Results of homograft aortic valve replacement for active endocarditis

Since July 1985, cryopreserved homograft prostheses have been used for aortic valve replacement in 10 patients, aged 2 to 77 years, with active endocarditis. Five patients had positive bacterial cultures from excised valves, and all had clinical findings of uncontrolled infection while receiving appropriate antibiotics. Homograft valves (four) or valved conduits (six) were implanted for treatment of sepsis (6 patients), congestive heart failure (3) or recurrent emboli (1 patient), and complicating native (5 patients) or prosthetic valve (5) endocarditis. Staphylococci (6 patients), streptococci (3), and Candida (1) were infecting organisms. Preoperatively, Doppler echocardiography showed aortic regurgitation in all patients. At operation, 9 patients had gross vegetations, 9 had single or multiple abscess cavities, and 5 had pericarditis. Complex reconstruction of the aortic valve and annulus with homograft conduits was necessary in 6 patients (3 with previous aortoventriculoplasty). Two early deaths (ventricular failure, perioperative stroke) occurred. Mean follow-up of all operative survivors was 2.1 years (range, 0.6 to 3.6 years), and one late death resulted from arrhythmia. Homograft valve regurgitation increased in 1 patient, and 7 late survivors are asymptomatic. No patient has had recurrence of endocarditis. We conclude that cryopreserved homograft aortic valve/root replacement is an effective method for management of active endocarditis complicated by annular destruction.     

Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis

Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Methods. From 1986 through 1998, 81 adults with aortic valve endocarditis underwent valve replacement (AVR). The mean age of the 65 men and 16 women was 44 ± 14 years. Sixty-three (78%) patients had active endocarditis at the time of operation. Non-native valve endocarditis was present in 29 (36%) patients, in 9 of whom the infection was a recurrence. Aortic valve replacements were performed with 46 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 11 required mitral valve replacement or repair (homo-Ross DVR). Follow-up was 90% complete within 2 years of the end of the study with a mean of 3.7 ± 3.4 years.

Results. Early mortality was 16% (13 of 81 patients). This was 12% (3 of 25 patients) for Ross-AVR, 17% (8 of 46 patients) for homo-AVR, and 20% (2 of 10 patients) for prosth-AVR. Overall late mortality was 10% (7 of 68 patients) with a valve-related late mortality of 7% (5 of 68 patients). Actuarial survival at 5 years was 88% ± 9% in Ross-AVR, 69% ± 11% in homo-AVR, and 29% ± 22% in prosth-AVR (p = 0.03). Endocarditis recurred in 12.5% (1 of 8 patients) with prosth-AVR and 3% (2 of 60 patients) in homo-Ross AVR.

Conclusions. Valve replacement in the presence of native and prosthetic endocarditis remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients even if concomitant mitral valve replacement is required, and risk of valve-related death or recurrent endocarditis is low at medium-term follow-up.     

Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.     

Prosthetic valve endocarditis associated with paravalvular aortic and mitral abscesses

A 63-year-old female, who had undergone aortic and mitral valve replacement 16 years ago, was admitted because of urinary tract infection. The patient developed cerebral hemorrhage. Methicillinresistant Staphylococcus aureus was isolated from her blood culture. Transesophageal echocardiography revealed paravalvular aortic and mitral abscesses, and the diagnosis of prosthetic valve endocarditis was established. A redo double valve replacement was performed. Both paravalvular abscess cavities were debrided and closed with fresh autologous pericardial patches, and mechanical valves were implanted. The patient's postoperative course was uneventful, and she had no sign of recurrent infection 3 years postoperatively.     

Aortic valve endocarditis with aortic root abscess cavity: surgical treatment with aortic valve homograft

Aortic valve endocarditis with an aortic root abscess cavity was treated by a modification of the standard technique of aortic homograft implantation in 3 patients. At a mean follow-up of 35 months, all 3 patients were well without reoperation or signs of aortic incompetence. This technique may, in some cases, be an alternative to the more complex procedure of homograft aortic root replacement with coronary reimplantation.     

Reoperative cryopreserved root and ascending aorta replacement for acute aortic prosthetic valve endocarditis

BACKGROUND: Prosthetic aortic valve endocarditis (PVE) is an important complication of aortic valve replacement (AVR) and is a particularly difficult situation after an operation combining AVR with ascending aortic replacement. METHODS: From 1988 through 2000, 27 patients with aortic valve PVE after previous ascending aortic replacement (aortic root replacement in 13, aortic valve replacement with a supracoronary graft in 14) underwent reoperation for aortic root replacement with a cryopreserved aortic allograft and prolonged intravenous antibiotic therapy. All patients were considered to have active PVE (25 with positive cultures); root abscess formation was present in 89% and aortoventricular discontinuity in 41%. RESULTS: One patient (3.7%) died in-hospital, and permanent pacemakers were required in 10 patients (37%). Mean postoperative follow-up interval was 3.9 +/- 3.0 years, and survival at 1, 2, 5, and 7.5 years was 92%, 88%, 70%, and 56%, respectively. One patient underwent reoperation for recurrent PVE 8 months after operation. CONCLUSIONS: Radical debridement of infected prosthetic material and tissue, and allograft aortic root and ascending aorta replacement, combined with intravenous antibiotic therapy, appears to achieve a low hospital mortality and a high degree of freedom from recurrent infection for patients with PVE after AVR and ascending aortic replacement.     

Indications for and results of cryopreserved homograft valve replacement

The cryopreserved aortic homograft valve is one of the most reliable of the stentless biological prosthesis if implanted properly. Due to the limited availability of homograft valves in Japan, the indications for their use are different from those in other countries. The first indication is active infective endocarditis in the aortic valve position, especially infection surrounding artificial implants. Another indication is for reconstruction of the right ventricular outflow tract during pulmonary autografting. Finally, aortic valve replacement in young women of childbearing age who wish become pregnant is an accepted indication. Since 1992, cryopreserved homograft valves have been used in Japan, and the number of surgeries performed with them has gradually increased. While efforts have been made to expand the homograft bank system in some areas, the supply remains insufficient. Because the demand for homografts is high, it is extremely important to establish a nationwide tissue bank system as soon as possible.     

Short-term result of aortic valve replacement with cryopreserved homograft valve in the University of Tokyo Tissue Bank

The short-term results after aortic root replacement with 11 cryopreserved aortic homografts was examined. Since 1998, the University of Tokyo Tissue Bank has supplied 11 aortic homograft valves. Nine of the recipients were male, and the average age was 51.2 years. Nine out of 11 patients had suffered from a serious condition of native or prosthetic valve infectious endocarditis. All of the patients underwent aortic root replacement, and the blood type between the patient and the homograft was matched in 8 of the patients. Only 1 patient died (9.1%) in the short-term due to sepsis. The preoperative degree of aortic valve regurgitation in all of the cases was third or fourth while the regurgitation disappeared after the operation in all of them. Thinking of the serious condition of our cases preoperatively, the 9.1% operative mortality was quite acceptable. Long-term follow-up is necessary to estimate the quality of the homografts.     

A case report of translocation method for active infective aortic valve endocarditis with aortic root abscesses]

We experienced a case of 51-year-old woman who underwent emergency aortic valve replacement by translocation method for active infective aortic valve endocarditis with aortic root abscesses. Postoperative course was complicated as the following. Three days later, the perforation of noncoronary sinus of Valsalva into the right atrium was noted and she developed progressive heart failure due to the massive left-to-right shunt. The second operation was performed immediately for the patch closure of the perforation through the right atriotomy. Two months later, unstable angina appeared because of the stenosis of the vein graft to the left coronary artery, leading to the emergency third operation in which LITA was placed to the left anterior descending artery. In spite of these complications she recovered gradually and she was discharged 6 months after the first operation. She is now doing well in NYHA class 2. Translocation method is quite useful for such a case of the aortic valve endocarditis with periannular abscesses in whom conventional valve replacement is supposed to be impossible, but the long durability of this type of the repair is unknown. Careful follow-up of the patient is mandatory.     

Successful aortic valve replacement for severe aortic regurgitation combined with annular abscess due to active infected endocarditis

Two men, 58 and 72 years old, were diagnosed as severe aortic regurgitation complicated by aortic annular abscess due to active endocarditis infection diagnosed by echocardiography. We conducted aortic valve replacement using gelatine-resorcine-formol biological glue to close the abscess cavity and remodel the new aortic annulus. Although 1 man developed complete atrial-ventral blockage postoperatively and required that a permanent pacemaker be implanted, neither experienced recurrence of infectious perivalvular leakage.     

Aortic root replacement using a homograft for recurrent valve endocarditis

Prosthetic valve endocarditis is a relatively rare condition associated with high mortality. Endocarditis affecting 2 successive mechanical valves at the aortic position has not, to the best of our knowledge, been described. We reported such a patient whose condition was further complicated by mitral regurgitation, pulmonary hypertension, worsening heart failure, and cardiac conduction abnormalities. Considering the failure of 2 previous mechanical valves, we conducted a homograft replacement of the aortic root with coronary reattachment. Mitral regurgitation was treated by annuloplasty. The patient's early postoperative course was uneventful and he was doing well 16 months after surgery. We discuss the overall treatment strategy for recurrent prosthetic valve endocarditis and potential homograft advantages.     

Trans-catheter aortic valve implantation after previous aortic homograft surgery

In patients with previous heart surgery, the operative risk is elevated during conventional aortic valve re-operations. Trans-catheter aortic valve implantation is a new method for the treatment of high-risk patients. Nevertheless, this new procedure carries potential risks in patients with previous homograft implantation in aortic position. Between April 2008 and February 2011, 345 consecutive patients (mean EuroSCORE (European System for Cardiac Operative Risk Evaluation): 38 ± 20%; mean Society of Thoracic Surgeons (STS) Mortality Score: 19 ± 16%; mean age: 80 ± 8 years; 111 men and 234 women) underwent trans-apical aortic valve implantation. In three patients, previous aortic homograft implantation had been performed. Homograft degeneration causing combined valve stenosis and incompetence made re-operation necessary. In all three patients, the aortic valve could be implanted using the trans-apical approach, and the procedure was successful. In two patients, there was slight paravalvular leakage of the aortic prosthesis and the other patient had slight central leakage. Neither ostium obstruction nor mitral valve damage was observed. Trans-catheter valve implantation can be performed successfully after previous homograft implantation. Particular care should be taken to achieve optimal valve positioning, not to obstruct the ostium of the coronary vessels due to the changed anatomic situation and not to cause annulus rupture.