8. The Advantage of Autograft and Homograft Valve Replacement for Complex Aortic Valve Endocarditis

Christian J. Knot-Craig, Kazuo Niwaya, KathyLee Santangelo, K Chandrasekaran, Ronald C. Elkins

University of Oklahoma Health Sciences Center

Oklahoma City, Okla.

To evaluate whether homografts (homo-AVR) or autografts (Ross-AVR) are superior to prosthetic valves (prosth-AVR) for infective endocarditis involving the arotic root, we reviewed 74 patients treated between 1986 and 1997. The mean age of the 64 men and 10 women was 40.7 years. Fifty-seven (77 percent) patients had active endocarditis. Previous AV procedures included aortic valvuloplasty (n=3) and AVR with a prosthetic valve (n=21), homograft (n=4), or Ross (n=2). Intraoperative findings included valve cusp destruction (n=29), valvular vegetation (n=28), annular abscess (n=27), intracardiac fistula (n=4), and extra-cardiac abscess (n=2). AVR were performed with 39 homografts (homo-AVR), 25 autografts (Ross-AVR), and 10 prosthetic valves (prosth-AVR). Among Ross-AVR and homo-AVR patients, 10 required concomitant mitral valve replacement (MVR) or repair (homo-Ross DVR). Four patients had AVR and MVR with prosthetic valves. Follow-up was complete for 99 percent patients at mean of 2.7 years postoperatatively. Early mortality was 20.2 percent (14/74). This was 12 percent (3/23) for Ross-AVR, 25.6 percent (10/39) for homo-AVR, and 20 percent (2/10) for prosth-AVR, respectively. Early mortality for homo-Ross DVR was 10 percent (1/10). Overall, late mortality was 10.2 percent (6/59). There was one late valve-related death in the homo-AVR group (3.4 percent, 1/29), three in prosth-AVR (37.5 percent, 3/8), but zero in the Ross points (Ross-AVR and homo-Ross DVR). Five-year survival was 88±7 percent in Ross-AVR, 66±8 percent in homo-AVR and 50±20 percent in prosth-AVR (N.S.) Recurrent endocarditis occurred in two patients. 1 Ross-AVR remains a formidable challenge. Autografts and homografts are the preferred replacement aortic valves for these patients and risk of valve-related death or recurrent endocarditis is low at medium term follow-up.