title: Are homografts superior to conventional prosthetic valves in the setting of infective endocarditis involving the aortic valve?
abstract: BACKGROUND
  Surgical dogma suggests that homografts should be used preferentially, compared with conventional xenograft or mechanical prostheses, in the setting of infective endocarditis (IE), because they have greater resistance to infection. However, comparative data that support this notion are limited.
  
  
  METHODS
  From the prospective databases of 2 tertiary academic centers, we identified 304 consecutive adult patients (age ≥17 years) who underwent surgery for active IE involving the aortic valve (AV), in the period 2002 to 2014. Short- and long-term outcomes were evaluated using propensity scores and inverse-probability weighting to adjust for selection bias.
  
  
  RESULTS
  Homografts, and xenograft and mechanical prostheses, were used in 86 (28.3%), 139 (45.7%), and 79 (26.0%) patients, respectively. Homografts were more often used in the setting of prosthetic valve endocarditis (58.1% vs 28.8%, P = .002) and methicillin-resistant Staphylococcus (25.6% vs 12.1%, P = .002), compared with conventional prostheses. Early mortality occurred in 17 (19.8%) in the homograft group, and 20 (9.2%) in the conventional group (P = .019). During follow-up (median: 29.4 months; interquartile-range: 4.7-72.6 months), 60 (19.7%) patients died, and 23 (7.7%) experienced reinfection, with no significant differences in survival (P = .23) or freedom from reinfection rates (P = .65) according to the types of prostheses implanted. After adjustments for baseline characteristics, using propensity-score analyses, use of a homograft did not significantly affect early death (odds ratio 1.61; 95% confidence interval [CI], 0.73-3.40, P = .23), overall death (hazard ratio 1.10; 95% CI, 0.62-1.94, P = .75), or reinfection (hazard ratio 1.04; 95% CI, 0.49-2.18, P = .93).
  
  
  CONCLUSIONS
  No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
authors.forename: Joon Bum
authors.initials: JB
authors.lastname: Kim
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Julius I
authors.initials: JI
authors.lastname: Ejiofor
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Maroun
authors.initials: M
authors.lastname: Yammine
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Janice M
authors.initials: JM
authors.lastname: Camuso
authors.affiliation: Tufts University School of Medicine, Boston, Mass.
authors.forename: Conor W
authors.initials: CW
authors.lastname: Walsh
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Masahiko
authors.initials: M
authors.lastname: Ando
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Serguei I
authors.initials: SI
authors.lastname: Melnitchouk
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: James D
authors.initials: JD
authors.lastname: Rawn
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Marzia
authors.initials: M
authors.lastname: Leacche
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: MacGillivray
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: Lawrence H
authors.initials: LH
authors.lastname: Cohn
authors.affiliation: Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors.forename: John G
authors.initials: JG
authors.lastname: Byrne
authors.affiliation: Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass. Electronic address: tsundt@partners.org.
authors.forename: Thoralf M
authors.initials: TM
authors.lastname: Sundt
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000368:Aged; D064591:Allografts; D001021:Aortic Valve / Q000473:pathology / Q000601:surgery*; D001705:Bioprosthesis; D016208:Databases, Factual; D004696:Endocarditis / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000601:surgery*; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods; D064593:Heterografts; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D011379:Prognosis; D016016:Proportional Hazards Models; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D014463:Ultrasonography; D014481:United States
keywords: Infective endocarditis; homograft; prognosis; surgery; valve replacement