title: Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated?
abstract: BACKGROUND
  The use of prosthetic material (rather than a homograft) for ascending aorta/aortic valve replacement (Bentall procedure) in cases of acute prosthetic valve endocarditis is controversial. We report favorable results using this technique almost exclusively (a homograft was used in only 3 patients with hematological problems) during a 12-year interval.
  
  
  METHODS
  Twenty-eight patients (55 +/- 14 years; 22 male) underwent a Bentall procedure for acute prosthetic valve endocarditis between 1988 and 2000. Twenty-five patients had undergone previous aortic valve replacement (1 with concomitant mitral valve replacement, 4 with coronary artery bypass grafting), and 3 had had a previous Bentall operation. The median interval between initial surgery and reoperation was 13 months (range, 1 to 106). Sixty-eight percent of operations were urgent or emergencies. Ninety-three percent of patients had significant aortic regurgitation; complete annuloaortic dehiscence occurred in 71%, and in 57%, an abscess was found. Causative organisms were identified in 25 of 28 patients: Staphylococcus epidermidis (9), Staphylococcus aureus (7), Streptococcus viridans (6), Pseudomonas (2), and Legionella (1).
  
  
  RESULTS
  Twenty-three patients had mechanical and 5 had biological valves implanted during the Bentall procedure. Hypothermic circulatory arrest was used in 64%. Hospital mortality was 11%: there was one intraoperative death, and two before discharge (one cardiac, one sepsis). Eighty-nine percent survived without stroke. During follow-up (median, 44.5 months; complete in 92%), 1 patient died of recurrent endocarditis at 4 months.
  
  
  CONCLUSIONS
  These results indicate that prosthetic root replacement may be superior to use of a homograft for acute aortic prosthetic valve endocarditis, with only a 4% incidence of recurrent endocarditis and reoperation.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York, USA. chagl@hotmail.com
authors.forename: Christian
authors.initials: C
authors.lastname: Hagl
authors.forename: Jan D
authors.initials: JD
authors.lastname: Galla
authors.forename: Steven L
authors.initials: SL
authors.lastname: Lansman
authors.forename: Daniel
authors.initials: D
authors.lastname: Fink
authors.forename: Carol A
authors.initials: CA
authors.lastname: Bodian
authors.forename: David
authors.initials: D
authors.lastname: Spielvogel
authors.forename: Randall B
authors.initials: RB
authors.lastname: Griepp
mesh_terms: D000328:Adult; D000368:Aged; D001011:Aorta / Q000637:transplantation*; D001021:Aortic Valve / Q000637:transplantation*; D001705:Bioprosthesis; D001807:Blood Vessel Prosthesis; D002423:Cause of Death; D000075202:Contraindications; D004697:Endocarditis, Bacterial / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000401:mortality / Q000601:surgery*; D012086:Reoperation / Q000379:methods / Q000401:mortality; D015996:Survival Rate; D014184:Transplantation, Homologous