title: Root Replacement for Graft Infection Using an All-Biologic Xenopericardial Conduit.
abstract: The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material.
  
  
  
  Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%).
  
  
  
  The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen.
  
  
  
  Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany. Electronic correspondence: sabina.guenther@med.uni-muenchen.de.
authors.forename: Sabina PW
authors.initials: SP
authors.lastname: Guenther
authors.affiliation: Institute of Clinical Radiology, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Angela
authors.initials: A
authors.lastname: Reichelt
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Sven
authors.initials: S
authors.lastname: Peterss
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Erik
authors.initials: E
authors.lastname: Bagaev
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Hagl
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Maximilian A
authors.initials: MA
authors.lastname: Pichlmaier
authors.affiliation: Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
authors.forename: Nawid
authors.initials: N
authors.lastname: Khaladj
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D001705:Bioprosthesis; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016459:Prosthesis-Related Infections / Q000601:surgery*; D012189:Retrospective Studies