Chirurgische Therapie der Prothesen-Endokarditis nach Aortenklappenersatz: Retrospektive Datenanalyse

Background: The Prosthetic valve endocarditis (PVE) is a severe complication after aortic valve replacement (AVR). Occurring with an incidence of 0.57 % per person-year after surgical AVR it is a rare complication. Nonetheless, PVE can be associated with considerable 1-year mortality rates ranging up to 60 % in patients receiving nonsurgical or delayed surgical treatment. Various factors, such as an atypical clinical presentation or a lower sensitivity of the Duke criteria used for the diagnosis of infective endocarditis (IE), may lead to a delayed diagnosis. Early cardiac surgery as well as antimicrobial therapy are considered as the gold standard of PVE treatment. Multiple surgical treatment options with different techniques of AVR and aortic root replacement (ARR) are available, depending on the extent of tissue destruction. Methods: The aim of this study is to evaluate the outcomes of surgical treatment in patients suffering from aortic PVE. A retrospective data analysis was performed at the Department of Cardiothoracic and Vascular Surgery at Kepler University Hospital Linz. In the period from January 2017 to July 2022, a total of 149 operations related to IE were performed. Any surgeries performed on the native aortic valve and other heart valves were excluded. In total 23 patients (age: 69 [62.5; 74]; female proportion: 26 %; EuroSCORE II: 12.1 % [8.5; 25.5]) who underwent a cardiac surgery for aortic PVE during the observation period were included. The patients were followed up until December 2022 in order to properly evaluate short-term as well as long-term outcomes. Results: Aortic PVE occurred at a median period of 44 months [7.5; 124.5] after AVR. Early PVE (< 365 days after AVR) was recorded in eight patients (34.8 %). Staphylococcus aureus (30.4 %) was identified as the most frequently isolated microorganism causing PVE. Cardiac surgical treatment was performed after a median hospitalization time of ten days [4; 16.5]. The aortic root was replaced in 16 patients (69.6 %): Five patients (21.7 %) received an aortic root bioprosthesis, four patients (17.4 %) a bovine BioConduit, three patients (13 %) a biological composite conduit and three patients (13 %) an aortic homograft. The remaining patients (30.4 %) were treated with biological AVR. Concomitant procedures were performed in six patients (26.1 %): Two patients (8.7 %) underwent implantation of cardiac pacemaker and four patients (17.4 %) aortocoronary bypass surgery, two of these cases (8.7 %) also required implantation of an ECLS system. The median aortic cross-clamp time amounted to 117 minutes [77; 148]. Postoperative complications included pacemaker implantation in five patients (21.7 %), hemorrhage with need for rethoracotomy in one patient (4.3 %) and implantation of an ECLS system in one patient (4.3 %). The 30-day mortality was 13 %. Median follow-up time was ten months [4; 30.8] with a mortality of 4.3 %. Implantation of an ICD-CRT system was needed in one patient (4.3 %). Freedom from reoperation and recurrent IE was 100 % within the follow-up period. Conclusion: Considering the high mortality rate of PVE, surgical treatment of aortic PVE in this experienced cardiac surgical center achieves highly satisfactory results in terms of short-term and long-term outcomes. However, further research is needed, particularly with regard to long-term outcomes in context of multicenter prospective studies with larger case numbers.