Surgical Management of Aortic (and Root) Endocarditis Joseph E. Bavaria, MD Brook Roberts – Maul Measey Professor of Surgery Vice Chief, Cardiovascular Surgery University of Pennsylvania Philadelphia, PA USA ACC NY CV Symposium 2015
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