Survival and Quality of Life After Aortic Root Replacement With Homografts in Acute Endocarditis

doi:10.1016/j.athoracsur.2010.06.100

The Annals of Thoracic Surgery

Volume 90, Issue 6, December 2010, Pages 1862-1867

https://doi.org/10.1016/j.athoracsur.2010.06.100 Get rights and content

Background

Treatment of prosthetic aortic valve endocarditis and native aortic valve endocarditis with abscess formation is associated with high mortality and morbidity. Aortic root replacement with a freestanding aortic homograft is an attractive alternative. We report outcome and quality of life after homograft replacement for infective endocarditis.

Methods

Sixty-two patients with infective prosthetic valve endocarditis (n = 31) or native valve endocarditis with abscess (n = 31), operated with homograft replacement were included. Thirty-day mortality, severe operative complications (dialysis, stroke, pacemaker implantation, myocardial infarction, and prolonged mechanical ventilation), midterm survival, reoperations, and quality of life were assessed after a mean follow-up of 37 ± 11 months.

Results

Nine patients (15%) died within 30 days and 22 patients (35%) had severe perioperative complications. Preoperative and perioperative variables univariately associated with early mortality were higher (Cleveland Clinic risk score [p = 0.014], extracorporeal circulation time [p = 0.003], prolonged inotropic support [p = 0.03], reoperation for bleeding [p = 0.01], and perioperative myocardial infarction [p < 0.001].) Cumulative survival was 82%, 78%, 75%, and 67% at one, three, five, and ten years, respectively. One patient was reoperated due to recurrence of endocarditis nine months after surgery and one after five years due to homograft failure. Quality of life, as assessed by the 36 item short-form health survey scales for physical and mental health, was not significantly different to an age-matched and gender-matched healthy control group.

Conclusions

Severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality. Long-term survival and quality of life are satisfactory in patients surviving the immediate postoperative period.

Section snippets

Patients

All patients (n = 62) operated with a cryopreserved homograft for active aortic PVE or aortic NVE with periannular aortic root abscess between January 1997 and June 2008 were included in the study. The regional research ethics committee waived informed consent for the study. Mean age was 57 ± 15 years (range, 19 to 80) and 48 patients (77%) were male. Thirty-one patients (50%) had PVE and 31 patients had NVE. Thirty-two (52%) of the patients had previously undergone one (n = 28), two (n = 3),

Mortality

Nine patients (15%) died during the first 30 postoperative days; six in the prosthetic endocarditis group and three in the native endocarditis group (p = 0.28). Seven patients died of multiorgan failure; five due to heart failure and two due to progressive sepsis. Two patients died from neurologic complications. Eight of the nine (89%) patients who died had a periannular abscess (Table 4). Four nonsurvivors had autopsies. None of the patients had any technical issues with the coronary artery

Comment

The main findings of the present study were the following: (1) severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality; and (2) long-term survival and quality of life are satisfactory in patients surviving the immediate postoperative period.

In the present study, 30-day mortality in the subset of patients with PVE was 19%, which is comparable or better than most reports on the subject [3, 4, 6, 7, 10] but

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Cited by (49)

Determinants of adherence to oral hygiene prophylaxis guidelines in patients with previous infective endocarditis
2023, Archives of Cardiovascular Diseases
Infective endocarditis (IE) is characterized by low incidence but high mortality. Patients with a history of IE are at highest risk. Adherence to prophylaxis recommendations is poor. We sought to identify determinants of adherence to oral hygiene guidelines on IE prophylaxis in patients with a history of IE.
Using data from the cross-sectional, single-centre POST-IMAGE study, we analysed demographic, medical and psychosocial factors. We defined patients as adherent to prophylaxis if they declared going to the dentist at least annually and brushing their teeth at least twice a day. Depression, cognitive status and quality of life were assessed using validated scales.
Of 100 patients enrolled, 98 completed the self-questionnaires. Among these, 40 (40.8%) were categorized as adherent to prophylaxis guidelines, and were less likely to be smokers (5.1% vs. 25.0%; P = 0.02) or have symptoms of depression (36.6% vs. 70.8%; P < 0.01) or cognitive decline (0% vs. 15.5%; P = 0.05). Conversely, they had higher rates of: valvular surgery since the index IE episode (17.5% vs. 3.4%; P = 0.04), searching for information on IE (61.1% vs. 46.3%, P = 0.05), and considering themselves as adherent to IE prophylaxis (58.3% vs. 32.1%; P = 0.03). Tooth brushing, dental visits and antibiotic prophylaxis were correctly identified as measures to prevent IE recurrence in 87.7%, 90.8% and 92.8% of patients, respectively, and did not differ according to adherence to oral hygiene guidelines.
Self-reported adherence to secondary oral hygiene guidelines on IE prophylaxis is low. Adherence is unrelated to most patient characteristics, but to depression and cognitive impairment. Poor adherence appears related more to a lack of implementation rather than insufficient knowledge. Assessment of depression may be considered in patients with IE.
Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes
2021, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Our 30-day mortality of 6.7% in the root abscess group is well below what has been recently reported. This mortality rate is also better than most reported in the literature for patients with and without root abscesses treated with homograft.10,13-15 Despite the increased complexity of the operation, the mortality rate in patients with a root abscess was only fractionally higher than in patients without an abscess.
To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically.
From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data.
Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%).
Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.
Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic
2019, Journal of Thoracic and Cardiovascular Surgery
To study mid-term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft.
Patients undergoing aortic root homograft replacement from 2011-2017 were studied retrospectively. Aortic root replacement was performed using a modified Bentall technique. Primary outcomes included both short-term and mid-term survival. Secondary outcomes included immediate postoperative complications.
A total of 138 patients underwent cryopreserved homograft replacement of the aortic root for aortic root abscesses. Eighty-five patients (61.6%) underwent reoperative sternotomy, and 12 patients (8.7%) underwent second or third reoperative sternotomy. Sixty-seven (48.5%) patients had severe aortic insufficiency preoperatively. Operative mortality was 12.3% (17 patients). Five patients (3.6%) sustained a permanent stroke. Twenty-one patients (15.2%) required dialysis for renal failure, and 21 patients (15.2%) had complete heart block necessitating a permanent pacemaker. Estimated 5-year mortality for the cohort was 43%.
Cryopreserved homograft replacement is a safe and desirable option for high-risk patients with infective endocarditis and aortic root abscess. Homograft accommodation for a widely debrided aortic annular bed provides a reasonable surgical strategy for patients needing aortic root replacement with annular abscess.
Stepping down from the ivory tower: Inviting the patient for mutual responsibility
2018, Journal of Thoracic and Cardiovascular Surgery
Cardiac surgery in patients with a porcelain aorta
2018, Journal of Thoracic and Cardiovascular Surgery
Return to the workforce following infective endocarditis—A nationwide cohort study
2018, American Heart Journal
Citation Excerpt :
Second, younger age and higher socioeconomic status were associated with a higher likelihood of returning to the workforce, whereas comorbidities, stroke during admission, longer length of hospital stay, and additional hospital admissions within a year postdischarge after IE were associated with a lower likelihood of returning to the workforce. Previous studies suggest that a substantial part of patients treated for IE may experience physical and cognitive difficulties such as fatigue, physical weakness, concentration difficulties, and memory loss, resulting in impaired health-related quality of life and poor self-perceived physical health postdischarge.3,24-28 Only a single questionnaire-based study has investigated employment status in 37 patients with IE and found that 65% were working 1 year after discharge.3
The ability to return to work after infective endocarditis (IE) holds important socioeconomic consequences for both patients and society, yet data on this issue are sparse. We examined return to the workforce and associated factors in IE patients of working age.
Using Danish nationwide registries, we identified 1,065 patients aged 18-60 years with a first-time diagnosis of IE (1996-2013) who were part of the workforce prior to admission and alive at discharge.
One year after discharge, 765 (71.8%) patients had returned to the workforce, 130 (12.2%) were on paid sick leave, 76 (7.1%) received disability pension, 23 (2.2%) were on early retirement, 65 (6.1%) had died, and 6 (0.6%) had emigrated. Factors associated with return to the workforce were identified using multivariable logistic regression. Younger age (18-40 vs 56-60 years; odds ratio, 2.85; 95% CI, 1.71-4.76) and higher level of education (higher educational level vs basic school; 5.47, 2.05-14.6) and income (highest quartile vs lowest; 3.17, 1.85-5.46) were associated with return to the workforce. Longer length of hospital stay (>90 vs 14-30 days; 0.16, 0.07-0.38); stroke during IE admission (0.38, 0.21-0.71); and a history of chronic kidney disease (0.29, 0.11-0.75), chronic obstructive pulmonary disease (0.31, 0.13-0.71), and malignancy (0.39, 0.22-0.69) were associated with a lower likelihood of returning to the workforce.
Seven of 10 patients who were part of the workforce prior to IE and alive at discharge were part of the workforce 1 year later. Younger age, higher socioeconomic status, and absence of major comorbidities were associated with return to the workforce.

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Original articleAdult cardiacSurvival and Quality of Life After Aortic Root Replacement With Homografts in Acute Endocarditis

Background

Methods

Results

Conclusions

Section snippets

Patients

Mortality

Comment

Prog Cardiovasc Dis

J Thorac Cardiovasc Surg

Am Heart J

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

Original article
Adult cardiac
Survival and Quality of Life After Aortic Root Replacement With Homografts in Acute Endocarditis