Emergency surgery for acute infective aortic valve endocarditis: performance of cryopreserved homografts and mode of failure1

  • Vogt, P. R.
  • von Segesser, Ludwig K.
  • Jenni, R.
  • Niederhäuser, U.
  • Genoni, M.
  • Künzli, A.
  • Schneider, J.
  • Turina, M. I.

  • aClinic for Cardiovascular Surgery, University Hospital, Rämistr. 100, CH-8091 Zurich, Switzerland

    bDivision of Echocardiography, University Hospital, Rämistr. 100, CH-8091 Zurich, Switzerland

    cDepartment of Pathology, University Hospital, Rämistr. 100, CH-8091 Zurich, Switzerland

Received 9 February 1996; revised 15 April 1996; accepted 25 April 1996

* Corresponding address. Tel.: +41 1 2551111; fax: +41 1 2551111.

1 Presented at the Ninth Annual Meeting of the European Association for Cardio-Thoracic Surgery, Paris, France, 24-27 September, 1995.

European Journal of Cardio-Thoracic Surgery 11(1):p 53-61, January 1997. | DOI: 10.1016/S1010-7940(96)01063-9

Abstract

Objective:

To describe our experience in the surgical treatment of infective, native and prosthetic aortic valve endocarditis, using cryopreserved homograft valves.

Methods:

Between January 1988 and September 1995, 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 root abscesses were found in 39/49 (80%) patients, ventriculo-aortic disconnection in 27/49 (55%). An intracardiac fistula, originating from the left ventricular outflow tract was found in 25/49 (51%) patients. Indications for emergency surgery were congestive heart failure due to severe aortic valve regurgitation in 44/49 (90%) and systemic emboli in 5/49 (10%) patients. Preoperatively, 23/49 (47%) patients were in New York Heart Association (NYHA) class IV, and 5/49 (10%) were in acute circulatory failure. Mean left ventricular ejection fraction was 53 ± 10% (25-65). Streptococci (27%) and staphylococci (27%) were the most important microorganisms found. The homograft was implanted as a scalloped freehand valve (34/49; 70%), as an intra-aortic inclusion cylinder (4/49; 6%) or as a free-standing root replacement (12/49; 24%). Combined procedures were necessary 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 had to be reoperated, all reoperations except one being homograft related. After a mean follow-up of 35 ± 22 months (2-90), 4/44 (9%) patients had their 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 homograft degeneration 87 ± 6%. Explanted homografts were acellular and non-vital, containing bacteria and/or leucocytes. B-lymphocytes were found in all and in one, T-cell lymphocytes were present.

Conclusion:

Emergency aortic valve replacement with cryopreserved homografts for acute native or prosthetic aortic valve endocarditis has a low operative mortality. The late incidence of recurrent endocarditis or homograft failure up to 7 years is acceptable. Cryopreserved homografts are non-viable. The presence of T-cell lymphocytes in explanted homografts indicates that rejection may be possible.

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