- Email: [email protected]
Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement
Ross Operation for Active Culture-Positive Aortic Valve Endocarditis With Extensive Paravalvular Involvement Alain Prat, MD, Jose I. Saez de Ibarra, MD, Andre Vincentelli, MD, Christophe Decoene, MD, Olivier H. Fabre, MD, Bruno Jegou, MD, and Christine Savoye, MD Departments of Cardiac Surgery, Anesthesiology, and Echography, Cardiologic Hospital, University of Lille, Lille, France
Background. We evaluated the midterm results of the Ross operation in active advanced endocarditis. Methods. Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n ⴝ 5), hemodynamic deterioration (n ⴝ 3), or both (n ⴝ 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered
an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. Results. There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). Conclusions. The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.
T
All procedures were performed by a single surgeon (AP). In this cohort 11 patients had active extensive aortic valve endocarditis. In all of these the following Stanford’s criteria were fulfilled: clinical features of active infection; positive preoperative blood cultures; intraoperative findings of active infection; proof of infection in the excised material by tissue examination or culture. The patients ranged in age from 26 to 45 years (median age, 33 years). Nine of the 11 patients were men. Body surface area ranged from 1.45 to 1.97 m2 (median, 1.80 m2). Five patients had a bicuspid aortic valve. One patient was known to have an aortic regurgitation before infection. Etiology of endocarditis was established in 9 patients: dental procedures in 5, intravenous drug abuse in 3, and infected hysterotomy after a cesarean delivery in 1. Isolated aortic root disease was present in 8 patients, aortic and mitral valve infection in 2, and aortic and tricuspid valve infection in 1 patient. There was one case of prosthetic aortic valve endocarditis occurring 10 years after aortic valve replacement. Indications for operation were uncontrolled infection in 5 patients (46%), hemodynamic deterioration in 3 (27%), or both in 3 patients (27%). Four patients were in the New York Heart Association class III (36%), 6 were in class IV (54%), and 1 was operated on while in cardiogenic shock (10%). The operation was urgent in 10 patients and emergent in 1 patient. Six patients (54%) had had systemic emboli before the operation. Four of them suffered an embolic cerebrovas-
reatment of endocarditis with extensive aortic root involvement remains a challenge. In this difficult issue, timing for operation is an important determinant of early and late results. Therefore, it is important to consider surgical intervention in all patients with valve endocarditis who develop signs of valve dysfunction and heart failure, persistent sepsis, large vegetation, and recurrent emboli. Operation is mandatory in case of aortic root abscesses. The Ross procedure was introduced in our Department in March 1992 and has since been offered to children and young adults (⬍ 45 years) candidates for aortic valve replacement [1, 2]. As of June 1994, encouraged by the results obtained in elective operations, we adopted this procedure in urgent cases of active aortic endocarditis with extensive paravalvular destruction. This report summarizes our experience with the Ross procedure in this group of patients.
Material and Methods Patient Characteristics Between March 1992 and June 2000, a Ross operation was performed at our institution on 150 consecutive patients. Accepted for publication June 20, 2001. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire de Lille, Blvd du Pr J. Leclercq, 59037 Lille Cedex, France; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 2001;72:1492– 6) © 2001 by The Society of Thoracic Surgeons
0003-4975/01/$20.00 PII S0003-4975(01)03020-X
Ann Thorac Surg 2001;72:1492– 6
cular accident without hemorrhage diagnosed by a screening computerized tomographic scan. The median interval from a neurologic event and the cardiac operation was 13 days. Two patients had a peripheral systemic emboli (spleen ⫽ 1, posterior tibial artery ⫽ 1). The causative organisms were identified in all of the patients. The predominant organisms were streptococcal and staphylococcal species: Staphylococcus aureus (n ⫽ 5), Staphylococcus epidermidis (n ⫽ 1), Streptococcus viridans (n ⫽ 2), Streptococcus sanguis (n ⫽ 1), Enterococcus faecalis (n ⫽ 1), and Acynetobacter sp. (n ⫽ 1). The duration of the preoperative antibiotic therapy ranged from 2 to 56 days (median, 16 days). All of the patients had positive blood cultures and 8 had positive tissue cultures.
Preoperative Evaluation Preoperative transesophageal echocardiography was performed in all patients. A grade IV aortic insufficiency was found in all patients. Moreover, paravalvular lesions were also detected in all of the patients. A moderate to severe mitral valve insufficiency was found in 2 patients, and severe tricuspid valve insufficiency in 1 patient. Anatomic details will be disclosed in the following paragraph. The left ventricular ejection fraction was more than 50% in 7 patients, between 30 and 50% in 3 patients, and less than 30% in 1 patient. The median left ventricular end-diastolic diameter was 65 mm, ranging from 60 mm to 75 mm.
Operative Findings Intraoperative findings correlated closely with those of preoperative transesophageal echocardiography, consisting in annular abscesses (n ⫽ 5), aorticomitral junction abscesses (n ⫽ 4), septal perforation (n ⫽ 1), infective vegetations (n ⫽ 9), cusps perforations or destructions (n ⫽ 3), aortic sinus wall abscesses (n ⫽ 2), and aorta– right atrium fistula (n ⫽ 1). In addition to the aortic valve, the endocarditis affected the anterior leaflet of the mitral valve in 2 patients (prolapse consecutive to ruptured chordae in 1 patient, leaflet perforation in 1 patient). The tricuspid valve leaflets and chordae tendinae were extensively damaged in 1 patient.
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between aortic and autograft annulus was found, the proximal suture line was reinforced with a strip of autologous glutaraldehyde-tanned pericardium (2 patients); the use of Teflon felt was prohibited. No aortic annulus enlargement procedure was needed in this group of patients. Total aortic root replacement with a pulmonary autograft was the method of implantation performed in all patients. The right ventricle outflow tract was reconstructed with a cryopreserved pulmonary homograft conduit in 8 patients. Homografts were supplied by the European Homograft Bank of Brussels (Belgium). Pulmonary homograft sizes ranged from 24 mm to 26 mm (median, 25 mm). In 3 patients the right ventricle outflow tract was reconstructed with a 27-mm or 29-mm Freestyle stentless bioprosthesis, because homografts were not available at the time of operation. Additional significant surgical procedures were performed in 4 patients. A mitral valve repair was performed in 2 patients: transposition of chordae from the posterior to the anterior leaflet in one and repair of the anterior leaflet with an autologous pericardial patch in the other patient. A cryopreserved mitral homograft was used to replace totally the tricuspid valve and a pericardial patch to close a fistula between aorta noncoronary sinus and right atrium in 1 patient. An autologous pericardial patch was required for closure of a ventricular septal defect in another patient. The cross-clamp time ranged from 93 to 166 minutes (median, 127 minutes) and the cardiopulmonary bypass time from 111 to 189 minutes (median, 156 minutes).
Follow-up Follow-up was complete in 100% of patients. All the patients were examined at our institution between May 2000 and August 2000. The cumulative follow-up period was 458 months with a minimum of 9 months and a maximum of 72 months (median, 40 months). Postoperative Doppler-echocardiography within 2 weeks of operation and prospective serial evaluations at 6 and 12 months and then at yearly intervals were obtained in 100% of patients.
Surgical Procedures Operative techniques for the Ross operation have been previously described in detail [1, 2]. In the context of septic surgical field we followed some specific principles: periannular abscesses were thoroughly debrided and necrotic tissue was excised down to healthy tissue; proximal suture line of the pulmonary autograft was performed with evenly distributed interrupted braided sutures at the level of the aortic annulus, crossing the anterior leaflet of the mitral valve and the membranous septum, or at the level of the lower border of the cleansed cavities. In cases of large tissue loss, autologous glutaraldehyde-tanned pericardial patches were used to close the defect and to ensure secure attachment of the autograft and respect the horizontal plane of the proximal suture line. When a discrepancy in excess of 5 mm
Results Mortality and Morbidity There was no intraoperative or in-hospital death. One patient with a low cardiac output was treated with inotropic drugs. Chest tube losses in the first 24 hours ranged from 200 to 860 mL (median, 340 mL). Eight of the 11 patients did not receive transfusion or blood products during hospitalization. There was no neurologic status impairment after operation. Antibiotic therapy was continued for 3 to 6 weeks after operation. Duration of antibiotic treatment was determined by the nature of the causative organism, the operative findings, and the clinical response.
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Late Follow-up There was no late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period. There were no thromboembolic events, no repeat operation for autograft or homograft failure, or any other valve-related complications. All the patients are now in New York Heart Association class I.
Postoperative Echocardiographic Evaluation The first postoperative evaluation of the pulmonary autograft showed either no incompetence or a trace in 10 patients, and a grade 1 incompetence in 2 patients. Homograft evaluation showed a mean gradient of less than 10 mm Hg in every patient. At the most recent follow-up, no patient had an aortic insufficiency more than grade 1. Similarly, there was a slight, but not significant, increase of the pulmonary mean gradient (3.9 ⫾ 3.2 mm Hg versus 10.5 ⫾ 6.7 mm Hg). Postoperative echocardiography was unremarkable in the 3 patients who underwent concomitant mitral and tricuspid valve repairs, and revealed the absence of residual mitral regurgitation and a grade 1-4 tricuspid regurgitation.
Comment Endocarditis limited to the aortic valve leaflets is not difficult to deal with and would have an excellent outcome with any current prosthetic device. On the other hand, management of extensive aortic valve endocarditis remains a challenge. Debridement and radical removal of infected and necrotic tissue is mandatory to eradicate the infection. Numerous operative techniques have been reported to achieve secure aortic root and left ventricular outflow tract reconstruction and a lower rate of subsequent infection. In severe forms of paravalvular destruction the treatment is usually aortic root replacement with either a composite graft [3, 4] or an homograft [5, 6]. d’Udekem and colleagues [7] published their results on radical excision of infected tissues and repair of tissue loss with autologous pericardium and prosthetic valve replacement, with an absence of recurrence at 10 years of 79.9%. In 1992, Haydock and associates [8] highlighted the superiority of aortic homografts over biological or mechanical prostheses for the treatment of acute endocarditis. In 108 patients (79 homografts and 29 prostheses), the absence of recurrence of infection at 1, 5, and 15 years was 98%, 90%, 72%, respectively, for the homografts, and 87%, 85%, 24% for the prostheses. Subsequently, in many institutions, aortic root replacement with an aortic homograft has now become the treatment of choice for extensive aortic endocarditis [5] with an overall incidence of recurrent of endocarditis ranging from 0% to 10%. In our Department cryopreserved homografts have been used in patients with annular abscesses as well [9]. As of
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June 1994, in patients aged less than 45 years, the treatment of choice for active endocarditis with paravalvular involvement has been pulmonary autograft aortic root replacement. Aortic homografts are still implanted in older patients. Recently, with the Ross procedure in this difficult issue, impressive results have been published. Oswalt [10] reported no mortality and no recurrent infection in 20 patients for up to 3.5 years and Pettersson and colleagues [11] reported a 5% mortality and no reinfection in 35 patients for up to 56 months. However, in these series, active and healed endocarditis were not clearly individualized. In our series, including only patients with advanced disease, we had no mortality and no recurrent endocarditis with a median follow-up of 3 years. Despite its outstanding results, the Ross operation remains controversial and is used infrequently in aortic valve endocarditis. In our series of Ross procedures, the only method used for placing the pulmonary autograft in the aortic position was total aortic root replacement [2]. This procedure is particularly well suited for left ventricular outflow tract reconstruction after extensive debridement of infected and necrotic perivalvular tissue in active endocarditis, and necessary in the vast majority of patients with advanced aortic endocarditis [12]. The advantages of the pulmonary autograft have been clearly established: resistance to infection, virtual absence of thromboembolism, long-term durability superior to any other tissue valve, and excellent hemodynamic performance [2, 12, 13]. Nevertheless, criticism of the Ross operation is often made. This technique constitutes a double valve replacement for a single valve disease, requires longer crossclamp times, and similar results can be achieved with the use of an aortic homograft. We believe that these drawbacks are more than offset by the advantage of implanting a fully viable valve. Furthermore, we did not experience problems in weaning the patients off bypass with current myocardial protection techniques. In young patients the goal of surgical treatment is to achieve good results not only in the short but also in the long term. Aortic root replacement with an aortic homograft carries the risk of difficult reoperation due to homograft aortic wall calcification. Furthermore, in our tissue bank, there is a relative abundance of pulmonary homografts in larger sizes that we use for our patients, and on the contrary a lack of available of aortic homografts. Traditionally a cryopreserved pulmonary homograft is used as a pulmonary replacement device for the Ross operation. Because of the urgent or emergent condition, and exclusively when no pulmonary or aortic homograft was available in the tissue bank, we used a stentless porcine bioprosthesis (Freestyle, Medtronic Inc, Minneapolis, MN). We are fully aware of the potential risk of prosthetic valve infection in the right ventricle outflow tract, but we think that this risk is probably very low and we never experienced this problem. Konertz and colleagues [14] reported good short-term results (median follow-up, 12 months) in 9 adult patients with the same device.
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In patients with mitral or tricuspid valve involvement, all attempts should be made to achieve valve repair. Should a valve replacement become necessary, then a mitral homograft would be the best substitute to obtain freedom from long-term anticoagulation therapy in all patients [15]. Although a limited number of patients were treated in the present study, we are encouraged by the absence of mortality and recurrence of infection. In the light of our results, we would recommend this operation for extensive active aortic root endocarditis in children and young adults. It should nevertheless be emphasized that, due to its relative complexity, the Ross operation should only be undertaken, particularly in emergency cases, if the surgical team is experienced with this procedure in elective cases.
References 1. Prat AG, Doisy VC, Savoye C, Moreau DC, Monier EJ, Stankowiak C. Total aortic root replacement with pulmonary autografts:short-term results in 45 consecutive patients. J Heart Valve Dis 1995;4:368–73. 2. Prat A, Grandmougin D, Decoene C, et al. Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients. Ann Thorac Surg 1998; 66:S148 –52. 3. Watanabe G, Haverich A, Speier R, Dresler C, Borst HG. Surgical treatment of active infective endocarditis with paravalvular involvement. J Thorac Cardiovasc Surg 1994;107: 171–7. 4. David TE. Surgical management of aortic root abscess. J Card Surg 1997;12:S262– 6.
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5. Dearani JA, Orszulak TA, Schaff HV, Daly RC, Anderson BJ, Danielson GK. Results of allograft aortic valve replacement for complex endocarditis. J Thorac Cardiovasc Surg 1997;113: 285–91. 6. Dossche KM, de la Riviere AB, Morshuis WJ, Schepens MA, Defauw JJ, Ernst SM. Cryopreserved aortic allografts for aortic root reconstruction:a single institution’s experience. Ann Thorac Surg 1999;67:1617–22. 7. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of surgery for active infective endocarditis. Eur J Cardiothorac Surg 1997;11:46–52. 8. Haydock D, Barratt-Boyes B, Macedo T, Kirklin JW, Blackstone E. Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg 1992;103:130–9. 9. Grandmougin D, Prat A, Fayad G, Decoene C, Pol A, Warembourg H. Acute aortic endocarditis with annular destruction: assessment of surgical treatment with cryopreserved valvular homografts. J Heart Valve Dis 1999;8:234– 41. 10. Oswalt J. Management of aortic infective endocarditis by autograft valve replacement. J Heart Valve Dis 1994;3:377–9. 11. Pettersson G, Tingleff J, Joyce F. Treatment of aortic valve endocarditis with the Ross operation. Eur J Cardiothorac Surg 1998;13:678– 84. 12. Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandrasekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603– 8. 13. Prat A, Saez de Ibarra J, Vincentelli A, Decoene C, Savoye C, Goffin Y. Late autograft and homograft endocarditis after the Ross operation. J Thorac Cardiovasc Surg 1998;115:1388–9. 14. Konertz W, Sidiropoulos A, Hotz H, Borges A, Baumann G. Ross operation and right ventricular outflow tract reconstruction with stentless xenografts. J Heart Valve Dis 1996;5: 418–20. 15. Prat A, Fabre OH, Vincentelli A, Doisy V, Shaaban G. Ross operation and mitral homograft for aortic and tricuspid valve endocarditis. Ann Thorac Surg 1998;65:1450–2.
INVITED COMMENTARY Doctor Prat and his associates present a small series of 11 patients with complex aortic root endocarditis with paravalvular involvement who were successfully treated with a pulmonary autograft (Ross Procedure). All patients were very ill at the time of surgery, either due to sepsis or to hemodynamic compromise. In fact, one patient was in cardiogenic shock. There were no deaths and surprisingly little perioperative morbidity. Recurrent endocarditis had not occurred in any of these patients during the median follow up of 40 months. This is clearly an outstanding series. The authors are to be congratulated for their ability to manage this challenging and complex group of patients with an equally challenging and complex operation with such excellent results. Notwithstanding my praise for these superb results I cannot support the authors conclusion that “The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis”. The Ross operation may be excellent for young individuals requiring aortic valve replacement surgery. A number of reports suggest superior long-term results of © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
the Ross operation compared to any other aortic valve replacement procedure. Yet, even in the hands of highly skilled surgeons, the Ross operation is difficult and time consuming. It is also, according to the Ross Registry, associated with a higher perioperative mortality and morbidity compared to conventional isolated aortic valve replacement [1]. Only skilled surgeons who have performed a large number of these procedures are able to do so with acceptably low mortality and morbidity. Finally, and perhaps the greatest concern of the Ross Operation, is that a patient who comes to hospital with single valve disease leaves with the potential for double valve disease. Despite these drawbacks the advantages of the Ross operation may outweigh its disadvantages in highly selected patients. Should a patient, even a young one, with complex aortic root endocarditis of the type described by Prat undergo a Ross procedure? I believe they should not and wonder why a surgeon would expose such a patient, who already faces substantial risks of radical aortic root surgery, to even further risk of a Ross procedure? Almost all 0003-4975/01/$20.00 PII S0003-4975(01)03124-1
Background. We evaluated the midterm results of the Ross operation in active advanced endocarditis. Methods. Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n ⴝ 5), hemodynamic deterioration (n ⴝ 3), or both (n ⴝ 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered
an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. Results. There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). Conclusions. The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.
T
All procedures were performed by a single surgeon (AP). In this cohort 11 patients had active extensive aortic valve endocarditis. In all of these the following Stanford’s criteria were fulfilled: clinical features of active infection; positive preoperative blood cultures; intraoperative findings of active infection; proof of infection in the excised material by tissue examination or culture. The patients ranged in age from 26 to 45 years (median age, 33 years). Nine of the 11 patients were men. Body surface area ranged from 1.45 to 1.97 m2 (median, 1.80 m2). Five patients had a bicuspid aortic valve. One patient was known to have an aortic regurgitation before infection. Etiology of endocarditis was established in 9 patients: dental procedures in 5, intravenous drug abuse in 3, and infected hysterotomy after a cesarean delivery in 1. Isolated aortic root disease was present in 8 patients, aortic and mitral valve infection in 2, and aortic and tricuspid valve infection in 1 patient. There was one case of prosthetic aortic valve endocarditis occurring 10 years after aortic valve replacement. Indications for operation were uncontrolled infection in 5 patients (46%), hemodynamic deterioration in 3 (27%), or both in 3 patients (27%). Four patients were in the New York Heart Association class III (36%), 6 were in class IV (54%), and 1 was operated on while in cardiogenic shock (10%). The operation was urgent in 10 patients and emergent in 1 patient. Six patients (54%) had had systemic emboli before the operation. Four of them suffered an embolic cerebrovas-
reatment of endocarditis with extensive aortic root involvement remains a challenge. In this difficult issue, timing for operation is an important determinant of early and late results. Therefore, it is important to consider surgical intervention in all patients with valve endocarditis who develop signs of valve dysfunction and heart failure, persistent sepsis, large vegetation, and recurrent emboli. Operation is mandatory in case of aortic root abscesses. The Ross procedure was introduced in our Department in March 1992 and has since been offered to children and young adults (⬍ 45 years) candidates for aortic valve replacement [1, 2]. As of June 1994, encouraged by the results obtained in elective operations, we adopted this procedure in urgent cases of active aortic endocarditis with extensive paravalvular destruction. This report summarizes our experience with the Ross procedure in this group of patients.
Material and Methods Patient Characteristics Between March 1992 and June 2000, a Ross operation was performed at our institution on 150 consecutive patients. Accepted for publication June 20, 2001. Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hoˆpital Cardiologique, Centre Hospitalier Regional Universitaire de Lille, Blvd du Pr J. Leclercq, 59037 Lille Cedex, France; e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 2001;72:1492– 6) © 2001 by The Society of Thoracic Surgeons
0003-4975/01/$20.00 PII S0003-4975(01)03020-X
Ann Thorac Surg 2001;72:1492– 6
cular accident without hemorrhage diagnosed by a screening computerized tomographic scan. The median interval from a neurologic event and the cardiac operation was 13 days. Two patients had a peripheral systemic emboli (spleen ⫽ 1, posterior tibial artery ⫽ 1). The causative organisms were identified in all of the patients. The predominant organisms were streptococcal and staphylococcal species: Staphylococcus aureus (n ⫽ 5), Staphylococcus epidermidis (n ⫽ 1), Streptococcus viridans (n ⫽ 2), Streptococcus sanguis (n ⫽ 1), Enterococcus faecalis (n ⫽ 1), and Acynetobacter sp. (n ⫽ 1). The duration of the preoperative antibiotic therapy ranged from 2 to 56 days (median, 16 days). All of the patients had positive blood cultures and 8 had positive tissue cultures.
Preoperative Evaluation Preoperative transesophageal echocardiography was performed in all patients. A grade IV aortic insufficiency was found in all patients. Moreover, paravalvular lesions were also detected in all of the patients. A moderate to severe mitral valve insufficiency was found in 2 patients, and severe tricuspid valve insufficiency in 1 patient. Anatomic details will be disclosed in the following paragraph. The left ventricular ejection fraction was more than 50% in 7 patients, between 30 and 50% in 3 patients, and less than 30% in 1 patient. The median left ventricular end-diastolic diameter was 65 mm, ranging from 60 mm to 75 mm.
Operative Findings Intraoperative findings correlated closely with those of preoperative transesophageal echocardiography, consisting in annular abscesses (n ⫽ 5), aorticomitral junction abscesses (n ⫽ 4), septal perforation (n ⫽ 1), infective vegetations (n ⫽ 9), cusps perforations or destructions (n ⫽ 3), aortic sinus wall abscesses (n ⫽ 2), and aorta– right atrium fistula (n ⫽ 1). In addition to the aortic valve, the endocarditis affected the anterior leaflet of the mitral valve in 2 patients (prolapse consecutive to ruptured chordae in 1 patient, leaflet perforation in 1 patient). The tricuspid valve leaflets and chordae tendinae were extensively damaged in 1 patient.
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between aortic and autograft annulus was found, the proximal suture line was reinforced with a strip of autologous glutaraldehyde-tanned pericardium (2 patients); the use of Teflon felt was prohibited. No aortic annulus enlargement procedure was needed in this group of patients. Total aortic root replacement with a pulmonary autograft was the method of implantation performed in all patients. The right ventricle outflow tract was reconstructed with a cryopreserved pulmonary homograft conduit in 8 patients. Homografts were supplied by the European Homograft Bank of Brussels (Belgium). Pulmonary homograft sizes ranged from 24 mm to 26 mm (median, 25 mm). In 3 patients the right ventricle outflow tract was reconstructed with a 27-mm or 29-mm Freestyle stentless bioprosthesis, because homografts were not available at the time of operation. Additional significant surgical procedures were performed in 4 patients. A mitral valve repair was performed in 2 patients: transposition of chordae from the posterior to the anterior leaflet in one and repair of the anterior leaflet with an autologous pericardial patch in the other patient. A cryopreserved mitral homograft was used to replace totally the tricuspid valve and a pericardial patch to close a fistula between aorta noncoronary sinus and right atrium in 1 patient. An autologous pericardial patch was required for closure of a ventricular septal defect in another patient. The cross-clamp time ranged from 93 to 166 minutes (median, 127 minutes) and the cardiopulmonary bypass time from 111 to 189 minutes (median, 156 minutes).
Follow-up Follow-up was complete in 100% of patients. All the patients were examined at our institution between May 2000 and August 2000. The cumulative follow-up period was 458 months with a minimum of 9 months and a maximum of 72 months (median, 40 months). Postoperative Doppler-echocardiography within 2 weeks of operation and prospective serial evaluations at 6 and 12 months and then at yearly intervals were obtained in 100% of patients.
Surgical Procedures Operative techniques for the Ross operation have been previously described in detail [1, 2]. In the context of septic surgical field we followed some specific principles: periannular abscesses were thoroughly debrided and necrotic tissue was excised down to healthy tissue; proximal suture line of the pulmonary autograft was performed with evenly distributed interrupted braided sutures at the level of the aortic annulus, crossing the anterior leaflet of the mitral valve and the membranous septum, or at the level of the lower border of the cleansed cavities. In cases of large tissue loss, autologous glutaraldehyde-tanned pericardial patches were used to close the defect and to ensure secure attachment of the autograft and respect the horizontal plane of the proximal suture line. When a discrepancy in excess of 5 mm
Results Mortality and Morbidity There was no intraoperative or in-hospital death. One patient with a low cardiac output was treated with inotropic drugs. Chest tube losses in the first 24 hours ranged from 200 to 860 mL (median, 340 mL). Eight of the 11 patients did not receive transfusion or blood products during hospitalization. There was no neurologic status impairment after operation. Antibiotic therapy was continued for 3 to 6 weeks after operation. Duration of antibiotic treatment was determined by the nature of the causative organism, the operative findings, and the clinical response.
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Late Follow-up There was no late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period. There were no thromboembolic events, no repeat operation for autograft or homograft failure, or any other valve-related complications. All the patients are now in New York Heart Association class I.
Postoperative Echocardiographic Evaluation The first postoperative evaluation of the pulmonary autograft showed either no incompetence or a trace in 10 patients, and a grade 1 incompetence in 2 patients. Homograft evaluation showed a mean gradient of less than 10 mm Hg in every patient. At the most recent follow-up, no patient had an aortic insufficiency more than grade 1. Similarly, there was a slight, but not significant, increase of the pulmonary mean gradient (3.9 ⫾ 3.2 mm Hg versus 10.5 ⫾ 6.7 mm Hg). Postoperative echocardiography was unremarkable in the 3 patients who underwent concomitant mitral and tricuspid valve repairs, and revealed the absence of residual mitral regurgitation and a grade 1-4 tricuspid regurgitation.
Comment Endocarditis limited to the aortic valve leaflets is not difficult to deal with and would have an excellent outcome with any current prosthetic device. On the other hand, management of extensive aortic valve endocarditis remains a challenge. Debridement and radical removal of infected and necrotic tissue is mandatory to eradicate the infection. Numerous operative techniques have been reported to achieve secure aortic root and left ventricular outflow tract reconstruction and a lower rate of subsequent infection. In severe forms of paravalvular destruction the treatment is usually aortic root replacement with either a composite graft [3, 4] or an homograft [5, 6]. d’Udekem and colleagues [7] published their results on radical excision of infected tissues and repair of tissue loss with autologous pericardium and prosthetic valve replacement, with an absence of recurrence at 10 years of 79.9%. In 1992, Haydock and associates [8] highlighted the superiority of aortic homografts over biological or mechanical prostheses for the treatment of acute endocarditis. In 108 patients (79 homografts and 29 prostheses), the absence of recurrence of infection at 1, 5, and 15 years was 98%, 90%, 72%, respectively, for the homografts, and 87%, 85%, 24% for the prostheses. Subsequently, in many institutions, aortic root replacement with an aortic homograft has now become the treatment of choice for extensive aortic endocarditis [5] with an overall incidence of recurrent of endocarditis ranging from 0% to 10%. In our Department cryopreserved homografts have been used in patients with annular abscesses as well [9]. As of
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June 1994, in patients aged less than 45 years, the treatment of choice for active endocarditis with paravalvular involvement has been pulmonary autograft aortic root replacement. Aortic homografts are still implanted in older patients. Recently, with the Ross procedure in this difficult issue, impressive results have been published. Oswalt [10] reported no mortality and no recurrent infection in 20 patients for up to 3.5 years and Pettersson and colleagues [11] reported a 5% mortality and no reinfection in 35 patients for up to 56 months. However, in these series, active and healed endocarditis were not clearly individualized. In our series, including only patients with advanced disease, we had no mortality and no recurrent endocarditis with a median follow-up of 3 years. Despite its outstanding results, the Ross operation remains controversial and is used infrequently in aortic valve endocarditis. In our series of Ross procedures, the only method used for placing the pulmonary autograft in the aortic position was total aortic root replacement [2]. This procedure is particularly well suited for left ventricular outflow tract reconstruction after extensive debridement of infected and necrotic perivalvular tissue in active endocarditis, and necessary in the vast majority of patients with advanced aortic endocarditis [12]. The advantages of the pulmonary autograft have been clearly established: resistance to infection, virtual absence of thromboembolism, long-term durability superior to any other tissue valve, and excellent hemodynamic performance [2, 12, 13]. Nevertheless, criticism of the Ross operation is often made. This technique constitutes a double valve replacement for a single valve disease, requires longer crossclamp times, and similar results can be achieved with the use of an aortic homograft. We believe that these drawbacks are more than offset by the advantage of implanting a fully viable valve. Furthermore, we did not experience problems in weaning the patients off bypass with current myocardial protection techniques. In young patients the goal of surgical treatment is to achieve good results not only in the short but also in the long term. Aortic root replacement with an aortic homograft carries the risk of difficult reoperation due to homograft aortic wall calcification. Furthermore, in our tissue bank, there is a relative abundance of pulmonary homografts in larger sizes that we use for our patients, and on the contrary a lack of available of aortic homografts. Traditionally a cryopreserved pulmonary homograft is used as a pulmonary replacement device for the Ross operation. Because of the urgent or emergent condition, and exclusively when no pulmonary or aortic homograft was available in the tissue bank, we used a stentless porcine bioprosthesis (Freestyle, Medtronic Inc, Minneapolis, MN). We are fully aware of the potential risk of prosthetic valve infection in the right ventricle outflow tract, but we think that this risk is probably very low and we never experienced this problem. Konertz and colleagues [14] reported good short-term results (median follow-up, 12 months) in 9 adult patients with the same device.
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In patients with mitral or tricuspid valve involvement, all attempts should be made to achieve valve repair. Should a valve replacement become necessary, then a mitral homograft would be the best substitute to obtain freedom from long-term anticoagulation therapy in all patients [15]. Although a limited number of patients were treated in the present study, we are encouraged by the absence of mortality and recurrence of infection. In the light of our results, we would recommend this operation for extensive active aortic root endocarditis in children and young adults. It should nevertheless be emphasized that, due to its relative complexity, the Ross operation should only be undertaken, particularly in emergency cases, if the surgical team is experienced with this procedure in elective cases.
References 1. Prat AG, Doisy VC, Savoye C, Moreau DC, Monier EJ, Stankowiak C. Total aortic root replacement with pulmonary autografts:short-term results in 45 consecutive patients. J Heart Valve Dis 1995;4:368–73. 2. Prat A, Grandmougin D, Decoene C, et al. Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients. Ann Thorac Surg 1998; 66:S148 –52. 3. Watanabe G, Haverich A, Speier R, Dresler C, Borst HG. Surgical treatment of active infective endocarditis with paravalvular involvement. J Thorac Cardiovasc Surg 1994;107: 171–7. 4. David TE. Surgical management of aortic root abscess. J Card Surg 1997;12:S262– 6.
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5. Dearani JA, Orszulak TA, Schaff HV, Daly RC, Anderson BJ, Danielson GK. Results of allograft aortic valve replacement for complex endocarditis. J Thorac Cardiovasc Surg 1997;113: 285–91. 6. Dossche KM, de la Riviere AB, Morshuis WJ, Schepens MA, Defauw JJ, Ernst SM. Cryopreserved aortic allografts for aortic root reconstruction:a single institution’s experience. Ann Thorac Surg 1999;67:1617–22. 7. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of surgery for active infective endocarditis. Eur J Cardiothorac Surg 1997;11:46–52. 8. Haydock D, Barratt-Boyes B, Macedo T, Kirklin JW, Blackstone E. Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses. J Thorac Cardiovasc Surg 1992;103:130–9. 9. Grandmougin D, Prat A, Fayad G, Decoene C, Pol A, Warembourg H. Acute aortic endocarditis with annular destruction: assessment of surgical treatment with cryopreserved valvular homografts. J Heart Valve Dis 1999;8:234– 41. 10. Oswalt J. Management of aortic infective endocarditis by autograft valve replacement. J Heart Valve Dis 1994;3:377–9. 11. Pettersson G, Tingleff J, Joyce F. Treatment of aortic valve endocarditis with the Ross operation. Eur J Cardiothorac Surg 1998;13:678– 84. 12. Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandrasekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603– 8. 13. Prat A, Saez de Ibarra J, Vincentelli A, Decoene C, Savoye C, Goffin Y. Late autograft and homograft endocarditis after the Ross operation. J Thorac Cardiovasc Surg 1998;115:1388–9. 14. Konertz W, Sidiropoulos A, Hotz H, Borges A, Baumann G. Ross operation and right ventricular outflow tract reconstruction with stentless xenografts. J Heart Valve Dis 1996;5: 418–20. 15. Prat A, Fabre OH, Vincentelli A, Doisy V, Shaaban G. Ross operation and mitral homograft for aortic and tricuspid valve endocarditis. Ann Thorac Surg 1998;65:1450–2.
INVITED COMMENTARY Doctor Prat and his associates present a small series of 11 patients with complex aortic root endocarditis with paravalvular involvement who were successfully treated with a pulmonary autograft (Ross Procedure). All patients were very ill at the time of surgery, either due to sepsis or to hemodynamic compromise. In fact, one patient was in cardiogenic shock. There were no deaths and surprisingly little perioperative morbidity. Recurrent endocarditis had not occurred in any of these patients during the median follow up of 40 months. This is clearly an outstanding series. The authors are to be congratulated for their ability to manage this challenging and complex group of patients with an equally challenging and complex operation with such excellent results. Notwithstanding my praise for these superb results I cannot support the authors conclusion that “The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis”. The Ross operation may be excellent for young individuals requiring aortic valve replacement surgery. A number of reports suggest superior long-term results of © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
the Ross operation compared to any other aortic valve replacement procedure. Yet, even in the hands of highly skilled surgeons, the Ross operation is difficult and time consuming. It is also, according to the Ross Registry, associated with a higher perioperative mortality and morbidity compared to conventional isolated aortic valve replacement [1]. Only skilled surgeons who have performed a large number of these procedures are able to do so with acceptably low mortality and morbidity. Finally, and perhaps the greatest concern of the Ross Operation, is that a patient who comes to hospital with single valve disease leaves with the potential for double valve disease. Despite these drawbacks the advantages of the Ross operation may outweigh its disadvantages in highly selected patients. Should a patient, even a young one, with complex aortic root endocarditis of the type described by Prat undergo a Ross procedure? I believe they should not and wonder why a surgeon would expose such a patient, who already faces substantial risks of radical aortic root surgery, to even further risk of a Ross procedure? Almost all 0003-4975/01/$20.00 PII S0003-4975(01)03124-1