Emergency surgery for acute infective aortic valve endocarditis: Performance of cryopreserved homografts and mode of failure

• Published in: European journal of cardio-thoracic surgery 1997-01, Vol.11 (1), p.53-61
• Main Authors: VOGT, P. R, VON SEGESSER, L. K, JENNI, R, NIEDERHÄUSER, U, GENONI, M, KÜNZLI, A, SCHNEIDER, J, TURINA, M. I
• Format: Article
• Language: English
• Subjects: Actuarial Analysis; Acute Disease; Adult; Aged; Aortic Valve Insufficiency - mortality; Aortic Valve Insufficiency - physiopathology; Aortic Valve Insufficiency - surgery; Bacterial diseases; Bacterial endocarditis, myocarditis and pericarditis. Bacterial diseases of the aorta, limb vessels and lymphatic vessels; Biological and medical sciences; Bioprosthesis; Cryopreservation; Emergencies; Endocarditis, Bacterial - mortality; Endocarditis, Bacterial - physiopathology; Endocarditis, Bacterial - surgery; Female; Follow-Up Studies; Heart Valve Prosthesis; Hemodynamics - physiology; Human bacterial diseases; Humans; Infectious diseases; Male; Medical sciences; Middle Aged; Postoperative Complications - etiology; Postoperative Complications - mortality; Postoperative Complications - surgery; Prosthesis Failure; Reoperation; Staphylococcal Infections - mortality; Staphylococcal Infections - physiopathology; Staphylococcal Infections - surgery; Streptococcal Infections - mortality; Streptococcal Infections - physiopathology; Streptococcal Infections - surgery; Survival Rate; Transplantation, Homologous
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/S1010-7940(96)01063-9

OBJECTIVE: To describe our experience in the surgical treatment ofinfective, native and prosthetic aortic valve endocarditis, usingcryopreserved homograft valves. METHODS: Between January 1988 and September1995, cryopreserved homografts were implanted in 49 patients (mean age 47+/- 15 years; range 19-79) with acute infective endocarditis of the native(21/49; 43%) or the prosthetic (28/49; 57%) aortic valve. Aortic rootabscesses were found in 39/49 (80%) patients, ventriculo-aorticdisconnection in 27/49 (55%). An intracardiac fistula, originating from theleft ventricular outflow tract was found in 25/49 (51%) patients.Indications for emergency surgery were congestive heart failure due tosevere aortic valve regurgitation in 44/49 (90%) and systemic emboli in5/49 (10%) patients. Preoperatively, 23/49 (47%) patients were in New YorkHeart Association (NYHA) class IV, and 5/49 (10%) were in acute circulatoryfailure. Mean left ventricular ejection fraction was 53 +/- 10% (25-65).Streptococci (27%) and staphylococci (27%) were the most importantmicroorganisms found. The homograft was implanted as a scalloped freehandvalve (34/49; 70%), as an intra-aortic inclusion cylinder (4/49; 6%) or asa free-standing root replacement (12/49; 24%). Combined procedures werenecessary in 11/49 (22.5%) patients. RESULTS: Hospital mortality was 8.2%(4/49): 2/49 (4.1%) patients died from endocarditis-related sepsis, one(2%) from low cardiac output and one (2%) from a cerebrovascular accident.After a mean interval of 21 +/- 15 months (2- 48), 9/45 (20%) patients hadto be reoperated, all reoperations except one being homograft related.After a mean follow-up of 35 +/- 22 months (2-90), 4/44 (9%) patients hadtheir homograft replaced by a mechanical prosthesis. After 5 years,actuarial freedom from late death was 97 +/- 3%; from late reoperation 69+/- 9%; from late endocarditis 85 +/- 8%; and from late homograftdegeneration 87 +/- 6%. Explanted homografts were acellular and non-vital,containing bacteria and/or leucocytes. B- lymphocytes were found in all andin one, T-cell lymphocytes were present. CONCLUSION: Emergency aortic valvereplacement with cryopreserved homografts for acute native or prostheticaortic valve endocarditis has a low operative mortality. The late incidenceof recurrent endocarditis or homograft failure up to 7 years is acceptable.Cryopreserved homografts are non-viable. The presence of T- celllymphocytes in explanted homografts indicates that rejection may bepossible.