Aortic Root Replacement for Destructive Endocarditis—Microbiological Considerations: A Single-Center Study

Objectives: Destructive endocarditis of the aortic root is associated with high mortality. Our purpose was to characterize these patients and their outcomes.

Methods: From 1999 to 2018, eighty patients were admitted to our institution due to aortic valve endocarditis with perianular extension of infection and then underwent total aortic root replacement. We created patient subgroups with and without already implanted aortic valve prostheses. We analyzed their clinical and microbiological data and outcomes in addition to predictors of short- and long-term mortality.

Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset (up to 12 months after valve replacement) prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE (after the 12th postoperative month). Streptococcus spp. was identified in six (19.4%) of the NVE cases and in no cases of PVE. The other microbiological findings among late-onset PVE and NVE patients were similar. Coagulase-negative Staphylococcus was predominant in early-onset PVE (62.5%, n = 5). Blood cultures obtained from 27 (33.75%) patients were negative. Only 46 (57.5%) patients had received appropriate empirical antibiotics before the admission. All microorganisms were associated with similar risks. We identified independent risk factors for mortality: (1) aortoventricular dehiscence (odds ratio [OR] = 5.4; 95% confidence interval [CI]: 1.8–16.3); (2) PVE (OR = 5.9; 95% CI: 1.6–22.0); (3) concomitant bypass surgery (OR = 8.7; 95% CI: 2.6–28.4); (4) bailout bypass surgery (OR = 13.1, 95% CI: 2.5–69.0); and (5) no antibiotics at admission (OR = 5.0, 95% CI: 1.5–16.6). Postoperative complications were similarly distributed among all three subgroups. The NVE group had the lowest long-term mortality (p = 0.044) and incidence of composite endpoint (p = 0.024). These rates did not differ between early- and late-onset PVE (p = 0.499).

Conclusion: Mortality in PVE is significantly higher than in NVE. Empirical antibiotics administration before the diagnosis increases the number of cases with negative blood cultures and prolongs the diagnostics. Delayed begin of appropriate therapy leads to uncontrolled infection and increases the risk of poor outcome. Patients with destructive endocarditis have often history of incorrect empirical therapy with antibiotics. In cases of very severe perianular tissues destruction, the outcome does not depend on the etiological agent. Several predictors of mortality were identified.