206 Part V / Valvular Heart Disease
Whereas some patients with native valve endocarditis respond to antibiotic therapy,
surgical intervention is required in many patients. In the current era, earlier surgical
intervention is increasingly advised. Indications for surgery have included the presence
of congestive heart failure from valve dysfunction, persistent sepsis, local annular
abnormalities (abscesses), conduction abnormalities, fistulas into adjacent cardiac
chambers, systemic embolization, progressive renal insufficiency, enlarging vegeta-
tions, and prosthetic valve endocarditis.
In general, operation performed in the setting of active infection can be challenging,
especially when there is destruction of adjacent tissue (e.g., aortic root abscess with ven-
tricular septal defect or aorta–ventricular discontinuity). Knowledge of abnormalities not
only of the valve but also of contiguous structures (e.g., annular abscess) is of great
importance to the surgeon prior to going to the operating room. This anatomical infor-
mation is readily discernible with transesophageal echocardiography. Although valve
repair is preferred, it may not be possible, especially if there is significant destruction of
cusp or leaflet or subvalvular tissue. If the infection is limited to the cusps of the native
valve, complete valvular resection and replacement with a mechanical or biologic pros-
thesis may suffice. Concomitant annular abnormalities require aggressive debridement
and reconstructive procedures. Reconstructive techniques following radical debridement
are dependent on the structures resected. Fistulas and chamber defects may be closed
with autologous or preserved pericardium (89,90). Alternatively, prosthetic grafts may
be used but these may increase the risk of recurrent, or persistent, endocarditis. It has
been our practice to locally disinfect the infected annulus and abscess cavity with phe-
nol. Mechanical or biologic valvular prostheses can then be implanted.
Aortic valve homografts have been used following radical debridement of complex
aortic valve endocarditis (i.e., presence of root abnormalities) (91,92). Homografts
include harvested ascending aorta and a varying amount of attached ventricular
myocardium as well as preservation of the anterior leaflet of the mitral valve. This
additional tissue, although it is usually trimmed for nonendocarditis aortic valve
replacement, can be preserved to reconstruct adjacent defects (Figs. 3 and 4). If there is
severe destruction of the aortic root, root excision and subsequent replacement with
coronary reimplantation with the aortic valve homograft can be performed. This is
often required for prosthetic valve endocarditis. Additionally, aortic homografts appear
to be more resistant to infection than other valve substitutes and thus may be ideal for
complex aortic infections. In our practice, the aortic valve homograft is the prosthesis
of choice for complex aortic valve endocarditis.
In mitral valve endocarditis, valvular replacement is usually required because of the
destruction of leaflet tissue. Isolated leaflet destruction without annular involvement
may be repaired with autologous pericardium. This is less likely in the acute setting
when the tissue is more friable and more likely in a delayed (treated) setting where the
tissue is more fibrous and likely to hold sutures. The feasibility of valve repair ulti-
mately depends on the tissue quality and is determined at the time of operation.
Although the mitral valve homograft has been used with some success, late follow-up
is not yet available (93–95).
In some cases, multiple valve replacements may be required. When aortic valve
endocarditis is complicated by annular abscess formation, mitral valve replacement
may be necessary. Fully one-tenth of aortic annular abscesses may require mitral valve
replacement (96).
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