The Hidden Burden of Native Aortic Valve Endocarditis: Reevaluating Diagnostic and Pathologic Challenges

Native aortic valve endocarditis (NAVE) can manifest with invasive disease, which may require complex aortic root reconstruction. Therefore, this study aimed to examine the incidence of invasive pathologic features in NAVE, the yield of preoperative diagnosis, and surgical approaches in a single-center experience.

From 2002 to 2020, 1488 patients underwent surgical intervention for aortic valve endocarditis at a tertiary institution, including 644 patients with NAVE. Data were obtained from an institutional endocarditis registry database, and matching was performed to ensure balanced baseline characteristics.

Among 644 patients with NAVE, 260 (40%) had intraoperative findings of invasive disease. Staphylococcus aureus was the most common pathogen (26%). Preoperative echocardiography detected invasion in only 43% of patients, with a sensitivity of 52.1% for transesophageal echocardiography and 35.3% for transthoracic echocardiography. Computed tomographic angiography confirmed invasion in 50% (19 of 38) of echocardiography-positive cases and in 22% (9 of 41) of echocardiography-negative cases, with a sensitivity of 35.4%. Compared with patients with noninvasive NAVE, patients with invasive NAVE had prolonged cardiopulmonary bypass times, ventilation duration, and intensive care unit stays (P < .001, P= .004, and P = .005, respectively). Aortic valve replacement with an allograft was the most frequently performed surgical intervention for extensive invasive disease, with patch repair for focal invasion. Survival at 15 years was similar in propensity-matched invasive NAVE vs noninvasive NAVE (40% vs 39%; P = .76).

NAVE not uncommonly manifests with invasive pathologic features that can be missed on preoperative imaging. Thus, a high index of suspicion for invasive disease is advised, with preparation for a possible complex operation.