p value less than 0.05 was considered significant.

Multivariate analysis of early mortality was performed using logistic regression. A forward stepwise selection method was used to add variables to the model requiring significance at p value less than 0.10 for entry and p less than 0.05 retention in the model. Actuarial survivorship was calculated by Kaplan–Meier methods.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Early mortality (30-day mortality) was 16% (13 of 81 patients) overall. This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Early mortality for homo-Ross DVR was 9% (1 of 11 patients). Causes of early death are described in Table 3. Perioperative morbidity included massive coagulopathy (n = 8), requirement for intraaortic balloon pumping (n = 5), transient complete heart block (n = 3), new stroke (n = 1), and recurrent ventricular tachycardia mandating an implantable defibrillator (n = 1).

Recurrent endocarditis of aortic valve occurred in 3 patients, one after a Ross-AVR 6 years postoperatively, one after a homo-AVR 1 year postoperatively (both were intravenous drug abusers), and one in a patient with a prosth-AVR at 3 years. There were no late embolic phenomena, and no late structural deterioration of the replaced valves during the follow-up period.

Late mortality occurred in 10% (7 of 68 patients). Valve-related late mortality was 7% (5 of 68 patients): this includes two valve-related late deaths in Ross-homo-AVR patients (3%, 2 of 60), and three valve-related late deaths in prosth-AVR patients (37%, 3 of 8) (p < 0.05). No late deaths occurred in either the Ross-AVR or the homo-Ross DVR. Five-year Kaplan-Meier survival is estimated to be 88% ± 22% for Ross-AVR, 69% ± 11% for homo-AVR, and 29% ± 22% for prosth-AVR (p = 0.03).

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Indications for operation for infective aortic endocarditis are well defined and generally accepted [16]; these include hemodynamic compromise, persistent sepsis despite antibiotic treatment, peripheral embolism with vegetations, large mobile vegetations, aortic root abscesses, prosthetic valve endocarditis, or fungal endocarditis. However, operation for native and prosthetic aortic valve endocarditis remains a formidable surgical challenge with reported early mortality rates up to 28% [5]. Because of the poor late results and the unacceptably high rates of recurrent endocarditis with prosthetic valves, recent attention has focused on the use of homografts and autografts in this context [2–9], particularly as they seem to be more resistant to recurrent infection. Indeed, the cryopreserved aortic homograft is considered by many investigators to be the valve replacement of choice for aortic valve endocarditis [1, 2, 5–7, 17]. The homografts mold well to the fragile infected aortic annulus [8], have good resistance to infection [6, 9], have excellent hemodynamic performance especially in small sizes [10, 11], and do not require anticoagulation. Our clinical experience with the Ross operation in noninfected patients needing aortic valve replacements encouraged us to extend use of the pulmonary autograft to certain patients with aortic valve endocarditis [4, 13]. We have used the cryopreserved aortic homograft since 1986 and the pulmonary autograft since 1987 in patients with aortic valve endocarditis.

To minimize the risk of recurrent prosthetic valve endocarditis, and thereby improve late survival, complete debridement of all infected tissue is mandatory. Adequate debridement, however, often causes difficulty in securely fixing a rigid or stented replacement prosthesis, resulting in either recurrent endocarditis or valve dehiscence, both of which we experienced in this series.

Aortic homografts and pulmonary autografts have equal compliance to the aortic annulus [8], making possible adequate debridement of infected tissue with less risk of valve dehiscence from the fragile aortic annulus. In addition, even if concomitant mitral valve replacement is required because of the extended infection, the flexible homograft or autograft in the aortic position should not interfere with surgical repair to the mitral valve should this be necessary. In this regard, using the attached anterior mitral leaflet of the aortic homograft as a patch is very useful.

Recently, Song and colleagues [18] showed in vivo increased gene expression for procollagen in cryopreserved aortic homografts. This fact suggests that the cryopreserved homograft may have the capacity to reproduce collagen, thereby enhancing local healing early postoperatively. This may help explain its recognized resistance to infection. The pulmonary autograft is thought to be fully viable and therefore, may have the capability to produce several kinds of cytokines that militate against infection [19].

Even if the surgical intervention is accurately completed, aggressive adjuvant perioperative care is critical to the outcome. Of the 11 early deaths among autograft AVR and homo-AVR in this study, 8 patients died perioperatively of uncontrollable bleeding or unremitting sepsis despite full medical support. Although in some instances this may reflect technical inaccuracies, overwhelming intraoperative sepsis and ensuing coagulopathy is an imminent risk when operating on patients with active endocarditis. Although this early mortality rate was similar to other recent reports [1, 2, 4, 5], early diagnosis and earlier intervention may help reduce the early mortality. Six early deaths in homo-Ross-AVR patients occurred in patients with prosthetic valve endocarditis, further emphasizing the formidable challenge these patients pose.

In analyzing possible risk factors associated with early mortality, certain trends emerged. The first is that individual surgical experience is relevant to the outcome in these critically ill patients; this is reflected in the improved results in the most recent time period (1994 to 1998, n = 43) compared to the earliest time period (1986 to 1989, n = 16) (12% versus 25%), and further supported by the results of surgeons with more experience (more than six operations) compared to those with less exposure to these patients (10% versus 26%). The second trend approaching significance is that patients with active endocarditis, particularly when the organism is Staphylococcus and occurs on a prosthetic valve, have a higher early risk. The fact that these risk factors did not reach statistical significance probably reflects sample size and the presence of confounding variables in the series.

Once the patients have survived the perioperative period, the cryopreserved homografts and the pulmonary autografts are well known to provide excellent long-term durability [9, 13], superior hemodynamic performance [11], and freedom from thrombosis without anticoagulation [20]. This was confirmed in our study in which we found late survival benefit in the use of homografts and autografts, a low incidence of recurrent endocarditis, and few valve-related complications except in patients with continuing intravenous drug abuse problems.

Among the homograft and autograft patients, two developed recurrent endocarditis (1 homo-AVR, 1 Ross); both were intravenous drug abusers. Even the autograft (Ross operation) is not immune from endocarditis, but we believe it is the operation of choice, especially in young patients with endocarditis needing the aortic valve. Concomitant mitral valve repair or replacement should not discourage the use of the homograft or autograft; 10 patients with homografts and one with a Ross-AVR underwent concomitant mitral valve replacement with an early mortality of 9% and no late mortality.

In this series the choice of aortic valve substitute evolved over time. Initially, the decision was based on surgeon preference and experience; currently, we believe that the homograft and autograft (Ross operation) represent the best available aortic valve substitutes for patients with endocarditis involving the aortic valve. For patients with active endocarditis and limited involvement of the aortic annulus, no associated medical comorbidity, and a life expectancy exceeding 20 years, we favor the Ross operation; for all other patients with active endocarditis we prefer the homograft usually as a root replacement. For patients with inactive or healed endocarditis and a life expectancy of more than 20 years we advocate the Ross operation; for the remainder we prefer the homograft unless there is a reason to anticoagulate the patient, in which case acceptable alternatives include a prosthetic valve or nonstented porcine valve. Active endocarditis remains a surgical challenge but early intervention is encouraged when it involves the aortic valve. At present, autograft and cryopreserved homograft aortic valve replacement are the valves of choice for patients with aortic valve endocarditis, even if concomitant mitral valve replacement is required.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Karen Dale for the preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
This article has been selected for the open discussion on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kazuo Niwaya Christopher J. Knott-Craig Ronald C. Elkins Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Niwaya, K. Articles by Elkins, R. C. Search for Related Content PubMed PubMed Citation Articles by Niwaya, K. Articles by Elkins, R. C.