title: Stentless bioprostheses: a versatile and durable solution in extensive aortic valve endocarditis.
abstract: OBJECTIVE
  Infective endocarditis of the aortic valve with local aortic root destruction requires radical resection of infected tissues and subsequent reconstruction of periannular structures and the left ventricular outflow tract (LVOT). Homografts or stentless bioprostheses are recommended for use in this specific patient group. The Freestyle stentless bioprosthesis is a porcine aortic root prosthesis, which approaches the surgical versatility of the homograft, but has the advantage of ready availability and uniform quality. We assessed clinical and echocardiographic outcome following the use of this prosthesis in extensive aortic valve endocarditis.
  
  
  METHODS
  Between June 2000 and December 2014, 55 Freestyle prostheses were implanted for aortic valve endocarditis involving the root in 54 patients (74% male). The mean age at operation was 61 ± 13 years. The mean EuroSCORE II was 20.1 ± 13.5. Twenty-nine (54%) patients had prosthetic valve endocarditis. The median follow-up time after surgery was 3.5 years, ranging from 0 to 15 years.
  
  
  RESULTS
  Early and late mortality were 11% (6 patients) and 14% (7 patients), respectively. Estimated overall survival at 1 and 5 years was 83 and 70%, respectively. There was no survival difference between patients with native or prosthetic valve endocarditis. One patient underwent reoperation for recurrent endocarditis 2.3 years after the initial procedure. No other prosthesis failure occurred. At a median follow-up of 3.3 years, mean gradient over the prosthesis was 4.3 ± 2.3 mmHg. No patient had more than mild aortic regurgitation.
  
  
  CONCLUSIONS
  The Freestyle stentless bioprosthesis is a valuable option to reconstruct the LVOT after debridement in extensive aortic valve endocarditis. It is readily available with a versatility and clinical outcome comparable with that of homografts. Although early mortality remains considerable in this high-risk group of patients, late survival is good with low rates of recurrence of endocarditis, immediate local control and good haemodynamic performance on echocardiography.
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Adriaan W
authors.initials: AW
authors.lastname: Schneider
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Hazekamp
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Michel I M
authors.initials: MI
authors.lastname: Versteegh
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Eline F
authors.initials: EF
authors.lastname: Bruggemans
authors.affiliation: Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Eduard R
authors.initials: ER
authors.lastname: Holman
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Robert J M
authors.initials: RJ
authors.lastname: Klautz
authors.affiliation: Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands j.braun@lumc.nl.
authors.forename: Jerry
authors.initials: J
authors.lastname: Braun
mesh_terms: D000328:Adult; D000368:Aged; D001021:Aortic Valve / Q000382:microbiology / Q000601:surgery*; D001705:Bioprosthesis / Q000009:adverse effects; D004452:Echocardiography; D004697:Endocarditis, Bacterial / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery*; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000000981:diagnostic imaging / Q000382:microbiology / Q000601:surgery; D015607:Stents
keywords: Aortic root abscess; Aortic root replacement; Infective endocarditis; Stentless bioprosthesis