Homograft Root Replacement Does Not Provide Superior Outcomes in Invasive Aortic Valve Endocarditis Compared With Prosthetic Valve Conduits

Abstract

Background: Surgical dogma advocates for the use of homograft in invasive aortic valve endocarditis due to a perceived advantage in the prevention of recurrent infection. However, conclusive data to support this strategy are lacking. This study evaluated outcomes of root replacement in invasive aortic valve endocarditis using homografts or prosthetic-valved conduits.

Methods: A retrospective review of a single U.S. academic center’s aortic database identified 150 patients who underwent aortic root replacement for invasive aortic valve endocarditis from 2002 to 2022. Patients undergoing the Ross procedure or aortic valve replacement without root replacement were excluded from the study. Patients were divided into two groups based upon the type of valved conduit implanted. Preoperative characteristics, postoperative morbidity, reintervention for recurrence of infection, and short- and long-term survival were compared between the two groups.

Results: There were 70 patients who underwent a homograft root replacement (homograft), and 80 patients who received either a bioprosthetic or mechanical-valved conduit (prosthetic). The mean age of patients was 53.3 ± 15.6 and 21.3% were female. The overall incidence of preoperative stroke and aortic root abscess was 42% and 71%, respectively. There was no difference between the two groups in age, gender, end-stage renal disease, cardiogenic shock, and aortic root abscess. The prosthetic group had a higher incidence of preoperative stroke (prosthetic 52% vs. homograft 25%, p = 0.02). The incidence of preoperative prosthetic valve endocarditis was 30% for the cohort and significantly higher in the homograft group (p = 0.02). Reoperative sternotomy was 78.7% among the groups with a higher likelihood among the homograft group. Cardiopulmonary bypass and cross clamp times were shorter in the prosthetic group (p < 0.05). There was no difference in postoperative stroke or renal failure between the two groups. The 30-day mortality for the entire cohort was 20.1% and was increased in the homograft group (homograft 25.7% vs. prosthetic 16.3%, p = 0.15). At 7 years follow-up, survival was 62% in the prosthetic group and 53% in the homograft group. The need for reintervention due to recurrence of infection was 3.2% for the entire series and equivalent (homograft 3.5%, vs. prosthetic 4.2%, p = 0.82) between the groups.

Conclusions: The use of homograft for root replacement does not provide significant improved short- or long-term outcomes compared with prosthetic-valved conduits in invasive endocarditis. In this patient population, these data refute the necessity for a more complex procedure using homograft in these high-risk patients and conduit selection should be tailored to individual anatomy and surgeon-specific experience.