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Ann Thorac Surg 2001;71:104
© 2001 The Society of Thoracic Surgeons
a London Health Sciences Centre, University Campus, PO Box 5339, London, ON N6A 5A5, Canada
e-mail: rjnovick{at}julian.uwo.ca
This article from Odense University Hospital reports a series of 50 patients with aortic or mitral valve endocarditis who underwent surgical debridement followed by insertion of nonallograft (mainly mechanical) prosthetic valves over a 5-year interval. Although 42% of patients were in New York Heart Association functional class IV status preoperatively, the patients in this series had a relatively low prevalence of predictors of adverse outcome compared with other series in the literature on the treatment of endocarditis. Only 4% of the authors’ patients had prosthetic, as opposed to native, valve endocarditis; only 12% required preoperative mechanical ventilation and 4% dialysis; only 34% had staphylococcus cultured preoperatively or intraoperatively and no patients had fungal infection. Furthermore, despite the presence of annular abscesses in 48% of patients, there were very few instances of ventriculoaortic or aortomitral discontinuity that mandated complex repairs.
The authors confirmed that urgent operation for endocarditis remains a formidable challenge, with a 12% hospital mortality rate and a 9% late mortality rate after a median follow-up of 45 months. Only 1 of 44 surviving patients developed recurrent endocarditis and this patient did not undergo complete removal of all infected tissue at the initial operation. The relatively low recurrence rate of endocarditis in patients undergoing radical debridement followed by insertion of standard, stented prosthetic valves has also been described in two other recent series, each containing more than 100 endocarditis patients [1, 2].
The literature on surgical treatment of endocarditis has been hampered by reports on heterogeneous populations of patients observed over a prolonged interval of time. Moreover, the low prevalence of endocarditis is one of the reasons why no randomized trial of different types of surgical management has been performed and why the choice of valve for this condition has depended invariably on the local anatomic situation at operation, patient comorbidity factors, and especially surgeon preference. The largest reported series on surgical treatment of endocarditis dates to 1992 and showed a reduced early mortality rate and a higher freedom from recurrent endocarditis with allograft as opposed to prosthetic valves [3]. Aagaard and Andersen in their discussion maintained that the differences in outcome in this study may have been due not only to the replacement device chosen, but to differences in patient selection, surgical approach, year of operation, and perioperative management. The fact remains, however, that in cases of aortic valve endocarditis with advanced aortic root pathology, the use of cryopreserved valves or pulmonary autografts offers versatility and practical advantages. These valves mold well to the fragile, infected aortic annulus, help fill periannular abscess cavities with viable tissue, have an excellent resistance to infection, exhibit satisfactory hemodynamic performance even in small sizes, and do not require anticoagulation [4]. Cryopreserved allograft valves are, however, not readily available in many centers, especially in urgent or emergent operative settings. In addition, both autografts and allografts are subject to structural deterioration and a significant minority require replacement in the intermediate term postoperatively [5, 6]. Structural deterioration of autografts and allografts may indeed occur at a higher rate in endocarditis than nonendocarditis patients, as seen in the patient who required three aortic valve operations in this study and in a recent case report [7].
In summary, the choice of replacement valve in cases of surgically treated endocarditis will likely remain controversial for some time and is dependent on an institution’s experience with allograft and autograft valves in nonendocarditis settings and on the prevailing local "surgical culture." Earlier surgical referral of patients with intractable endocarditis is as important as the details of operative management for this condition. Hopefully earlier referral will result in fewer patients coming to operation in a condition of multisystem failure with advanced aortic root pathology. Working closely with referring cardiologists to expedite the surgical referral of endocarditis patients will likely give the highest yield in reducing the operative risk in these challenging patients.
References
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