OBJECTIVE
To evaluate the results of aortic allograft redo surgery in patients with prosthetic infectious endocarditis of the aortic valve and aortitis of the ascending, thoracoabdominal and infrarenal aorta.
MATERIAL AND METHODS
We analyzed prospective data of 23 patients with active infection who underwent in situ aortic repair with aortic allograft for infective prosthetic endocarditis of the aortic root after aortic valve (AV) replacement with mechanical prosthesis (n=8), Bentall — DeBono procedure (n=3) and infectious prosthetic aortitis of infrarenal aorta (n=11), infectious prosthetic aortitis of thoracoabdominal aorta (n=1) after endovascular replacement. EHS (Euro Heart Survey) criteria were used for clinical assessment of patients with infective prosthetic endocarditis and infectious prosthetic aortitis. Surgeries were performed between January 2014 and January 2021 in nine cardiovascular centers. Clinical manifestations, indications and features of surgery, early postoperative mortality and morbidity, delayed mortality and incidence of graft-related complications were analyzed.
RESULTS
Twenty-three patients underwent aortic replacement with allograft for active synthetic graft infection. Of these, 11 patients (group 1) underwent replacement of ascending aorta and aortic valve (mean age 47.3±14.8 years, males predominated, 63.6%). In most patients (n=7), surgery were urgent and emergency. Infrarenal abdominal aorta replacement and aorto-bifemoral replacement with allograft in situ were performed in 11 patients of the 2nd group (men, mean age 62.1±4.4 years) including 1 patient who underwent redo replacement of abdominal aorta with left-sided aortofemoral bypass and amputation of the right lower limbs with hip joint disarticulation. Nine patients in this group underwent urgent and emergency surgery. A patient with active infection of thoracoabdominal aortic stent-graft underwent urgent redo replacement of thoracoabdominal aorta. There were no between-group differences in anthropometric indicators. At the same time, mean age was higher in group 2 (p=0.01). Atherosclerotic lesions of peripheral arteries and coronary artery disease (p=0.001) prevailed in group 2. Peripheral artery disease was found in 90.9% of patients (p<0.001), CAD — in 72.7%, carotid artery lesions — in 45.5% of cases. Heart failure NYHA class 3 (p=0.018), embolism (p=0.045) and fever ≥38 °C (p=0.04) prevailed in group 1. Staphylococcus aureus and microbial associations were more common in group 2. The most common complication after replacement of ascending aorta and aortic valve was acute cardiovascular failure (n=5; 45.5%), after replacement of infrarenal abdominal aorta — sepsis (n=5; 45.5%). Two patients died early (<30 days) after replacement of ascending aorta and redo replacement of aortic valve due to acute cardiac (n=1) and multiple organ failure (n=1). Seven early deaths after infrarenal abdominal aortic replacement were due to sepsis (n=5), multiple organ failure (n=1) and acute heart failure (n=1). Mortality was significantly lower in group 1 (18.2% and 63.6%, respectively, p=0.04). Late death (n=1) due to arrosive bleeding was observed after redo thoracoabdominal aortic replacement. Mortality was significantly higher in patients with sepsis: 6 (85.7%) out of 7 patients with sepsis vs. 3 (20%) out of 15 patients without sepsis (p=0.007). The mean follow-up period after discharge was 23.8±4.8 months (median 24.5 months), range — 2 — 61 months. None patient died after discharge.
CONCLUSION
Ascending and infrarenal abdominal aorta reconstruction in situ with aortic allografts is effective for active infective prosthetic endocarditis of aortic root and infective prosthetic aortitis. The EHS criteria can be used to evaluate patients with infective prosthetic endocarditis and aortitis.
