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[Surgical correction with homograft in native or prosthetic aortic valve infective endocarditis]
Amando Gamba1, Amedeo Terzi, Paolo Ferrazzi
1U.O. di Cardiochirurgia, Azienda Ospedaliera Ospedali Riuniti Largo Barozzi, 24100 Bergamo.
Background:
Aortic valve surgery for infective endocarditis is still a high-risk procedure and the optimal valve substitute remains controversial. The aim of this study was to evaluate the results of our experience using homografts in the treatment of native (NVE) or prosthetic valve endocarditis (PVE).
Methods:
Between May 1992 and December 2000, 37 patients with NVE and 16 patients with PVE underwent aortic valve replacement with homografts for infective endocarditis. In the two groups of patients the mean age was 57 and 61 years and 38% and 50% were in NYHA functional class IV or V. At the time of surgery, 28 patients had gross vegetations, 23 single or multiple abscess cavities, 3 ventricular septal perforations, and 9 mitral valve endocarditis. Homograft insertion was performed in a subcoronary position in 47 cases and as a root replacement in 6 cases. In 21 cases associated surgical procedures were also performed.
Results:
Follow-up was 94% complete at a mean of 56 months after valve replacement. There were 1 hospital and 7 delayed deaths; the actuarial survival at 5 years was 85.5 +/- 6% for NVE and 80.8 +/- 10% for PVE. Endocarditis recurred early in 2 cases (both with fungal infection) and late in 3 cases with an endocarditis-free 5-year period of 87.1 +/- 5%. Delayed echocardiography demonstrated aortic incompetence classified as grade II in 40 cases and as grade III and IV in 2 cases. Thirty-nine patients are in NYHA class I and 3 in class II or III.
Conclusions:
On the basis of our experience we can conclude that in case of acute endocarditis, if the results of surgery are to be optimized, an early diagnosis and aggressive medical therapy need to be combined with earlier surgical referral. In the presence of NVE without annular abscesses the likelihood of recurrent endocarditis is probably more likely to depend on the infective organism than on the type of valve implanted. Our results support the suggestion that in the presence of NVE with extensive annular abscesses or in case of PVE the homograft valve is the replacement device of choice.