title: Homograft use in reoperative aortic root and proximal aortic surgery for endocarditis: A 12-year experience in high-risk patients.
abstract: OBJECTIVE
  We examined the early and midterm outcomes of homograft use in reoperative aortic root and proximal aortic surgery for endocarditis and estimated the associated risk of postoperative reinfection.
  
  
  METHODS
  From January 2001 to January 2014, 355 consecutive patients underwent reoperation of the proximal thoracic aorta. Thirty-nine patients (10.9%; mean age, 55.4 ± 13.3 years) presented with active endocarditis; 30 (76.9%) had prosthetic aortic root infection with or without concomitant ascending and arch graft infection, and 9 (23.1%) had proximal ascending aortic graft infection with or without aortic valve involvement. Sixteen patients (41.0%) had genetically triggered thoracic aortic disease. Twelve patients (30.8%) had more than 1 prior sternotomy (mean, 2.4 ± 0.6).
  
  
  RESULTS
  Valved homografts were used to replace the aortic root in 29 patients (74.4%); nonvalved homografts were used to replace the ascending aorta in 10 patients (25.6%). Twenty-five patients (64.1%) required concomitant proximal arch replacement with a homograft, and 2 patients (5.1%) required a total arch homograft. Median cardiopulmonary bypass, cardiac ischemia, and circulatory arrest times were 186 (137-253) minutes, 113 (59-151) minutes, and 28 (16-81) minutes. Operative mortality was 10.3% (n = 4). The rate of permanent stroke was 2.6% (n = 1); 3 additional patients had transient neurologic events. One patient (1/35, 2.9%) returned with aortic valve stenosis 10 years after the homograft operation. During the follow-up period (median, 2.5 years; range, 1 month to 12.3 years), no reinfection was reported, and survival was 65.7%.
  
  
  CONCLUSIONS
  This is one of the largest North American single-center series of homograft use in reoperations on the proximal thoracic aorta to treat active endocarditis. In this high-risk population, homograft tissue can be used with acceptable early and midterm survival and a low risk of reinfection. When necessary, homograft tissue may be extended into the distal ascending and transverse aortic arch, with excellent results. These patients require long-term surveillance for both infection and implant durability.
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex. Electronic address: opsmile01@aol.com.
authors.forename: Ourania
authors.initials: O
authors.lastname: Preventza
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
authors.forename: Ahmed S
authors.initials: AS
authors.lastname: Mohamed
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
authors.forename: Denton A
authors.initials: DA
authors.lastname: Cooley
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
authors.forename: Victor
authors.initials: V
authors.lastname: Rodriguez
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
authors.forename: Faisal G
authors.initials: FG
authors.lastname: Bakaeen
authors.affiliation: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
authors.forename: Lorraine D
authors.initials: LD
authors.lastname: Cornwell
authors.affiliation: Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
authors.forename: Shuab
authors.initials: S
authors.lastname: Omer
authors.affiliation: Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Coselli
mesh_terms: D000328:Adult; D000368:Aged; D064591:Allografts; D001013:Aorta, Thoracic / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D003646:Debridement; D020878:Device Removal; D004696:Endocarditis / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013781:Texas; D013997:Time Factors; D016896:Treatment Outcome