Objective

Complex aortic valve infective endocarditis (IE) is a deadly disease and replacement (AVR) is the treatment of choice. While homografts have been promoted previously, root replacement using stentless bioprostheses (SBP) is an alternative in these patients. Nevertheless, there is an ongoing debate about the optimal prosthesis used in these patients. We analysed our results and compare the outcome of mechanical prostheses (MV) with that of stented (BP) and SBP.

Methods

Our in-hospital database was retrospectively explored for patients with IE, operated between 2000 and 2015. Valve replacements with homografts were excluded. A total of 187 patients received MV (n=45), BP (n=112) or SBP (n=30). Complex IE was defined as the presence of prosthetic valve endocarditis (PVE), root involvement or septic emboli, resulting in three groups, MV (n=22), BP (n=54) and SBP (n=26). We analysed short-, long-term- and event-free-survival.

Results

SBP patients were older (mean age: MV: 40.6±12.0yrs, BP: 54.7±62.6yrs, SBP: 56.9±16.2yrs, p<0.01), had more often PVE (MV: 13.6%, BP: 24.1%, SBP: 61.5%, p<0.01) and root involvement (68.2%, 53.7%, 96.2%, p<0.01). Survival was best in the SBP group (87.6% vs. MV: 85.6%, BP: 73.1%) at 1 year and 5 years (SBP: 87.7%, MV: 85.6%, BP: 57.3% and better compared to BP (p=0.03). Event-free Survival was 71.8%, 63.6% and 83.3% at one and 60.7%, 48.7% and 70.6% at five years (p=ns).

Conclusion

Despite a higher pre-operative risk of SBP patients, survival was similar compared to a younger cohort of MV patients and superior to patients with BP. This is most likely an effect of the more radical excision of infected material and should be the preferred surgical option particularly in older patients with complex IE. In younger patients the risk of re-infection should be weight against the risk of structural valve degeneration when the decision is made in favour of MV.