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139 Complicated Infective Aortic Endocarditis: Comparison of Different Surgical Strategies
  1. Miriam Silaschi,
  2. Niki Nicou,
  3. Ranjit Deshpande,
  4. Max Baghai,
  5. Rafal Dworakowski,
  6. Olaf Wendler
  1. King’s College Hospital

Abstract

Introduction Infective endocarditis (IE) of the aortic valve complicated by root involvement or an infected prosthesis is a life-threatening condition. While homografts have been promoted previously for treatment, root replacement using stentless bioprostheses (SBP) is an attractive alternative. Still, there is ongoing debate about the optimal substitute in this setting. We compare outcomes of treatment with mechanical prostheses (MP), stented prostheses (SP) and SBP.

Methods Our in-hospital database was explored for patients treated surgically for aortic IE (2000–2015). Valve replacements with homografts were excluded (n = 12). A total of 187 patients received MP (n = 45), SP (n = 112) or SBP (n = 30). All patients with complicated IE (prosthetic valve endocarditis (PVE) or root involvement, n = 77) were included as study cohort. The group was divided according to substitute received (MP (n = 16), SP (n = 36) and SBP (n = 25)). We analysed short-, long-term- and event-free-survival (100% complete).

Results SBP and SP patients were older (SBP: 57.8 ± 15.9yrs, MP: 41.7 ± 12.4yrs, SP: 59.7 ± 15.1yrs, p < 0.01). SBP patients suffered more often from PVE (64.0% in SBP vs. 18.7% in MP and 36.1% in SP, p = 0.01), and showed more often root involvement (100% in SBP vs. 93.7% in MP and 83.3% in SP, p = 0.08). MP patients tended to have a higher rate of active intravenous drug use (SBP: 4.0%, MP: 25.0%, SP: 8.3%, p = 0.08). Mean follow-up was 1489 days. Survival was best in the SBP group (87.1% vs. MP: 81.3%, SP: 71.9%) at one year and at five years (SBP: 87.1%, MP: 81.3%, SP: 59.8%, SBP vs. SP p = 0.06). Event-free Survival was 87.1% (SBP), 81.3% (MP), 71.8% (SP) at one year and 74.5% (SBP), 71.8% (MP) and 49.9% (SP) at five years (p = 0.09). Re-operation for re-infection occurred in 8.0% (SBP), 18.7% (MP) and 16.7% (SP) (p = 0.55). No patient experienced valve deterioration.

Conclusion Despite a higher pre-operative risk of SBP patients, survival was similar compared to a younger cohort of MP patients and superior to patients with SP. This is most likely an effect of the more radical excision of infected material and should be the preferred surgical option particularly in older patients with complicated IE. In younger patients, the risk of re-infection should be weight against the risk of valve degeneration when the decision is made in favour of MP.

  • Endocarditis
  • Aortic Valve
  • Prosthesis

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