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Surgical Management of
Aortic (and Root) Endocarditis
Joseph E. Bavaria, MDBrook Roberts – Maul Measey Professor of Surgery
Vice Chief, Cardiovascular SurgeryUniversity of Pennsylvania
Philadelphia, PA USA
ACC NY CV Symposium 2015
Infective Endocarditis(Especially of the Aortic Root)
• Effects 15,000 patients yearly in US
• Surgery indicated for:
– Heart failure or cardiogenic shock due to valvular
dysfunction
– Aggressive disease: abscess, heart block, emboli
– Vegitation > 1cm diameter (class II)
– Resistant infections (1 week), Fungus
• Optimal prosthetic choice is unclear
–homograft preferred by many but…..
Clinical Management of IE
• Clinical Decision-Making regarding IE of Aortic
Valve at Penn.
– IE LIMITED to Aortic Valve Leaflets, then simple
AVR.
– IE involves annulus, abscess, aortic wall, fistula, or
extensive then perform an AORTIC ROOT
PROCEDURE
AATS 2014
Severe Prosthetic Valve Endocarditis
or Aorto-Ventricular Destruction/Dehiscense
Infective Endocarditis with Root
Indications: Mortality
• Series that combined Either:
– Active Prosthetic Valve IE
– Destructive Root Abscess (+/- Fistula, etc)
• With a FULL ROOT PROCEDURE
• Musci et al 2010; n = 221; Native Valve =
16.1% Prosthetic Valve = 25.4% mortality
• Leyh et al 2004; n = 29; 18.5% mortality
• Perrotta et al 2010; n = 62; 15% mortality
Deep Dissection parallel to the LVOT
Technical Considerations(Ventriculo-Aortic Discontinuity)
Conduct of Operation Decisions
• Concepts regarding the Mitral Valve in IE
Aortic Root replacement (either REDO root or
Primary)
– Band vs Ring and TEE assessment of Co-aptation
– Homograft Curtain
• Rebuilding the Annulus with Pericardium vs
Direct anastomosis to the Mitral valve, RVOT,
and trigones
AATS 2010
Aortic Root Choices
N=134
Mechanical
(MC), 43,
32%
Biologic
(BC), 55,
41%
Homograft
(HG), 36,
27%
Rifampin Coated Grafts with ALL Dacron cases (all MC and BC that were pericardial conduits)
No difference in major in-hospital
eventsALL (n=134)
(%)
Mechanical
(n=43)
(%)
Biologic
(n=55) (%)
Homograft
(n=36)
(%)
In Hosp Mortality 30(22) 8 (18) 13 (23) 9 (25)
Length of Stay 18 ± 16 19 ± 21 15 ± 13 20 ± 13
Septicemia 18 (13) 9 (20) 7 (12) 2 (5)
DSWI 3 (2) 1 (2) 1 (1) 1 (2)
Permanent Stroke 5 (3) 1 (2) 1 (1) 3 (8)
Reop for Bleed /
Tamponade
12 (9) 5 (11) 4 (7) 3 (8)
Renal Failure/HD 26/12 (19/9) 6/4 (14/9) 14/6 (25/10) 6/2 (16/5)
Cardiac Arrest 10 (7) 4 (9) 2 (3) 4 (11)
Heart Block 27 (20) 9 (20) 15 (27) 3 (8)
MSOF 16 (11) 8 (18) 5 (9) 3 (8)
Prolonged Vent 51 (38) 17 (39) 23 (41) 11 (30)
No difference in Long-term Survival…
1 – year survival (%) 5-year survival (%)
All 68 59
Mechanical 67 58
Biologic 65 62
Homograft 61 58
… or reinfection …
Freedom from
Reinfection
1 year (%) 5 years (%)
Mechanical 84 74
Biologic 94 89
Homograft 75 64
… or reoperation…
Freedom from
Reoperation
1 year (%) 5 years (%)
Mechanical 96 89
Biologic 97 90
Homograft 86 86
… or readmission rate
Freedom from
Readmission
1 year (%) 5 years (%)
Mechanical 76 60
Biologic 88 83
Homograft 63 63
ACC NYC 2015
Thomas Eakins: Gross Clinic (1878@JEFF)
and Agnew Clinic (1889@PENN)
Note the progress in 10 years!
Thank You