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Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis

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Abstract

Delayed diagnosis or surgery sometimes causes more extensive destruction of aortic periannular abscess, or pseudoaneurysm, resulting in left ventricular–aortic discontinuity, particularly in patients with prosthetic valve endocarditis. The condition complicates the surgical procedures and causes worsening of short- and long-term outcomes. In-hospital mortality in patients with prosthetic valve endocarditis has been reported to be as high as 15–20 %, even at leading hospitals in the world. Contemporary modes of surgery for periannular abscess/pseudoaneurysm involve drainage of the cavity, radical debridement of necrotic tissue, annular reconstruction of the destroyed annulus, and root replacement using an optimal conduit. Radical debridement is of primary importance and is the universally accepted procedure, which frequently requires annular reconstruction using a pericardial patch. Conventional aortic valve replacement using a mechanical or stented biological valve, aortic valve replacement with translocation, aortic root replacement using an allograft, pulmonary autograft (Ross procedure), stentless biological valve, or a composite graft are conduits of choice. All things considered, allograft is believed to be the best conduit for a destroyed annulus because of better fit and its resistance to infection; however, recent reports have failed to confirm the superiority of allograft over other conduits in terms of long-term survival and freedom from reoperation/recurrence of infection. Short- and long-term outcomes have been studies for every type of conduit, but the selection of conduits for aortic root replacement is still controversial.

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References

  1. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med. 2001;345(18):1318–30.

    Article  PubMed  CAS  Google Scholar 

  2. Funakoshi S, Kaji S, Yamamuro A, et al. Impact of early surgery in the active phase on long-term outcomes in left-sided native valve infective endocarditis. J Thorac Cardiovasc Surg. 2011;142(4):836–42.

    Article  PubMed  Google Scholar 

  3. Kang DH, Kim YJ, Kim SH, et al. Early surgery versus conventional treatment for infective endocarditis. N Engl J Med. 2012;366(26):2466–73.

    Article  PubMed  CAS  Google Scholar 

  4. Graupner C, Vilacosta I, SanRoman J, et al. Periannular extension of infective endocarditis. J Am Coll Cardiol. 2002;39(7):1204–11.

    Article  PubMed  Google Scholar 

  5. Daniel WG, Mugge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324(12):795–800.

    Article  PubMed  CAS  Google Scholar 

  6. Ellis SG, Goldstein J, Popp RL. Detection of endocarditis-associated perivalvular abscesses by two-dimensional echocardiography. J Am Coll Cardiol. 1985;5(3):647–53.

    Article  PubMed  CAS  Google Scholar 

  7. Baumgartner FJ, Omari BO, Robertson JM, et al. Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features. Ann Thorac Surg. 2000;70(2):442–7.

    Article  PubMed  CAS  Google Scholar 

  8. Okada K, Tanaka H, Takahashi H, et al. Aortic root replacement for destructive aortic valve endocarditis with left ventricular–aortic discontinuity. Ann Thorac Surg. 2008;85(3):940–5.

    Article  PubMed  Google Scholar 

  9. Symbas PN, Vlasis SE, Zacharopoulos L, Lutz JF. Aortic–left ventricular discontinuity and aortic regurgitation from acute endocarditis. South Med J. 1982;75(12):1476–8.

    Article  PubMed  CAS  Google Scholar 

  10. Anguera I, Miro JM, San Roman JA, et al. Periannular complications in infective endocarditis involving prosthetic aortic valves. Am J Cardiol. 2006;98(9):1261–8.

    Article  PubMed  Google Scholar 

  11. Anguera I, Miro JM, Evangelista A, et al. Periannular complications in infective endocarditis involving native aortic valves. Am J Cardiol. 2006;98(9):1254–60.

    Article  PubMed  Google Scholar 

  12. Manzano MC, Vilacosta I, San Roman JA, et al. Acute coronary syndrome in infective endocarditis. Rev Esp Cardiol. 2007;60(1):24–31.

    Article  PubMed  Google Scholar 

  13. Arnett EN, Roberts WC. Prosthetic valve endocarditis: clinicopathologic analysis of 22 necropsy patients with comparison observations in 74 necropsy patients with active infective endocarditis involving natural left-sided cardiac valves. Am J Cardiol. 1976;38(3):281–92.

    Article  PubMed  CAS  Google Scholar 

  14. Blumberg EA, Karalis DA, Chandrasekaran K, et al. Endocarditis-associated paravalvular abscesses. Do clinical parameters predict the presence of abscess? Chest. 1995;107(4):898–903.

    Article  PubMed  CAS  Google Scholar 

  15. Bashore TM, Cabell C, Fowler V Jr. Update on infective endocarditis. Curr Probl Cardiol. 2006;31(4):274–352.

    Article  PubMed  Google Scholar 

  16. Fowler VG Jr, Miro JM, Hoen B, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. JAMA. 2005;293(24):3012–21.

    Article  PubMed  CAS  Google Scholar 

  17. Musci M, Weng Y, Hubler 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(3):665–73.

    Article  PubMed  Google Scholar 

  18. Anguera I, Miro JM, Vilacosta I, et al. Aorto-cavitary fistulous tract formation in infective endocarditis: clinical and echocardiographic features of 76 cases and risk factors for mortality. Eur Heart J. 2005;26(3):288–97.

    Article  PubMed  Google Scholar 

  19. Wang A, Athan E, Pappas PA, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA. 2007;297(12):1354–61.

    Article  PubMed  CAS  Google Scholar 

  20. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of operation for paravalvular abscess. Ann Thorac Surg. 1996;62(1):48–53.

    Article  PubMed  Google Scholar 

  21. Carpenter JL. Perivalvular extension of infection in patients with infectious endocarditis. Rev Infect Dis. 1991;13(1):127–38.

    Article  PubMed  CAS  Google Scholar 

  22. Omari B, Shapiro S, Ginzton L, et al. Predictive risk factors for periannular extension of native valve endocarditis. Clinical and echocardiographic analyses. Chest. 1989;96(6):1273–9.

    Article  PubMed  CAS  Google Scholar 

  23. Evangelista A, Gonzalez-Alujas MT. Echocardiography in infective endocarditis. Heart. 2004;90(6):614–7.

    Article  PubMed  CAS  Google Scholar 

  24. Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413.

    Article  PubMed  Google Scholar 

  25. David TE, Gavra G, Feindel CM, Regesta T, Armstrong S, Maganti MD. Surgical treatment of active infective endocarditis: a continued challenge. J Thorac Cardiovasc Surg. 2007;133(1):144–9.

    Article  PubMed  Google Scholar 

  26. Kunis RL, Sherrid MV, McCabe JB, Grieco MH, Dwyer EM Jr. Successful medical therapy of mitral anular abscess complicating infective endocarditis. J Am Coll Cardiol. 1986;7(4):953–5.

    Article  PubMed  CAS  Google Scholar 

  27. Vlessis AA, Hovaguimian H, Jaggers J, Ahmad A, Starr A. Infective endocarditis: ten-year review of medical and surgical therapy. Ann Thorac Surg. 1996;61(4):1217–22.

    Article  PubMed  CAS  Google Scholar 

  28. Aagaard J, Andersen PV. Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices. Ann Thorac Surg. 2001;71(1):100–3.

    Article  PubMed  CAS  Google Scholar 

  29. Olinger GN, Maloney JJ. Repair of left ventricular–aortic discontinuity complicating endocarditis from an aortic valve prosthesis. Ann Thorac Surg. 1977;23(6):576–7.

    Article  PubMed  CAS  Google Scholar 

  30. Bailey WW, Ivey TD, Miller DW Jr. Dacron patch closure of aortic annulus mycotic aneurysms. Circulation. 1982;66(2 Pt 2):I127–30.

    PubMed  CAS  Google Scholar 

  31. Fiore AC, Ivey TD, McKeown PP, Misbach GA, Allen MD, Dillard DH. Patch closure of aortic annulus mycotic aneurysms. Ann Thorac Surg. 1986;42(4):372–9.

    Article  PubMed  CAS  Google Scholar 

  32. Bauernschmitt R, Vahl CF, Lange R, Jakob H, Hagl S. Surgical treatment of acute endocarditis of the aortic valve with paravalvular abscess: considerations justifying the use of mechanical replacement devices. Eur J Cardiothorac Surg. 1996;10(9):741–7.

    Article  PubMed  CAS  Google Scholar 

  33. d’Udekem Y, David TE, Feindel CM, Armstrong S, Sun Z. Long-term results of surgery for active infective endocarditis. Eur J Cardiothorac Surg. 1997;11(1):46–52.

    Article  PubMed  Google Scholar 

  34. Danielson GK, Titus JL, DuShane JW. Successful treatment of aortic valve endocarditis and aortic root abscesses by insertion of prosthetic valve in ascending aorta and placement of bypass grafts to coronary arteries. J Thorac Cardiovasc Surg. 1974;67(3):443–9.

    PubMed  CAS  Google Scholar 

  35. Nottin R, Al-Attar N, Ramadan R, et al. Aortic valve translocation for severe prosthetic valve endocarditis: early results and long-term follow-up. Ann Thorac Surg. 2005;79(5):1486–90.

    Article  PubMed  Google Scholar 

  36. Okita Y, Franciosi G, Matsuki O, Robles A, Ross DN. Early and late results of aortic root replacement with antibiotic-sterilized aortic homograft. J Thorac Cardiovasc Surg. 1988;95(4):696–704.

    PubMed  CAS  Google Scholar 

  37. Sabik JF, Lytle BW, Blackstone EH, Marullo AG, Pettersson GB, Cosgrove DM. Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis. Ann Thorac Surg. 2002;74(3):650–9.

    Article  PubMed  Google Scholar 

  38. Saito A, Motomura N, Kakimi K, et al. Vascular allografts are resistant to methicillin-resistant Staphylococcus aureus through indoleamine 2,3-dioxygenase in a murine model. J Thorac Cardiovasc Surg. 2008;136(1):159–67.

    Article  PubMed  CAS  Google Scholar 

  39. Yankah AC, Pasic M, Klose H, Siniawski H, Weng Y, Hetzer R. Homograft reconstruction of the aortic root for endocarditis with periannular abscess: a 17-year study. Eur J Cardiothorac Surg. 2005;28(1):69–75.

    Article  PubMed  Google Scholar 

  40. 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(2):480–7.

    Google Scholar 

  41. Sievers HH, Stierle U, Charitos EI, et al. Major adverse cardiac and cerebrovascular events after the Ross procedure: a report from the German–Dutch Ross Registry. Circulation. 2010;122(11 Suppl):S216–23.

    Article  PubMed  Google Scholar 

  42. Birk E, Sharoni E, Dagan O, et al. The Ross procedure as the surgical treatment of active aortic valve endocarditis. J Heart Valve Dis. 2004;13(1):73–7.

    PubMed  Google Scholar 

  43. Hagl C, Galla JD, Lansman SL et al. Replacing the ascending aorta and aortic valve for acute prosthetic valve endocarditis: is using prosthetic material contraindicated? Ann Thorac Surg 2002;74(5):S1781–5.

    Google Scholar 

  44. Schmidtke C, Dahmen G, Sievers HH. Subcoronary Ross procedure in patients with active endocarditis. Ann Thorac Surg. 2007;83(1):36–9.

    Article  PubMed  Google Scholar 

  45. Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandrasekaran K, Elkins RC. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg. 1999;67(6):1603–8.

    Article  PubMed  CAS  Google Scholar 

  46. Prat A, Saez de I, Vincentelli A et al. Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement. Ann Thorac Surg. 2001;72(5):1492–5.

    Google Scholar 

  47. Miskovic A, Monsefi N, Doss M, Ozaslan F, Karimian A, Moritz A. Comparison between homografts and Freestyle(R) bioprosthesis for right ventricular outflow tract replacement in Ross procedures. Eur J Cardiothorac Surg. 2012; in press.

  48. Bach DS, Kon ND, Dumesnil JG, Sintek CF, Doty DB. Ten-year outcome after aortic valve replacement with the freestyle stentless bioprosthesis. Ann Thorac Surg. 2005;80(2):480–6.

    Article  PubMed  Google Scholar 

  49. Katsumata T, Vaccari G, Westaby S. Stentless xenograft repair of excavating aortic root sepsis. J Card Surg. 1998;13(6):440–4.

    Article  PubMed  CAS  Google Scholar 

  50. Muller LC, Chevtchik O, Bonatti JO, Muller S, Fille M, Laufer G. Treatment of destructive aortic valve endocarditis with the Freestyle Aortic Root Bioprosthesis. Ann Thorac Surg. 2003;75(2):453–6.

    Article  PubMed  Google Scholar 

  51. 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(3):803–8.

    Article  PubMed  Google Scholar 

  52. El-Hamamsy I, Clark L, Stevens LM, et al. Late outcomes following freestyle versus homograft aortic root replacement: results from a prospective randomized trial. J Am Coll Cardiol. 2010;55(4):368–76.

    Article  PubMed  Google Scholar 

  53. 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(5):1416–20.

    Article  PubMed  Google Scholar 

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  1. Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Kenji Okada & Yutaka Okita

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  1. Kenji Okada
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  2. Yutaka Okita
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Correspondence to Kenji Okada.

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The review was submitted at the invitation of the editorial committee.

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Okada, K., Okita, Y. Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis. Gen Thorac Cardiovasc Surg 61, 175–181 (2013). https://doi.org/10.1007/s11748-012-0152-x

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