Revisiting the guidelines and choice the ideal substitute for aortic valve endocarditis

Abstract

Aortic valve replacement is the most commonly performed cardiac surgical operation worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the treatment goals. However, no detailed guidelines on prosthesis selection and surgical strategy are available.Management should be guided by a comprehensive evaluation of infection extension and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. We conducted a literature search of the PubMed database, EMBASE and Cochrane Library (through November 2019) for studies reporting to the use of biological substitutes in aortic valve endocarditis (AVE). Studies comparing long-term outcomes in the use of allogenic and autologous with conventional prostheses were investigated.Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. In cases of complex IE with the involvement of the root or the aorto-mitral continuity, the use of homografts are recommended, according to surgeon's and center experience. Homograft use needs to be balanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives. The choice of aortic valves substitute and surgical strategy in IE is multifaceted. Principles guiding the selection of prosthesis and surgical approach rely on the longterm durability and the avoidance of infection relapse. A decisional algorithm considering the extension of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence is provided. A multidisciplinary effort is required to achieve consistent outcomes.

Infective Endocarditis in High-Income Countries

“…The phenomenon of mutating epidemiology of infective endocarditis in high-income countries is related to substantial progress in the medical and surgical fields [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. Therefore, an increase of 25–30% of contemporary cases of IE are acquired in the health sector, either due to the progressive increase in medical care offered during hospitalization or nosocomial admission, or to the possibility of contracting the infection on an outpatient basis [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ].…”

“…Although revision surgery must be carefully considered on a case-by-case basis, in patients with LVAD or who have received a heart transplant, the indication for revision surgery is recommended. Antibiotic therapy should be guided based on the results of drug sensitivity tests [ 61 , 63 , 192 ].…”

Anesthesia Considerations in Infective Endocarditis

“…When aortic valve infective endocarditis extends to the aortic annulus and/or the aortic root, an allograft or stentless xenograft may be beneficial. 46,209,210 Sutureless valves might represent an option for selected high-risk patients, but further research is still needed. 211 In case of extended left-sided infective endocarditis, double valve replacement or even extended reconstruction of the mitral-aortic intervalvular fibrosa or additional surrounding tissue may be necessary—a procedure accompanied by high mortality, sometimes described as a “commando procedure.” 212 In very exceptional cases, heart transplantation might be the last option to treat infective endocarditis.…”

Pathophysiology of Infective Endocarditis in High-Income Countries

“…[54,55] The phenomenon of mutating epidemiology of infective endocarditis in high-income countries is related to substantial progress in the medical and surgical fields. [56][57][58][59][60][61][62][63][64][65][66] Therefore, an increase of 25-30% of contemporary cases of IE are acquired in the health sector, either due to the progressive increase in medical care offered during hospitalization or nosocomial admission or linked to the possibility of contracting the infection on an outpatient basis [1][2][3][4][5][6][7] In this context, there has been increasing use of long-term intravenous lines and invasive procedures which constitute an ideal gateway for pathogens leading to increased rates of staphylococcal bacteremia which today represents the first precursor of infective endocarditis. [67][68][69][70] Advances in cardiological disciplines have allowed wider use of prosthetic heart valves and cardiac devices such as permanent pacemakers.…”