Guenther Sabina PW, Reichelt Angela, Peterss Sven, Luehr Maximilian, Bagaev Erik, Hagl Christian, Pichlmaier Maximilian A, Khaladj Nawid
Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany. Electronic correspondence:
Institute of Clinical Radiology, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.
J Heart Valve Dis. 2016 Jul;25(4):440-447.
The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material.
Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%).
The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen.
Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.
升主动脉置换术（AAR）和/或主动脉瓣置换术（AVR）后并发根部破坏的移植物感染的管理仍然是一项挑战。除技术问题外，移植物材料的选择也存在争议。本研究的目的是调查使用异种心包全生物管道（BioIntegral）作为同种异体移植物或人工材料的替代物进行主动脉根部置换术（ARR）作为感染再次手术的初步结果。
2013年2月至2015年1月，共有18例连续患者（16例男性，2例女性；平均年龄61±14岁）在先前进行AVR（n = 6）、冠状动脉上主动脉置换术（SAR，n = 2）、AVR + SAR（n = 1）、根部置换术（n = 7）和根部重建术（n = 2）后平均55±61个月（范围：3至219个月）因感染接受再次手术。2例患者（11%）先前接受过不止一次心脏手术。17例患者（94%）在计算机断层扫描（CT）上可见感染迹象。9例患者（50%）进行了额外的18F-FDG PET-CT检查。
体外循环和主动脉阻断时间分别为289±77分钟和187±59分钟。9例患者（50%）需要低温循环停搏（HCA）+选择性顺行性脑灌注（SACP），11例患者（61%）需要同期手术。5例患者术后需要体外生命支持（ECLS），8例患者需要肾脏替代治疗。1例患者术中死亡，总体30天死亡率为22%（n = 4），原因是多器官功能衰竭。死亡的危险因素是需要ECLS的心肌功能衰竭（p = 0.02）和先前单纯AVR后需要进行根部置换（p = 0.05）。平均随访时间为12±5个月。1例患者（6%）发生早期移植物再感染，另1例患者出现胸膜脓胸，无持续管道感染的证据。因此，移植物再感染的无事件生存率为94%。未观察到结构性瓣膜恶化的病例。
在移植物感染患者中使用异种心包管道进行主动脉根部置换在技术上是可行的。血流动力学和手术操作与同种异体移植物相当，但现成可用的特性有利于这种方法。死亡率较高，但与其他系列和移植物相当，再感染率较低。关于感染根除和移植物耐久性的长期结果仍有待证实。
