Ann Thorac Surg 2007;84:1942. doi:10.1016/j.athoracsur.2007.07.098
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Tomislav Mihaljevic, MD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, F24, Cleveland, OH 44195
(Email: mihaljt{at}ccf.org).
This article by Avierinos and colleagues [1] represents a provocative analysis of outcomes of 127 consecutive patients with acute aortic valve endocarditis during a 15-year period who underwent aortic valve replacement with a prosthetic valve or a homograft. Choice of treatment was not randomized, and different techniques of valve replacement were used throughout the study. Study end points included in-hospital mortality, recurrence of infective endocarditis, and long-term survival.
The authors have found that none of the end points was affected by the choice of prosthesis or causative microorganism. The only predictor of poor outcome was prosthetic valve endocarditis. The authors have concluded that early surgery with thorough débridement of all infected tissue is the cornerstone of successful treatment of infective endocarditis, whereas choice of prosthesis appears irrelevant.
Although one can agree with the first part of the conclusion of the article, the second part of the conclusion could be greatly misleading for many surgeons. It appears that most patients with aortic annular disruption, fistula, and abscess were treated with homograft implantation, which is suggestive of the fact that those patients represent subpopulation with more advanced disease. Patients with acute aortic valve endocarditis localized at the leaflets may be served well by implantation of stented prostheses, but those with prosthetic valve endocarditis, circumferential abscesses, and fistulas represent an entirely different population. This was also reflected in the fact that two-thirds of those patients were treated by aortic homograft implantation. Surgeons’ preference dictated the use of different valve substitutes in this study, leaving an impression that homografts were predominantly used for patients with more advanced disease.
It is my impression that the presented data confirm the safe use of mechanical and biologic prostheses for a large number of patients with native valve endocarditis. This information is particularly valuable for surgeons who practice in environments with limited availability of homografts. However, it would not be wise to completely abandon the use of homograft root replacement in particular in patients with prosthetic valve endocarditis and aortic root abscess [2].
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- Avierinos JF, Thuny F, Chalvignac V. Surgical treatment of active aortic endocarditis: homografts are not the cornerstone of outcome Ann Thorac Surg 2007;84:1935-1942.[Abstract/Free Full Text]
- Lytle BW, Sabik JF, Blackstone EH, Svensson LG, Pettersson GB, Cosgrove 3rd DM. Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic endocarditis Ann Thorac Surg 2002;74:S1754-S1757discussion S1792–9.[Abstract/Free Full Text]
Related Article
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Surgical Treatment of Active Aortic Endocarditis: Homografts Are Not the Cornerstone of Outcome
- Jean-François Avierinos, Franck Thuny, Virginie Chalvignac, Roch Giorgi, Laurence Tafanelli, Jean-Paul Casalta, Didier Raoult, Thierry Mesana, Frederic Collart, Dominique Metras, Gilbert Habib, and Alberto Riberi
Ann. Thorac. Surg. 2007 84: 1935-1942.
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