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Eur J Cardiothorac Surg 2007;32:131-132. doi:10.1016/j.ejcts.2007.03.040
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Department of Cardiovascular Surgery, Hospital Clinic – IDIBAPS, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
Department of Infectious Diseases, Hospital Clinic – IDIBAPS, University of Barcelona, Barcelona, Spain
* Corresponding author. Tel.: +34 93 2275749; fax: +34 93 4514898. (Email: cmestres{at}clinic.ub.es).
Infective endocarditis (IE) is a rare disease but having significant impact on morbidity and mortality [1–3]. When it comes to prosthetic heart valves, a well-known complication after replacement therapy of heart valve disease, the problem becomes even more serious as antibiotic treatment does not fix the problem, requiring a compulsory association with early and radical surgery. In the case of the aortic position, prosthetic valve endocarditis (PVE) usually represents a complex problem due to the commonly associated extension of the disease beyond the aortic annulus to the surrounding structures with invasion of the fibrous body of the heart and eventually leading to abscess formation, and, in the most advanced disease, to aortocavitary fistulae [4,5].
Aggressive forms of PVE, as stated, do still represent a surgical challenge due to the extensive destruction of perivalvular structures. Then, in addition to the regular problems seen in IE, namely sepsis, congestive heart failure or embolic phenomena, PVE of the aortic root often renders the surgeon facing an additional problem, which is the destruction of the regular anatomy. The impact of anatomical misconfiguration of the aortic root due to PVE has also an eventual influence on mortality due to the need for extended cross-clamping and cardiopulmonary bypass times. The somewhat frequent multivalvular involvement adds potential surgical difficulties. In this setting, the surgeon is challenged by the way to reconstruct the aortic root and other structures [6].
In this issue, Lopes et al. [7] present the reader with a very elegant retrospective report on their experience with allograft aortic root replacement in complex PVE. Their results in a cohort of 41 patients who underwent root replacement over a period of 18 years are to be commended as in-hospital mortality was very low (4.8%). Postoperative morbid events equally presented in the low range with special focus on acute renal failure. This probably may represent a bias due to the retrospective nature of this study, because mortality among patients with complicated PVE who underwent surgery is much higher, usually ranging between 25 and 40% [8,9]. However, the most important message from their contribution is the excellent long-term results, both in terms of a very high (79%) 10-year survival rate after root replacement with an allograft and especially the absence of recurrence of IE. This, associated to a low (5%) reoperation rate in a decade, makes them to conclude that allograft aortic root replacement in complicated cases of PVE has to be seriously considered as a primary type of operation in this setting.
There are a number of reports dealing with such a serious problem [10,11] since the early contribution of Donaldson and Ross that defined the technique of root replacement using an aortic allograft [12]. All of them have focused on a critical point, which is the ability of the surgeons to deal with otherwise complex technical problems provided an allograft is not used. Any experienced surgeon must recognize the difficulties in approaching the destroyed aortic root when abscess of aortocavitary fistulae develops. Our own experience in this field confirms the seriousness of these conditions, the suboptimal results usually achieved and the need for an aggressive combined medical and surgical therapy [8,9,13]. On the contrary, allografts are meant to represent a proven alternative for the aortic root in IE. This has been confirmed by the excellent results reported by Yankah et al. [14] in an experience that covers almost two decades of follow-up with a cohort of 161 patients (50% PVE). The most important message was, in addition to an in-hospital mortality of 9.3% for elective/urgent patients and 14.3% for emergency surgery, a 17-year actuarial survival of 70.4%, 75% freedom from reoperation and 98.6% freedom from structural valve degeneration. This is a very remarkable achievement.
Some other points may need additional discussion like, as pointed out by Lopes et al. [7] quoting the thoughts of Tornos et al. [15], the compulsory need for surgical treatment in PVE. Although the clinical, echocardiographic and anatomical variations of aortic root PVE sometimes make it difficult to reach an agreement, what seems clear today is that aortic PVE seems to be a surgical disease, especially when some specific conditions such as brain embolization and staphylococcal infection are present, according to our own experience with large cooperative databases [8,16]. This particularly applies to this specific subset of pathogens and abscess as an indicator of advanced disease, which is usually the rule in PVE [3–5].
In conclusion, a number of issues are of practical interest regarding the use of allografts in complex aortic PVE. First, the need for an aggressive combined medical and surgical management; secondly, the need for an aggressive and radical surgical management and that the allografts allow the surgeon to effectively treat any condition within the aortic root. Finally, allografts do offer an additional benefit in terms of excellent long-term survival and freedom from complications. IE in general and PVE in particular represent the best indication for its use. The data from O’Brien et al. [17], who pioneered the use of cryopreserved allografts, are self-explanatory in this regard. Lopes et al. [7] have again brought the attention of the reader to the still challenging problem of the complex aortic root PVE through a fine analysis of a remarkable experience.
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oz P, Roman JA, de Alarcon A, Ripoll T, Navas E, Gonzalez-Juanatey C, Cabell CH, Sarria C, Garcia-Bolao I, Farias MC, Leta R, Rufi G, Miralles F, Pare C, Evangelista A, Fowler Jr. VG, Mestres CA, de Lazzari E, Guma JR, Aorto-cavitary fistula in infective endocarditis Working Group Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J 2005;26:288-297.
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