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Ann Thorac Surg 2007;83:36-39
© 2007 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Subcoronary Ross Procedure in Patients With Active Endocarditis

^a Klinik für Herzchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
^b Institut für Medizinische Biometrie und Statistik, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany

Accepted for publication July 26, 2006.

^_* Address correspondence to Prof Dr Sievers, Klinik für Herzchirurgie UKSH, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany (Email: claudia.schmidtke{at}uni-luebeck.de).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: The Ross procedure has gained increasing interest as an attractive alternative to a prosthetic aortic valve substitute within the last decade. Because of a probably better resistance to infection as one of its advantages, the pulmonary autograft is theoretically preferable for active endocarditis.

METHODS: Between June 1994 and July 2003, the Ross procedure was performed using the subcoronary and inclusion technique in 296 patients (231 male, 65 female). Twenty patients had an active endocarditis of the aortic valve at the time of operation. A bicuspid valve was present in 10 patients. One patient had previous aortic valve surgery. Clinical and echocardiographic follow-up was complete.

RESULTS: Early mortality was 1, late mortality was 0. There were no recurrence of endocarditis and no neurologic events during the mean follow-up of 47.3 ± 28.6 months. All patients were in New York Heart Association class I. Mean and maximum pressure gradient across the autograft was 3.5 ± 2.0 and 6.5 ± 3.4, respectively, with no autograft insufficiency in 15, 1+ in 4. Comparing postoperative with the last investigations, there were no significant changes of pressure gradients or grade of regurgitation. Mean and maximum homograft pressure gradients were 7.9 ± 3.7 and 16.2 ± 8.1 mm Hg, respectively, at last investigation; most patients had no or mild homograft regurgitation (0+, n = 13; 1+, n = 5; 2+, n = 1).

CONCLUSIONS: Native valve endocarditis can be treated with excellent results using the Ross procedure with the subcoronary and inclusion technique, with low mortality and morbidity rates and a very low recurrence rate of endocarditis.

	Introduction

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Active endocarditis still is a potentially life-threatening disease although morbidity and mortality could be reduced with appropriate medical and, if necessary, surgical treatment owing to advances in diagnostics, antimicrobial and surgical therapies. The surgical therapy of active native or prosthetic valve endocarditis is well established; however, it is a challenge, with reported mortality rates as high as 19.9% among patients with native valve and 56% among patients with a prosthetic valve endocarditis [1, 2]. In recent series of surgically treated patients, the operative mortality for native valve endocarditis was less than 10%, and for prosthetic valve endocarditis, it was 20% to 30% [3–6]. Furthermore, the choice of an optimal substitute for the diseased aortic valve is still debated controversially in endocarditis owing to a high reinfection rate of the implanted prosthesis [4, 7, 8].

The pulmonary autograft with its resistance to infection particularly related to its viability and due to its lack of prosthetic material is an attractive alternative to conventional aortic valve replacement in endocarditis and has further advantages such as immunologic identity, comparability with the native aortic valve concerning morphology and hemodynamics, antithrombogenicity, and noiselessness. Some experience exists with the full root Ross procedure for active endocarditis but not with the subcoronary or root inclusion technique, which preserves the native root of the patient. The single-center experience and the midterm results with the Ross procedure using the subcoronary and root inclusion technique in patients with active endocarditis are presented.

	Patients and Methods

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The Ethics Committee approved this retrospective study and waived the need to obtain patient consent for the study. Written informed consent was obtained from each patient for the operation.

Patient Characteristics
From June 1994 to July 2003, 296 patients (231 male, 65 female) were operated on with the Ross procedure using the subcoronary or root inclusion technique. Twenty of these patients (14 male, 6 female) had a diagnosis of active bacterial endocarditis affecting the native or, in 1 case, a mechanical prosthetic aortic valve. During the same period, a total of 112 patients were operated on for an active endocarditis in our hospital. The criteria for selecting the Ross procedure rather than a prosthetic valve were mainly age, boundary of the endocarditis process to the aortic root, presence of experienced surgeon, and availability of the homograft. Mean age of these patients with endocarditis was 44 ± 12.9 years (range, 25 to 64). The diagnosis was based on clinical and echocardiographic findings as well as on blood cultures according to the Duke criteria [9]. Preoperative left ventricular systolic function expressed as ejection fraction was 63% ± 15.2%. Concerning valve morphology, 2 aortic valves were functionally monocuspid, 10 were bicuspid, and 7 were tricuspid. An aortic valve insufficiency was present in 12 patients, and a combined aortic valve disease with leading regurgitation in 5 patients. All patients had high intensive antibiotic therapy before the operation.

Symptomatology of Endocarditis
Seven patients had already suffered one or more embolic complications (brain, 5; upper or lower limbs, 2; renal, 1; Osler nodes, 1). Five patients had a general condition impairment and were in New York Heart Association (NYHA) class IV (n = 1) or III (n = 4), 4 patients were in NYHA class II, and 11 were in class I. All patients had antibiotic therapy preoperatively.

Microbiology
A precise bacteriologic diagnosis could be performed in n = 9 patients (Streptococcus sp in 7, Enterococcus sp in 1, and Hemophilus sp in 1).

Operative Procedure
In all patients, conventional extracorporal circulation with moderate hypothermia (temperature 26°C nasopharyngeal) was used. Crystalloid cardioplegia was applied during the first 2 years; thereafter, cold blood cardioplegia was applied. Operative techniques for the Ross procedure using the subcoronary technique are described in detail elsewhere [10]. The principle of surgical intervention in the infected area was the excision and debridement of infected tissue down to healthy tissue. In case of infection and consequently loss of surrounding area, an autologous pericardial glutaraldehyde-tanned patch was inserted to close the defect. Mitral valve inspection was performed in all patients; in 1 patient, a concomitant vegetation was removed. Operative data including simultaneous procedures are listed in Table 1.

Echocardiographic Data Acquisition and Measurements
Examinations were performed with the patients in the left lateral decubitus position. A modified electrocardiographic lead I was continuously recorded. Echocardiographic measurements were determined by two independent observers from video- and digitally recorded studies, and the average value of 5 consecutive beats in sinus rhythm was taken. Transthoracic echocardiograms were performed using a 4-S (2.5 to 4.0 MHz) ultrasound transducer (SONOS 5500 System; Philips/Hewlett Packard, Andover, Massachusetts) preoperatively and postoperatively before discharge, followed by annual intervals. Average values of 5 consecutive beats were taken. Two-dimensional measurements and Doppler investigations were conducted according to the guidelines of the American Society of Echocardiography [11]. Measurements of diameters were taken in standard longitudinal and cross-sectional views and were on videotape or digitally recorded. Maximum velocities across the homograft and autograft were obtained by continuous wave Doppler imaging transducer. To assess aortic and pulmonary regurgitation, pulsed and continuous wave Doppler and color flow Doppler imaging were used. Peak systolic pressure gradient was calculated according to the modified Bernoulli equation (delta P [mm Hg] = 4 x v² [m/s]), where v is the peak systolic velocity.

Statistical Analysis
Categorical data are given as total numbers and relative frequencies. Continuous data are given as mean ± SD. Comparisons of time-related data are made using Wilcoxon signed-rank test. Insufficiency grades were compared using the exact McNemar test. A p value of less than 0.05 was considered statistically significant. Statistical analyses were performed using statistical software SAS 8.2 (SAS, Cary, North Carolina).

	Results

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Follow-up was 100% complete. Mean follow-up was 47.3 ± 28.6 months (cumulative, 74.9 patient-years; range, 2.2 to 94.6 months).

Mortality and Morbidity
There was 1 early death before discharge due to an occlusive embolism of the left main stem with unclear origin (early mortality rate less than 30 days, 5%; Fig 1). A permanent pacemaker insertion was necessary in 1 patient with third-degree atrioventricular block; 1 patient (endocarditis of mechanical aortic valve prosthesis) had a reintervention for pericardial effusion.

View larger version (5K): [in this window] [in a new window]   Fig 1. Kaplan-Meier curve survival rate.

No late death occurred. Cumulative survival over the follow-up period is depicted in Figure 1. No patient suffered from thromboembolic or bleeding events. At last investigation, all patients were in NYHA class I.

Reoperations and recurrence rate of endocarditis
No patient required reoperation of autograft or homograft. There was no recurrence of endocarditis.

Hemodynamics
Mean left ventricular ejection fraction was 67% ± 10.2%; mean cardiac output 5.1 ± 1.2 L/min.

Autograft function
Most patients had no (n = 15) or a mild aortic regurgitation (n = 4). There was no regurgitation greater than 1+. In comparison with postoperative grades of regurgitation, there were no differences (p = 0.625). Pressure gradients across the autograft showed physiological values at discharge (dPmax 7.6 ± 3.0 mm Hg, dPmean 4.4 ± 1.6 mm Hg) as well as during the last investigation (dPmax 6.2 ± 3.3 mm Hg, dPmean 3.4 ± 2.0 mm Hg) without significant changes during time course (p = 0.122 and p = 0.119, respectively).

Homograft function
No pulmonary insufficiency was present in 13, a regurgitation 1+ was present in 5, and 2+ in 1. There was no significant change of grade of regurgitation during time course (p = 0.500). The postoperative gradients before discharge showed lower values (dPmax 7.5 ± 3.5 mm Hg; dPmean 3.9 ± 1.6 mm Hg) in comparison with values at last examination (dPmax 16.2 ± 8.1 mm Hg, p = 0.014; dPmean 7.9 ± 3.7 mm Hg, p = 0.027).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Despite advances in diagnosis and antibiotic therapy, a surgical intervention is performed in approximately 50% of heart valve endocarditis [12]. The surgical cure of these patients is still a challenge. The ideal valve prosthesis in patients with active aortic valve endocarditis has not been determined until now. Aagaard and associates [13] and Bauernschmidt and associates [14] described good clinical results with bioprosthetic and mechanical substitutes. In contrast to conventional biologic and mechanical prostheses, the pulmonary autograft has the advantage of avoiding heterogenous material. Alexiou and coworkers [3] reported a series of 118 patients operated on for endocarditis, with a reinfection rate of mechanical prostheses of 9.8%.

Aside from a lower reinfection rate due to viable tissue and avoidance of foreign material, the Ross procedure has several more advantages in comparison with mechanical valves, for example, no need for oral anticoagulation, noiselessness, potential of growth, and better hemodynamics. Homografts, which are also a good option for active endocarditis (especially in children and younger patients), show also a good hemodynamic profile and have a low recurrence rate of endocarditis in comparison with mechanical valves but also have, as with bioprostheses, a limited life span [15, 16]. Vogt and coworkers [17] reported a series of 49 patients with emergency surgery for active endocarditis. After a mean interval of 21 months, 20% of the patients (9 of 45) had to be reoperated on; all reoperations except one were homograft related. The hospital mortality in this group was 8.2%. The reoperation rate of a homograft series in active endocarditis from Grinda and associates [18] was 13.5% (14 of 104 patients), and the hospital mortality was 4.8% (5 of 104) at 61 months; 6 of these patients (5.8%) had to be reoperated on owing to recurrent endocarditis. Future follow-up investigations are needed for ultimate evaluation of the pulmonary autograft in comparison with homografts.

Prat and coworkers [19] reported a series of 11 patients with active endocarditis with extensive paravalvular involvement operated on with the pulmonary autograft in total aortic root replacement, with no recurrent infection and no early or late death. The Ross procedure in total root replacing technique was also used by Petterson and associates [20], who operated on 35 patients with endocarditis (22 patients with active endocarditis) with good results concerning aortic valve function; one recurrent endocarditis of the right-sided homograft appeared; 2 patients died perioperatively. In our series, we performed the subcoronary and root inclusion technique even in cases of endocarditis not limited to the aortic valve (5 patients had annular abscesses), with good postoperative results. For final judgement of the pulmonary autograft in patients with paravalvular involvement of active endocarditis, larger sample sizes are required. However, in cases of extensive destruction of the aortic root in active endocarditis needing extensive reconstructive techniques, we did not perform the Ross procedure.

Critics mention not only the longer cross-clamp times but also that the double valve procedure of the Ross operation requires an opening of a noninfected orifice in an infected area [17]. In our series, we did not see any infection of the homograft in the right ventricular outflow tract in patients operated on for active endocarditis. Possibly, the advantage of the use of viable tissue in the infected area outweighs the risk of infection of the right-sided homograft. Actually, in our series we did not observe such an event.

Limitations
Because this study is observational, we cannot provide evidence of the superiority of the Ross procedure in the absence of controls.

In conclusion, the surgical therapy of native or prosthetic heart valve endocarditis is still a major challenge. The Ross procedure is feasible and can be safely performed using the subcoronary and root inclusion technique with good midterm results in patients with simple and expanded active aortic valve endocarditis. The low recurrence rate of infection due to the viable autograft and the low reoperation rate, as well as further advantages such as immunologic resistance, long-term durability of the autograft, growth potential, freedom from the need for anticoagulation therapy, and excellent hemodynamics, are exceptional, albeit there is some risk of development of a homograft stenosis in the right ventricular outflow tract that is inherent in the Ross procedure in general.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors thank Kristin Blankenberg (Institute for Medical Biometry and Statistics, University Hospital Schleswig-Holstein, Campus Lübeck) for the excellent statistical data management.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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