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