Pr. Vogt et al., EMERGENCY-SURGERY FOR ACUTE INFECTIVE AORTIC-VALVE ENDOCARDITIS - PERFORMANCE OF CRYOPRESERVED HOMOGRAFTS AND MODE OF FAILURE, European journal of cardio-thoracic surgery, 11(1), 1997, pp. 53-60
Objective: To describe our experience in the surgical treatment of inf
ective, native and prosthetic aortic valve endocarditis, using cryopre
served homograft valves. Methods: Between January 1988 and September 1
995, 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. Aort
ic root abscesses were found in 39/49 (80%) patients, ventriculo-aorti
c disconnection in 27/49 (55%). An intracardiac fistula, originating f
rom the left ventricular outflow tract was found in 25/49 (51%) patien
ts. Indications for emergency surgery were congestive heart failure du
e to severe aortic valve regurgitation in 44/49 (90%) and systemic emb
oli 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 t
he 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. Resu
lts: Hospital mortality was 8.2% (4/49): 2/49 (4.1%) patients died fro
m endocarditis-related sepsis, one (2%) from low cardiac output and on
e (2%) from a cerebrovascular accident. After a mean interval of 21 +/
- 15 months (2-48), 9/45 (20%) patients had to be reoperated, all reop
erations except one being homograft related. After a mean follow-up of
35 +/- 22 months (2-90), 4/44 (9%) patients had their homograft repla
ced by a mechanical prosthesis. After 5 years, actuarial freedom from
late death was 97 +/- 3%; from late reoperation 69 +/- 9%; from late e
ndocarditis 85 +/- 8%; and from late homograft degeneration 87 +/- 6%.
Explanted homografts were acellular and non-vital, containing bacteri
a and/or leucocytes. B-lymphocytes were found in all and in one, T-cel
l lymphocytes were present. Conclusion: Emergency aortic valve replace
ment with cryopreserved homografts for acute native or prosthetic aort
ic valve endocarditis has a low operative mortality. The late incidenc
e of recurrent endocarditis or homograft failure up to 7 years is acce
ptable. Cryopreserved homografts are non-viable. The presence of T-cel
l lymphocytes in explanted homografts indicates that rejection may be
possible. Copyright (C) 1997 Elsevier Science B.V.