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Eur J Cardiothorac Surg 2002;21:260-267
© 2002 Elsevier Science NL

Surgical management of acute aortic root endocarditis with viable homograft: 13-year experience

Department of Cardiothoracic and Vascular Surgery, Humboldt University Berlin, Deutsches Herzzentrum Berlin, Augustenburger Platz 1 D-13353 Berlin, Germany

Received 18 September 2001; received in revised form 25 October 2001; accepted 2 November 2001.

* Corresponding author. Tel.: +49-30-4593-2021; fax: +49-30-4593-2021
e-mail: yankah{at}dhzb.de

Objective: Cryopreserved homograft valves have been used for acute infective aortic root endocarditis with great success but it is compounded by its availability in all sizes. The long-term clinical results of geometric mismatched homografts are not well defined and addressed. Methods: Over a 15-year period (April 1986–June 2001), 816 patients presented with active infective endocarditis. One hundred and eighty-two of the patients aged between 9 and 78 years (mean: 51.0±1.13 years) consisting of 142 males and 40 females received homograft aortic valves. One hundred and ten patients were in NYHA functional class III and 72 in class IV and in cardiogenic shock. Of the patients, 2.7% suffered from septic embolism. One hundred and twenty-four (68.1%) patients presented with periannular abscesses and 58 (31.9%) with no abscess while 107 native valve (NVE) and 75 prosthetic valve (PVE) endocarditis were diagnosed preoperatively by transesophageal echocardiography (TEE) and confirmed intraoperatively. Freehand subcoronary implantation (FSCI) was used in 106 patients and root replacement in 76 patients. Results: The operative death was 8.5% and for patients in NYHA functional class IV and in cardiogenic shock was 14.5%. Late mortality rate was 7.9%. Patient survival after discharge from hospital at 1 year was 97% and at 10 years was 91%, respectively. Thirty-one (22.1%) patients underwent reoperation after 1.7 years (mean) with two deaths (6.4%). Early (60 days) and late reinfection rate was 2.7 and 3.6%, respectively. Freedom from reoperation for matched and undersized homografts at 10–13 years was 85 and 55%, respectively. The univariate model identified undersized homograft (P=0.002), FSCI (P=0.09) and reinfection (P=0.0001) as independent risk factors for developing early and late valve dysfunction resulting in reoperation and homograft explant. Conclusion: Early aggressive valve replacement with homograft for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery. Homografts exhibit excellent clinical performance and durability with a low rate of reinfection, if properly inserted. Undersized homograft is an incremental risk factor for early and late reoperation.

Key Words: Valvular endocarditis • Homograft replacement • Sizing techniques

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