Download PDF
CC BY 4.0 · Aorta (Stamford) 2022; 10(02): 43-51
DOI: 10.1055/s-0042-1743110
State-of-the-Art Review

Homograft Versus Valves and Valved Conduits for Extensive Aortic Valve Endocarditis with Aortic Root Involvement/Destruction: A Systematic Review and Meta-Analysis

Michael L. Williams 
1   Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
,
John D. L. Brookes
1   Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
,
Joseph S. Jaya 
2   Department of Surgery, Monash Health, Victoria, Australia
,
Eren Tan 
3   Department of Surgery, Eastern Health, Victoria, Australia
› Author Affiliations Funding None.
› Further Information
   Permissions and Reprints

Abstract

Aortic valve infective endocarditis is a life-threatening condition. Patients frequently present profoundly unwell and extensive surgery may be required to correct the underlying anatomical deficits and control sepsis. Periannular involvement occurs in more than 10% of patients with aortic valve endocarditis. Complex aortic valve endocarditis has a mortality rate of 10 to 40%. Longstanding surgical dogma suggests homografts represent the optimal replacement option in complex aortic valve endocarditis; however, there is a paucity of evidence and lack of consensus on the optimal replacement choice. A systematic review and meta-analysis was performed utilizing EMBASE, PubMed, and the Cochrane databases to review articles describing homografts versus aortic valve replacement and/or valved conduit graft implantation for complex aortic valve endocarditis. The outcomes of interest were mortality, reinfection, and reoperation. Eleven studies were included in this meta-analysis, contributing 810 episodes of complex aortic valve endocarditis. All included reports were cohort studies. There was no statistically significant difference in overall mortality (risk ratio [RR] 0.99; 95% confidence interval [CI], 0.61–1.59; p = 0.95), reinfection (RR 0.89; 95% CI, 0.45–1.78; p = 0.74), or reoperation (RR 0.91; 95% CI, 0.38–2.14; p = 0.87) between the homograft and valve replacement/valved conduit graft groups. Overall, there was no difference in mortality, reinfection, or reoperation rates between homografts and other valve or valved conduits in management of complex aortic endocarditis. However, there is a paucity of high-quality evidence in the area, and comparison of valve types warrants further investigation.

Keywords

endocarditis - aortic valve - homograft - aortic root abscess

Supplementary Material



Publication History

Received: 23 December 2020

Accepted: 30 August 2021

Article published online:
07 August 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Anguera I, Miro JM, Cabell CH. et al; ICE-MD investigators. Clinical characteristics and outcome of aortic endocarditis with periannular abscess in the International Collaboration on Endocarditis Merged Database. Am J Cardiol 2005; 96 (07) 976-981
    CrossrefPubMedGoogle Scholar
  • 2 Sponga S, Daffarra C, Pavoni D. et al. Surgical management of destructive aortic endocarditis: left ventricular outflow reconstruction with the Sorin Pericarbon Freedom stentless bioprosthesis. Eur J Cardiothorac Surg 2016; 49 (01) 242-248
    CrossrefPubMedGoogle Scholar
  • 3 Anguera I, Miro JM, Evangelista A. et al; Aorto-Cavitary Fistula in Endocarditis Working Group. Periannular complications in infective endocarditis involving native aortic valves. Am J Cardiol 2006; 98 (09) 1254-1260
    CrossrefPubMedGoogle Scholar
  • 4 Lee S, Chang BC, Park HK. Surgical experience with infective endocarditis and aortic root abscess. Yonsei Med J 2014; 55 (05) 1253-1259
    CrossrefPubMedGoogle Scholar
  • 5 Glazier JJ, Verwilghen J, Donaldson RM, Ross DN. Treatment of complicated prosthetic aortic valve endocarditis with annular abscess formation by homograft aortic root replacement. J Am Coll Cardiol 1991; 17 (05) 1177-1182
    CrossrefPubMedGoogle Scholar
  • 6 Kim JB, Ejiofor JI, Yammine M. et al. Are homografts superior to conventional prosthetic valves in the setting of infective endocarditis involving the aortic valve?. J Thorac Cardiovasc Surg 2016; 151 (05) 1239-1246 , 1248.e1–1248.e2
    CrossrefPubMedGoogle Scholar
  • 7 Jassar AS, Bavaria JE, Szeto WY. et al. Graft selection for aortic root replacement in complex active endocarditis: does it matter?. Ann Thorac Surg 2012; 93 (02) 480-487
    CrossrefPubMedGoogle Scholar
  • 8 David TE, Regesta T, Gavra G, Armstrong S, Maganti MD. Surgical treatment of paravalvular abscess: long-term results. Eur J Cardiothorac Surg 2007; 31 (01) 43-48
    CrossrefPubMedGoogle Scholar
  • 9 Knosalla C, Weng Y, Yankah AC. et al. Surgical treatment of active infective aortic valve endocarditis with associated periannular abscess–11 year results. Eur Heart J 2000; 21 (06) 490-497
    CrossrefPubMedGoogle Scholar
  • 10 Leyh RG, Knobloch K, Hagl C. et al. Replacement of the aortic root for acute prosthetic valve endocarditis: prosthetic composite versus aortic allograft root replacement. J Thorac Cardiovasc Surg 2004; 127 (05) 1416-1420
    CrossrefPubMedGoogle Scholar
  • 11 Kim JB, Sundt TM. Weak evidence, strong opinions, and high expectations. J Thorac Cardiovasc Surg 2017; 154 (06) 1901-1902
    CrossrefPubMedGoogle Scholar
  • 12 Leontyev S, Davierwala PM, Krögh G. et al. Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses. Eur J Cardiothorac Surg 2016; 49 (02) 447-454 , discussion 454–455
    CrossrefPubMedGoogle Scholar
  • 13 Brecker SJD, Pepper JR, Eykyn SJ. Aortic root abscess. Heart 1999; 82 (03) 260-262
    CrossrefPubMedGoogle Scholar
  • 14 Smail H, Saxena P, Zimmet AD. et al. Reconstruction and replacement of the aortic root in destructive endocarditis. Oper Tech Thorac Cardiovasc Surg 2015; 20 (04) 336-354
    CrossrefPubMedGoogle Scholar
  • 15 Musci M, Weng Y, Hübler M. et al. Homograft aortic root replacement in native or prosthetic active infective endocarditis: twenty-year single-center experience. J Thorac Cardiovasc Surg 2010; 139 (03) 665-673
    CrossrefPubMedGoogle Scholar
  • 16 Perrotta S, Lentini S. In patients with severe active aortic valve endocarditis, is a stentless valve as good as the homograft?. Interact Cardiovasc Thorac Surg 2010; 11 (03) 309-313
    CrossrefPubMedGoogle Scholar
  • 17 Flameng W, Daenen W, Jashari R, Herijgers P, Meuris B. Durability of homografts used to treat complex aortic valve endocarditis. Ann Thorac Surg 2015; 99 (04) 1234-1238
    CrossrefPubMedGoogle Scholar
  • 18 Gomes A, Jainandunsing JS, van Assen S. et al. A standardized approach to treat complex aortic valve endocarditis: a case series. J Cardiothorac Surg 2018; 13 (01) 32
    CrossrefPubMedGoogle Scholar
  • 19 Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 1999; 354 (9193): 1896-1900
    CrossrefPubMedGoogle Scholar
  • 20 Wells GA, Shea B, O'Connell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Accessed September 21, 2021 at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp
    PubMedGoogle Scholar
  • 21 Manager R. (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration. 2014
    PubMedGoogle Scholar
  • 22 Grant RL. Converting an odds ratio to a range of plausible relative risks for better communication of research findings. BMJ 2014; 348: f7450
    CrossrefPubMedGoogle Scholar
  • 23 Siniawski H, Lehmkuhl H, Weng Y. et al. Stentless aortic valves as an alternative to homografts for valve replacement in active infective endocarditis complicated by ring abscess. Ann Thorac Surg 2003; 75 (03) 803-808 , discussion 808
    CrossrefPubMedGoogle Scholar
  • 24 Siniawski H, Grauhan O, Hofmann M. et al. Aortic root abscess and secondary infective mitral valve disease: results of surgical endocarditis treatment. Eur J Cardiothorac Surg 2005; 27 (03) 434-440
    CrossrefPubMedGoogle Scholar
  • 25 Lupinetti FM, Lemmer Jr JH. Comparison of allografts and prosthetic valves when used for emergency aortic valve replacement for active infective endocarditis. Am J Cardiol 1991; 68 (06) 637-641
    CrossrefPubMedGoogle Scholar
  • 26 Elgalad A, Arafat A, Elshazly T. et al. Surgery for active infective endocarditis of the aortic valve with infection extending beyond the leaflets. Heart Lung Circ 2019; 28 (07) 1112-1120
    CrossrefPubMedGoogle Scholar
  • 27 Ramos A, García-Montero C, Moreno A. et al. Endocarditis in patients with ascending aortic prosthetic graft: a case series from a national multicentre registry. Eur J Cardiothorac Surg 2016; 50 (06) 1149-1157
    CrossrefPubMedGoogle Scholar
  • 28 Avierinos JF, Thuny F, Chalvignac V. et al. Surgical treatment of active aortic endocarditis: homografts are not the cornerstone of outcome. Ann Thorac Surg 2007; 84 (06) 1935-1942
    CrossrefPubMedGoogle Scholar
  • 29 Gulbins H, Kilian E, Roth S, Uhlig A, Kreuzer E, Reichart B. Is there an advantage in using homografts in patients with acute infective endocarditis of the aortic valve?. J Heart Valve Dis 2002; 11 (04) 492-497
    PubMedGoogle Scholar
  • 30 Leung DYC, Cranney GB, Hopkins AP, Walsh WF. Role of transoesophageal echocardiography in the diagnosis and management of aortic root abscess. Br Heart J 1994; 72 (02) 175-181
    CrossrefPubMedGoogle Scholar
  • 31 Savage EB, Saha-Chaudhuri P, Asher CR, Brennan JM, Gammie JS. Outcomes and prosthesis choice for active aortic valve infective endocarditis: analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2014; 98 (03) 806-814
    CrossrefPubMedGoogle Scholar
  • 32 Yanagawa B, Mazine A, Tam DY. et al. Homograft versus conventional prosthesis for surgical management of aortic valve infective endocarditis. A systematic review and meta-analysis. Innovations (Phila) 2018; 13 (03) 163-170
    CrossrefPubMedGoogle Scholar
  • 33 Feindel CM. It's not what you put in that is important, it's what you take out. J Thorac Cardiovasc Surg 2016; 151 (05) 1249-1250
    CrossrefPubMedGoogle Scholar
  • 34 Jashari R, Goffin Y, Van Hoeck B. et al. Belgian and European experience with the European Homograft Bank (EHB) cryopreserved allograft valves.–assessment of a 20 year activity. Acta Chir Belg 2010; 110 (03) 280-290
    CrossrefPubMedGoogle Scholar
  • 35 Bando K. Does type of prosthesis affect long-term outcomes after aortic valve replacement for infective endocarditis? How should we properly answer this question?. J Thorac Cardiovasc Surg 2017; 153 (04) 829-830
    CrossrefPubMedGoogle Scholar
  • 36 Byrne JG, Rezai K, Sanchez JA. et al. Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline. Ann Thorac Surg 2011; 91 (06) 2012-2019
    CrossrefPubMedGoogle Scholar