Repair versus replacement of the aortic valve in active infective endocarditis

Aortic valve repair has advantages over replacement in stable aortic regurgitation. It is unclear whether this is similar in active endocarditis.

From January 2000 to July 2009, 100 patients (age 54.9±15.1 years) underwent surgery for aortic valve endocarditis. Thirty-three patients were treated by valve repair (I) and 67 underwent valve replacement (II: 51 biologic, 10 mechanical valves, 6 Ross operations). In Group I, cusp and root lesions were treated by autologous pericardial patches. A root abscess was present in 32 cases (I: 27%, II 34%; P=0.82). Concomitant procedures (n=49) were mitral repair (I: 10, II: 11; P=0.12) and coronary bypass (I: 4, II: 11; P=0.77). All patients were followed. Cumulative follow-up was 268 patient-years (mean 2.7±3.0 years). In a retrospective analysis, we analysed the outcome.

Hospital mortality was 15% (I: 9%, II: 18%; P=0.37). Survival at 5 years was significantly better after repair (I: 88%, II 65%; P=0.047). Ten patients were reoperated (I: 35%, II: 10%; P=0.021) between 1 month and 5 years postoperatively. Actuarial freedom from aortic regurgitation of grade II or higher was 80% at 5 years (I: 66%, II: 87%; P=0.066). In Group I, this was influenced by aorto-ventricular (AV) morphology (tricuspid 80%, bicuspid 50%; P=0.0045). Freedom from reoperation in reconstructed tricuspid valves (n=20) was 87% at 5 years, which was identical to Group II (P=0.40). At 5 years, freedom from thromboembolic events was 93% (I: 100%, II: 90%; P=0.087) and that from bleeding complications was 100%.

AV repair for active endocarditis seems to lead to better survival compared with replacement. The use of large patches in combination with bicuspid anatomy results in increased risk of late failure.