Thorac Cardiovasc Surg 2023; 71(01): 29-37
DOI: 10.1055/s-0040-1722652
Original Cardiovascular

The Freestyle Valve in Severe Necrotizing Aortic Root Endocarditis: Comorbidity Upon Outcome

1   Department for Cardiac Surgery, Albertinen-Krankenhaus, Hamburg, Germany
,
Ann-Kathrin Ozga
2   Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
,
Michael Klusmeier
3   Department for Cardiology, Albertinen-Krankenhaus, Hamburg, Germany
,
Mathias Hillebrand
3   Department for Cardiology, Albertinen-Krankenhaus, Hamburg, Germany
,
Aysun Tulun
1   Department for Cardiac Surgery, Albertinen-Krankenhaus, Hamburg, Germany
,
Nora Pannek
1   Department for Cardiac Surgery, Albertinen-Krankenhaus, Hamburg, Germany
,
Friedrich-Christian Rieß
1   Department for Cardiac Surgery, Albertinen-Krankenhaus, Hamburg, Germany
› Author Affiliations
Funding None.

Abstract

Background Treatment of severe necrotizing aortic root endocarditis (SNARE) carries a substantial perioperative risk. As an alternative to homografts, we assessed short-term outcome and future prognosis in patients undergoing root replacement using the Freestyle valve.

Methods Between 2000 and 2018, a total of 45 patients (mean age 70.9 ± 8.3 years, 66% men) underwent aortic root replacement for SNARE using the Freestyle valve. Mean Society of Thoracic Surgeons mortality score and EuroScore II were 22.6% ± 17.1 and 29.3% ± 20.9, respectively. Prosthetic endocarditis was present in 70.1%, and aortic annulus patch repair was performed in 64% of the patients. Median follow-up was 3.6 years (range: 0.1–14.5) and was 100% complete.

Results The 30-day mortality was 15.5%. During follow-up, there were no reoperations, while reinfection was suspected in one patient. Survival was significantly inferior to the general population with a standardized mortality ratio of 10.7 (95% confidence interval [CI]: 9.1–12.6) (p < 0.0001). In 30-day survivors and after correction for significant comorbidities in a Cox proportional hazards model, estimated survival probabilities at 1, 5, and 10 years were 98.7 (95% CI: 92.5–99.8%), 94.1 (77.9–98.5%), and 63.8 (28.4–85.2%). Estimated mean difference in survival probability was better for the general population after postoperative year 6, but within the 95% CI for no difference.

Conclusion Use of the Freestyle valve is reliable solution for the most complex cases with a low rate of reinfection. Early mortality is substantial and caused by the patient's condition and severity of the infection. Excess late mortality can be attributed to patient-specific comorbidities.



Publication History

Received: 18 August 2020

Accepted: 03 November 2020

Article published online:
29 March 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 David TE, Gavra G, Feindel CM, Regesta T, Armstrong S, Maganti MD. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc Surg 2007; 133 (01) 144-149
  • 2 Anguera I, Miro JM, Cabell CH. et al; ICE-MD investigators. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol 2005; 96 (07) 976-981
  • 3 Fayad G, Vincentelli A, Leroy G. et al. Impact of antimicrobial therapy on prognosis of patients requiring valve surgery during active infective endocarditis. J Thorac Cardiovasc Surg 2014; 147 (01) 254-258
  • 4 Schneider AW, Hazekamp MG, Versteegh MIM. et al. Stentless bioprostheses: a versatile and durable solution in extensive aortic valve endocarditis. Eur J Cardiothorac Surg 2016; 49 (06) 1699-1704
  • 5 Jassar AS, Bavaria JE, Szeto WY. et al. Graft selection for aortic root replacement in complex active endocarditis: does it matter?. Ann Thorac Surg 2012; 93 (02) 480-487
  • 6 Leontyev S, Davierwala PM, Krögh G. et al. Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses. Eur J Cardiothorac Surg 2016; 49 (02) 447-454 , discussion 454–455
  • 7 Heinz A, Dumfarth J, Ruttmann-Ulmer E, Grimm M, Müller LC. Freestyle root replacement for complex destructive aortic valve endocarditis. J Thorac Cardiovasc Surg 2014; 147 (04) 1265-1270
  • 8 Perrotta S, Aljassim O, Jeppsson A, Bech-Hanssen O, Svensson G. Survival and quality of life after aortic root replacement with homografts in acute endocarditis. Ann Thorac Surg 2010; 90 (06) 1862-1867
  • 9 Yankah AC, Pasic M, Klose H, Siniawski H, Weng Y, Hetzer R. Homograft reconstruction of the aortic root for endocarditis with periannular abscess: a 17-year study. Eur J Cardiothorac Surg 2005; 28 (01) 69-75
  • 10 Sabik JF, Lytle BW, Blackstone EH, Marullo AG, Pettersson GB, Cosgrove DM. Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis. Ann Thorac Surg 2002; 74 (03) 650-659 , discussion 659
  • 11 Miceli A, Croccia M, Simeoni S. et al. Root replacement with stentless Freestyle bioprostheses for active endocarditis: a single centre experience. Interact Cardiovasc Thorac Surg 2013; 16 (01) 27-30
  • 12 Müller LC, Chevtchik O, Bonatti JO, Müller S, Fille M, Laufer G. Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis. Ann Thorac Surg 2003; 75 (02) 453-456
  • 13 Habib G, Lancellotti P, Antunes MJ. et al; ESC Scientific Document Group. 2015 ESC Guidelines for the management of infective endocarditis. Eur Heart J 2015; 36 (44) 3075-3128
  • 14 El-Hamamsy I, Clark L, Stevens LM. et al. Late outcomes following freestyle versus homograft aortic root replacement: results from a prospective randomized trial. J Am Coll Cardiol 2010; 55 (04) 368-376
  • 15 Durack DT, Lukes AS, Bright DK. Duke Endocarditis Service. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Am J Med 1994; 96 (03) 200-209
  • 16 Akins CW, Miller DC, Turina MI. et al; Councils of the American Association for Thoracic Surgery, Society of Thoracic Surgeons, European Assoication for Cardio-Thoracic Surgery, Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity. Guidelines for reporting mortality and morbidity after cardiac valve interventions. J Thorac Cardiovasc Surg 2008; 135 (04) 732-738
  • 17 Finkelstein DM, Muzikansky A, Schoenfeld DA. Comparing survival of a sample to that of a standard population. J Natl Cancer Inst 2003; 95 (19) 1434-1439
  • 18 R Core Team. A Language and Environment for Statistical Computing (Version 3.5.1). http://www.R-project.org/ . Accessed Nov 23, 2020
  • 19 Pettersson GB, Coselli JS, Pettersson GB. et al; AATS Surgical Treatment of Infective Endocarditis Consensus Guidelines Writing Committee Chairs, Writing Committee. 2016 The American Association for Thoracic Surgery (AATS) consensus guidelines: surgical treatment of infective endocarditis: Executive summary. J Thorac Cardiovasc Surg 2017; 153 (06) 1241-1258.e29
  • 20 Byrne JG, Rezai K, Sanchez JA. et al. Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline. Ann Thorac Surg 2011; 91 (06) 2012-2019
  • 21 Mokhles MM, Ciampichetti I, Head SJ, Takkenberg JJ, Bogers AJ. Survival of surgically treated infective endocarditis: a comparison with the general Dutch population. Ann Thorac Surg 2011; 91 (05) 1407-1412