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Ann Thorac Surg 2002;74:S1754-S1757
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
* Address reprint requests to Dr Lytle, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, F/25, Cleveland, OH 44195, USA
e-mail: lytleb{at}ccf.org
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement.
METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%.
RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 ± 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation.
CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.
Aortic valve prosthetic valve endocarditis (PVE) is an important complication of prosthetic aortic valve replacement (AVR). Accepted principles of treatment of PVE involve debridement of infected prosthetic material and tissue, aortic valve re-replacement, and prolonged antibiotic therapy. Our strategy for repeat AVR performed to treat PVE has been to perform aortic root replacement with a cryopreserved aortic allograft. This policy is based in large part on an apparent resistance of allografts to infection [1, 2]. Long-term outcomes following this strategy have been favorable, but agreement that allografts provide incremental benefit over the use of prosthetic valves for the treatment of PVE is not uniform [3].
Aortic valve PVE after aortic valve combined with ascending aorta replacement is an even more complex situation. There is a larger amount of prosthetic material in place; there are both proximal and distal aortic sites that can be location of infections, and the length of new aortic tissue or graft material that needs to be employed is increased. Few reports have examined this problem, none containing significant patient numbers. We reviewed the clinical data and outcomes for 27 patients undergoing reoperation for PVE after AVR combined with ascending aortic replacement from 1988 through 2000.
Patients and methods
Patients
With the aid of a computerized cardiovascular information registry, we identified 27 patients with previous aortic valve replacement and replacement of the ascending aorta who underwent treatment of aortic PVE with surgical debridement of infected tissue, aortic root and ascending aorta replacement with cryopreserved aortic allografts, and long-term intravenous antibiotic therapy. The medical records of these patients were reviewed to confirm and augment data collected routinely and concurrently with patient care. Use of these data for clinical research has been approved by the Institutional Review Board of the Cleveland Clinic Foundation. Mean age of the patient at the time of reoperation was 53 ± 15 years (range, 26 to 78 years), and all but 1 were men.
The prior operation had been a composite graft in 13 patients and an AVR with a supracoronary graft in 14. Data concerning indications for the previous ascending aortic replacement were available in 19 patients, 10 of whom had an ascending aortic aneurysm and 9 of whom had an aortic dissection. The previous aortic valve replacement had been a mechanical valve in 18 patients and a bioprosthesis in 9. Of the 13 patients with previous composite grafts, 11 were mechanical prostheses and two were bioprostheses. Eleven (42%) of the previous operations had been performed in centers other than our own.
Twenty-one patients had undergone one previous AVR, none performed for endocarditis. Six patients had undergone two previous AVRs: 3 for native valve endocarditis, and in 2 patients, this was the second episode of PVE.
Preoperative signs and symptoms included heart failure in 59% of patients, hypotension in 26%, septic embolism in 26%, persistent fever in 74%, and severe disruption of the aortic valve annulus junction in 62% (Table 1).
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3 months in 3 patients (11%), 6 months in 8 (30%), 1 year in 14 (52%), 2 years in 16 (59%), 5 years in 19 (70%), and 10 years in 24 (89%). Twenty-five patients (93%) had either positive preoperative blood cultures (22 patients) or positive cultures from the surgical specimen. The organisms involved are listed in Table 2, and involved gram-positive cocci in 24 patients.
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All patients received antibiotics before operation, and intravenous antibiotic therapy was continued for at least 8 weeks postoperatively. Patients with fungal endocarditis were placed on oral antibiotics.
Results
One patient (3.7%) died in-hospital. This patient was operated on emergently, and appeared to succumb from persistent sepsis and multiple metastatic abscesses. Complete heart block occurred in 10 patients (37%), respiratory failure requiring prolonged intubation in 6 (22%), and renal failure in 5 (19%).
Late follow-up documented seven deaths, with an estimated survival at 30 days, and 1, 2, 5, and 7.5 years of 96%, 92%, 88%, 70%, and 56%, respectively. None of the late deaths appeared to be due to recurrent infection. Follow-up was complete for all patients for a mean interval of 3.9 ± 3 years, to a maximum of 11.3 years. Among the survivors, 63% were followed for 2 years, 26% for 5 years, and 1 patient beyond 10 years (Fig 2). One patient developed recurrent endocarditis of the allograft 8 months after operation and underwent repeat surgery, again receiving an allograft aortic root replacement. That patient is alive 2.5 years after his second allograft operation.
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The patients in this series all appeared to have active PVE that involved the aortic valve-aortic annulus junction, usually a far-advanced infection. Twenty-five patients had positive cultures and the 2 patients without positive cultures exhibited evidence of active tissue destruction at the time of reoperation. All patients had some degree of disruption of the proximal anastomosis; 89% exhibited abscess formation, and 41% had aortoventricular discontinuity.
The relatively late stage of these infections was based in part on the fact that the diagnosis of PVE may be difficult (if the patient’s prior operation has been an aortic root replacement) because periprosthetic leak will not occur. Thus, annular disruption will become evident by echocardiography only at the point where a large enough false aneurysm of the proximal anastomosis is present that to-and-fro flow is visualized echocardiographically. Aortic root magnetic resonance imaging studies may allow detection of abnormal tissue signals that will give early clues to the presence of aortic root infection before disruption occurs. Another explanation for the advanced nature of these infections is that physicians may be reluctant to face the issue of PVE in situations complicated by the presence of an ascending aortic graft. Based on this review, our feeling is that the in-hospital risk of reoperation is not overwhelming, and that PVE in conjunction with previous ascending aortic replacement is better faced early than late.
Debridement of infected prosthetic material and infected tissue, reoperation for valve and ascending aorta re-replacement, and prolonged antibiotic therapy are all accepted strategies for the treatment of aortic root and ascending aorta infections. However, there is not uniform agreement of the advantage and desirability of using allografts for the re-replacement and whether or not this approach provides incremental benefit over the use of standard prostheses and Dacron material. Griepp and colleagues have reported success in the avoidance of reinfection by using standard prostheses and Dacron graft material [3].
We began using allografts in the treatment of aortic valve PVE because of the observation by ourselves and others that the long-term outcomes after even apparently successful treatment of PVE have been less favorable than the outcomes after aortic valve reoperations done for other reasons, and data indicating a lower risk of early PVE for patients receiving allografts [2, 4]. Success in the treatment of isolated aortic valve PVE led to extension of the allograft concept to these more complex situations. Our use of allograft material has coincided with an increased level of experience and confidence in dealing with the technical aspects of surgery for aortic root infection and a more aggressive stance towards debridement of infected material and tissue. It is hard to know which aspects of this strategy are responsible for improved outcomes.
Although our initial use of allografts was based on a desire to avoid recurrent infection, we have found that with experience, the technical aspects of allograft placement in such situations are not more difficult than the use of standard prostheses. In fact, the malleability of allografts allows adjustment for annular destruction caused by advanced infection. In situations requiring proximal aortic arch replacement, it was often necessary to use two aortic root allografts. Although descending aortic vascular allografts may be available, there is often a substantial size difference between these grafts and the aortic arch [5]. These are long operations, but attention to myocardial protection allows them to be carried out safely.
Late mortality after operation did not appear to be due to recurrent infection or to valve dysfunction. Late deaths appeared to be related to congestive heart failure and coronary disease preexisting reoperation and long-term complications of the PVE illness. We believe that the relatively low in-hospital risk associated with these reoperations mandates an aggressive approach to aortic root infection.
References
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