Homograft reconstruction of the aortic root for endocarditis with periannular abscess: a 17-year study.

OBJECTIVE

The study was conducted to evaluate the long-term results of homograft reconstruction of the left ventricular outflow tract with a cryopreserved aortic homograft in the presence of aortic root abscess associated with a biofilm bacterial infection.

METHODS

Between January 1987 and December 2003, 161 patients with aortic root abscess underwent freehand aortic valve (FAVR, N = 78) and aortic root replacement (ARR, N = 83) with an antibiotic treated cryopreserved aortic homograft. Their mean age was 53.1+/-15.6 years. Endocarditis of the native valve was found in 80 patients and of the prosthetic valve in 81; of the prosthetic valves 49 (60.5%) were mechanical and 32 (39%) bioprosthetic. Aortic ventricular discontinuity was found in 83 patients. The common responsible microorganisms were the biofilm bacteria: Staphylococcus (S. epidermidis: 34, S. aureus: 13) in 47 patients followed by Enterococcus in 23 and Streptococcus in 39. Surgery was urgent in 80 patients and emergent in 81, of whom 44 were in cardiogenic shock. Follow-up totaled 810.8 patient-years (mean: 5.0+/-4.3 years) and was 100% complete.

RESULTS

Operative mortality was 9.3% for elective/urgent and 14.3% for emergency surgery. A total of 7.3% patients died after hospital discharge during the 17-year follow-up period. The actuarial patient survival at 17 years was 70.4+/-3.6%. Early and late residual/recurrent infections and paravalvular leaks occurred in 4.3 and 2.5%, respectively. Reoperations were carried out in 30 patients, 11 for residual/recurrent infection and paravalvular leaks. Twenty-one patients with FAVR and 9 with ARR techniques underwent reoperation. Early reoperation rate was 4.3%. The actuarial freedom from residual/recurrent infection and paravalvular leaks was 91.6+/-2.4%. Actuarial freedom from reoperation at 17 years was 75+/-3.7%. It was 82.9+/-5.5% for ARR and 63.5+/-6.7% for AAVR technique. The actuarial freedom from structural valve deterioration (SVD) at 17 years was 98.6+/-0.4.% at a rate of %/patient-year.

CONCLUSIONS

Radical debridement of the infected aortic root and homograft ARR offer a low recurrent infection rate and an overall low valve-related morbidity and mortality for up to 17 years. The antibiotic permeable cryopreserved homograft has proven to be resistant to biofilm bacterial infection.