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Eur J Cardiothorac Surg 2005;28:510
© 2005 Elsevier Science NL
Letter to the Editor |
Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
Received 9 June 2005; accepted 10 June 2005.
* Corresponding author. Tel.: +49 30 4593 2000; fax: +49 30 4593 2100. (Email: siniawski{at}dhzb.de).
Key Words: Double valve endocarditis • Destructive endocarditis • Secondary mitral valve endocarditis • Superstentless valve substitute • Aortic root abscess
We thank Drs Al-Attar et al. for their positive reaction to our article. Our constant aim is to further improve the results of surgical treatment during ongoing endocarditic infection accompanied by aortic root destruction. We believe that there are three main possibilities of achieving this.
First and foremost, early operation is of the essence and accurate preoperative diagnosis is essential to optimize the timing. We found that double-valve disease usually spreads from the aortic valve to the mitral valve when aortic valve infection with the potential danger of spread to the mitral valve is not recognized early enough. Prompt recognition often means that only the aortic valve requires surgical attention. In our most recent work, the following predisposing factors for mortality were identified: septic shock (OR 3.44, CI 0.85–13.9) and false diagnosis (unrecognized root abscess with severe damage) in the referring hospital (OR 11.667, CI 3.127–43.522) (as yet unpublished data).
Secondly, valve selection plays an important role in preventing reinfection after operation. While there is no ideal infection-resistant valve prosthesis, in our experience the best choice at present is the homograft or the Shelhigh No-React prosthesis.
Thirdly, the choice of the optimal surgical valve replacement technique will always greatly influence the result achieved when severe damage means that valve reconstruction is not possible.
Dr Al-Attar and colleagues reported their favorable experience with translocation of the aortic valve for severe prosthetic valve endocarditis, ventriculo-aortic disconnection and aortic root abscess. The surgical technique used means that the coronary ostia are closed. Theoretically, there is a possible life-threatening complication because the myocardial blood supply is entirely dependent on a venous bypass while the coronary ostia are oversewn. This was already published by Danielson in the early 1970s—see book chapter by Hetzer et al. [1] where a case is illustrated.
We agree that inadequate excision of the infected local tissue during operation can cause the surgical procedure to fail. Therefore, excision of the infected part of the aortic wall and debridement of all infected adjacent tissue is essential regardless of the surgical technique or type of material used. We congratulate the colleagues from France on their excellent results. At our institution we have not used this technique, but prefer to use the ‘abscess exclusion’ technique as presented by Knosalla et al. [2].
References
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