Surgical Strategies in Aortic Root Endocarditis

Surgical Strategies in Aortic Root Endocarditis

Surgical Management of Aortic
Root Endocarditis
Joseph E. Bavaria, MD
Brook Roberts – Maul Measey Professor of Surgery
Vice Chief, Cardiovascular Surgery
University of Pennsylvania
Philadelphia, PA USA
AATS, Toronto, 2014
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
Resistant infections, Fungus
• Optimal prosthetic choice is unclear
– homograft preferred by many.
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
Severe Prosthetic Valve Endocarditis
or Aorto‐Ventricular Destruction/Dehiscense
AATS 2014
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
Patients and Methods
• Penn Aortic Surgery Database (2000 – 2010)
– 1337 Aortic root replacements
• Inclusion criteria: Active Endocarditis
– Full aortic root replacement
– Previous cardiac surgery
– Multiple valve involvement
• Exclusion criteria:
– Treated endocarditis
– Non‐infective
Aortic Root Choices
AATS 2010
N=134
Homograft Mechanical (HG), 36, (MC), 43, 27%
32%
Biologic (BC), 55, 41%
Rifampin Coated Grafts with ALL Dacron cases (all MC and BC that were pericardial conduits)
Preop Characteristics
ALL (n=134)
(%)
Mechanical (n=43)
(%)
Biologic (n=55)
(%) Homograft (n=36)
(%)
Age
58.3 ± 14.8
51.8 ± 12.7
62.7 ± 15.1
59.4 ± 14.3
Male
95 (70)
38 (88)
35(63)
22 (61)
Dyslipidemia
66 (49)
15 (34)
34 (61)
17 (47)
CVD
46 (34)
16 (37)
21 (38)
9 (25)
CVA
37 (27)
13 (30)
17 (30)
7 (19)
Chronic Lung Disease
27 (20)
4 (9)
16 (29)
7 (19)
DM
29 (21)
9 (20)
10 (18)
10 (27)
HTN
91 (67)
26 (60)
39 (70)
26 (72)
24/9 (17/6)
3/0 (7/0)
8/2 (14/3)
13/7 (36/19)
57 (42)
18 (41)
22 (40)
17 (47)
Renal Failure/HD
Smoker
ALL (n=134)
(%)
Mechanical (n=43) (%)
Biologic (n=55) (%) Homograft (n=36) (%)
h/o MI
19 (14)
7(16)
6 (10)
6 (16)
Heart Failure
116 (86)
37 (86)
48 (87)
31 (86)
Class I
22 (16)
7 (16)
2 (3)
3 (8)
Class II
15 (11)
7 (16)
2 (3)
6 (16)
Class III
49 (36)
19 (44)
16 (29)
14 (38)
Class IV
30 (22)
4 (9)
18 (32)
8 (22)
≤ 30 %
12 (9)
3 (7)
6 (10)
3 (8)
31 – 40%
13 (9)
4 (9)
5 (9)
4 (11)
41 – 50%
29 (21)
13 (30)
8 (14)
8 (22)
51 – 60%
47 (35)
17 (39)
19 (34)
11 (30)
> 60%
20 (14)
3 (7)
11 (20)
6 (16)
Cardiogenic shock
11 (8)
3 (7)
4 (7)
4 (11)
CPR
3 (2)
0
2 (3)
1 (2)
96 (71)
30 (69)
36 (65)
30 (83)
3
Ejection Fraction
Urgent/emergent
In‐situ AV type did not effect prosthetic selection
ALL (n=134)
(%)
Mechanical (n=43)
(%)
Biologic (n=55) (%) Homograft (n=36)
(%)
44 (32)
12 (27)
19 (34)
13 (36)
18 (13)
7 (16)
9 (16)
2 (5)
90 (67)
31 (72)
36 (65)
23 (63)
Previous AVR
69 (51)
20 (46)
31 (56)
18 (50)
Previous Root
21 (15)
11 (25)
5 (9)
5 (13)
Native BAV
Prosthetic
There was no difference in severity of infection in the three groups
ALL (n=134)
(%)
Dehiscence/Rupture/Ps
eudo‐aneurysm/Fistula
110
(82)
98
(73)
62
(46)
Mechanical (n=43)
(%)
36
(83)
28
(65)
17
(39)
Biologic (n=55)
(%)
46
(83)
42
(76)
30
(54)
Homograft (n=36)
(%)
28
(77)
28
(77)
15
(41)
Abscess or Dehiscence /Rupture/ Fistula
114
(85)
37
(86)
47
(85)
30
(83)
Abscess
Vegetations
No difference in infectious etiology
Organism ALL (n=129)
(%)
Mechanical (n=42)
(%)
Biologic (n=55)
(%) Homograft (n=33)
(%)
Culture negative
14 (10)
4 (9)
7 (12)
3 (5)
Fungal
12 (9)
6 (14)
4 (7)
2 (3)
MRSA
16 (12)
4 (9)
9 (16)
3 (5)
MSSA
18 (14)
5 (11)
4 (7)
9 (16)
Coag Negative staph
21 (16)
8 (19)
9 (16)
5 (9)
Enterococcus
19 (14)
5 (11)
8 (14)
6 (10)
Streptococcus
30 (23)
13 (31)
14 (25)
3 (5)
GNB
10 (7)
5 (11)
2 (3)
3 (5)
Others
15 (11)
5 (11)
8 (14)
2 (3)
58 (49.6%)
22 (56.4%)
23 (46.0%)
13 (46.4%)
Positive OR Tissue Cultures
ALL (n=134)
(%)
Mechanical (n=43)
(%)
Biologic (n=55) (%) Homograft (n=36)
(%)
Additional procedures
90 (67)
33 (76)
38 (69)
19 (52)
Hemiarch
28 (20)
13 (30)
13 (23)
2 (5)
CABG
16 (11)
4 (9)
5 (9)
7 (19)
MV Replacement
20 (14)
7 (16)
10 (18)
3 (8)
MV Repair
16 (11)
9 (20)
4 (7)
3 (8)
TV Repair/Replace
11 (8)
1 (2)
7 (12)
3 (8)
Perfusion Time (CPB)
293 ± 99
308 ± 98
300 ± 109
262 ± 80
Aortic Clamp Time
227 ± 75
244 ± 78
230 ± 76
201 ± 63
Circulatory arrest time
29 ± 15
(n=29)
31 ± 19
(n=14)
27 ± 10
(n=13)
21 ± 9
(n=2)
Homograft implantations are shorter, with less concomitant procedures
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
Deep Dissection parallel to the LVOT
No difference in major in‐hospital events
ALL (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)
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)
Renal Failure/HD
No difference in Long‐term Survival… All
Mechanical
Biologic
Homograft
1 – year survival (%)
68
67
65
61
5‐year survival (%)
59
58
62
58
… or reinfection …
Freedom from Reinfection
Mechanical
Biologic
Homograft
1 year (%)
5 years (%)
84
94
75
74
89
64
… or reoperation…
Freedom from Reoperation
Mechanical
Biologic
Homograft
1 year (%)
5 years (%)
96
97
86
89
90
86
… or readmission rate
Freedom from Readmission
Mechanical
Biologic
Homograft
1 year (%)
5 years (%)
76
88
63
60
83
63
In‐Hospital Mortality
Input Variable
OR
95% CI for OR
Lower
Upper
Late Mortality
OR
95% CI for OR
Lower
Upper
Age
1.005
0.970
1.041
1.014
0.993
1.035
Sex
2.515
0.883
7.166
1.542
0.870
2.731
Diabetes
4.912
1.747
13.811
2.253
1.270
3.998
Renal Failure
2.761
0.893
8.535
2.177
1.170
4.048
Abscess
9.153
1.045
80.184
1.291
0.610
2.731
Culture positive
0.995
0.219
4.519
1.293
0.552
3.029
1.331
0.351
5.037
1.142
0.556
2.343
1.434
0.4444
4.633
0.888
0.467
1.690
Prosthetic type ‐
Mechanical
Prosthetic type ‐
Biologic
Prosthetic type does not predict either in‐hospital, or long‐term mortality
Limitations
• Retrospective, non‐randomized data
• Differences in patient characteristics
– Although minimal
• Evolution of technique over the course of the study
• Long term Follow‐up is incomplete (81%)
• Lack of cause‐specific mortality data
Evolution in graft selection at PENN
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1
1
1
2
7
7
7
4
11
4
4
6
9
6
2
5
10
9
4
6
4
5
5
3
2
3
3
1
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
n=5
n=8
n=8
Mechanical
n=13
n=18
n=12
Biologic
n=14
n=16
n=24
Homograft
n=14
Conclusions
• Surgery for complex Aortic Root infective endocarditis remains a high‐risk procedure (22%)
• Presence of abscess, DM, renal failure increases risk of mortality
• Prosthetic graft selection does not impact survival, reoperation or reinfection rates
• Graft selection should be based on overall clinical picture, technical/anatomic considerations and availability, and not only on severity of infection
Thomas Eakins: Gross Clinic (1878@JEFF) and Agnew Clinic (1889@PENN)
Note the progress in 10 years!
Thank You
AATS 2014