Over 20 years experience with aortic homograft in aortic valve replacement during acute infective endocarditis^†

INTRODUCTION

Aortic homografts have been suggested as the best valve substitute for aortic valve replacement (AVR) [1] in the setting of acute infective endocarditis (AIE) of the aortic valve, due to their intrinsic resistance to infection [2], especially in the presence of periannular abscess. Nevertheless, the complexity of the intervention, the reduced availability and, not last, the concern for structural deterioration over time [3] have limited their widespread utilization.

The aim of this study was to evaluate the over 20-year experience with the aortic homograft implantation in patients with acute aortic endocarditis with special attention to predictors of long-term survival and homograft reoperation.

MATERIALS AND METHODS

Between January 1990 and December 2014, 363 patients underwent an aortic valve surgery for AIE at the St Luc's Hospital in Brussels: 290 of them (79.9%) underwent an AVR (214 biological valve, 71 mechanical prosthesis and 5 autograft) and 73 (20.1%) an aortic valve repair. An aortic homograft was implanted in 112 (38.6%) patients who represent the study cohort. The surgical indication and the choice of aortic valve substitute were discussed together by our surgical team. Most homografts were implanted by two surgeons (Gebrine El Khoury and Jean Rubay) during the study period. The general approach of our group can be described as follows. When endocarditis induced limited and localized lesion on normal cusp (e.g. cusp perforation and no calcific degeneration), the valve was generally repaired with pericardial patch. Biological and mechanical valves were generally favoured, in function of patient’s age, in cases of limited infection to the valve or in cases of abscess when aortic homograft was not available. Aortic homografts were preferred in most native and prosthetic endocarditis where infection extended beyond the valve towards aortic annulus and surrounding cardiac structure.

Patients' characteristics and operative data

Demographic characteristics of the study patients are summarized in Table 1. Forty-six patients (41.1%) had infection on a prosthetic valve endocarditis (PVE) and 66 (58.9%) on the native aortic valve endocarditis (NVE). Patients with a PVE were older than those with an NVE (64.6 ± 1.5 vs 54.2 ± 1.7, P < 0.001), had a higher incidence of abscess (65.2 vs 43.9%, P = 0.03) and higher prevalence of concomitant procedures (40.9 vs 20.0%, P = 0.02), and the most common technique of homograft implantation was the free-standing root (86.9 vs 50.8%, P < 0.001). At preoperative cardiac echo assessment, 45 patients (40.1%) had a diagnosis of abscess. However, at surgery, an abscess was found in 59 (62.7%) patients, 65.2% (n = 30) of the PVE and 43.9% (n = 29) of the NVE.

A causative organism was identified in 101 patients (90.2%), whereas 10 patients (8.9%) had negative blood cultures.

The diagnosis of infective endocarditis was based on clinical, echographic and biological findings according to the revised Duke's criteria [4]. Surgery was indicated according to the most updated American Heart Association/American College of Cardiology (ACC/AHA) guidelines in every moment; urgent surgery was considered for patients with cardiac or septic shock, severe valve regurgitation, large and mobile vegetations, periannular abscess, progressive heart failure, systemic embolism or resistance to antibiotic treatment. The proportion of the various indications for operation is illustrated in Table 1.

Recurrences of valve infection have been classified according to the 2015 European Society of Cardiology (ESC) Guidelines on the management of infective endocarditis [5, 6] (relapse refers to a repeat episode of endocarditis caused by the same microorganism, whereas reinfection is a new episode caused by a different microorganism).

Operative techniques

Most of the operations were performed through a median sternotomy, standard cardiopulmonary bypass and a warm blood cardioplegia; cold cardioplegia was used in 23 patients (20.5%) and especially in the very first period of the study (until the end of 1999).

The main goal of surgery was to completely remove all the infected tissues and to reconstruct the damaged cardiac structures. Subcoronary implantation and cylinder inclusion techniques were mostly used in the first period of the study and when no abscess complicated the surgery; whenever an abscess was present, the technique of choice was the free-standing root implantation.

When the tissue debridement resulted in a discontinuity of the mitro-aortic junction, we used the anterior mitral leaflet coming with the homograft or a part of it to close the defect and to anchor the patient's anterior mitral annulus to the homograft (24.1% of the cases). Then, we directly closed the left or the right atrium if possible or we added a pericardial patch when the lack of tissue was too important (20.5% of cases), as shown in Fig. 1. Intraoperative data are described in Table 2.

Table 2:

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Intraoperative data

.	N = 112 .
Annular/perivalvular abscess	52.7% (n = 59)
Technique of homograft implantation
Cylinder inclusion	13.4% (n = 15)
Subcoronary implant	19.6% (n = 22)
Free-standing root	64.3% (n = 72)
Adjunctive technique after abscess resection
Homograft alone	25.4% (n = 15)
Homograft + anterior mitral leaflet of the homograft	42.4% (n = 25)
Homograft ± anterior mitral leaflet of the homograft + pericardial patch	32.2% (n = 19)
Associated procedures
Mitral valve surgery	26.7% (n = 30)
Tricuspid valve surgery	3.6% (n = 4)
Ascending aorta replacement	23.2% (n = 26)
Coronary artery bypass surgery	12.5% (n = 14)
ECC mean time (min) ± SD	148 ± 50.3
Cross-clamping mean time (min) ± SD	115 ± 32.9

.	N = 112 .
Annular/perivalvular abscess	52.7% (n = 59)
Technique of homograft implantation
Cylinder inclusion	13.4% (n = 15)
Subcoronary implant	19.6% (n = 22)
Free-standing root	64.3% (n = 72)
Adjunctive technique after abscess resection
Homograft alone	25.4% (n = 15)
Homograft + anterior mitral leaflet of the homograft	42.4% (n = 25)
Homograft ± anterior mitral leaflet of the homograft + pericardial patch	32.2% (n = 19)
Associated procedures
Mitral valve surgery	26.7% (n = 30)
Tricuspid valve surgery	3.6% (n = 4)
Ascending aorta replacement	23.2% (n = 26)
Coronary artery bypass surgery	12.5% (n = 14)
ECC mean time (min) ± SD	148 ± 50.3
Cross-clamping mean time (min) ± SD	115 ± 32.9

ECC: extracorporeal circulation.

Table 2:

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Intraoperative data

.	N = 112 .
Annular/perivalvular abscess	52.7% (n = 59)
Technique of homograft implantation
Cylinder inclusion	13.4% (n = 15)
Subcoronary implant	19.6% (n = 22)
Free-standing root	64.3% (n = 72)
Adjunctive technique after abscess resection
Homograft alone	25.4% (n = 15)
Homograft + anterior mitral leaflet of the homograft	42.4% (n = 25)
Homograft ± anterior mitral leaflet of the homograft + pericardial patch	32.2% (n = 19)
Associated procedures
Mitral valve surgery	26.7% (n = 30)
Tricuspid valve surgery	3.6% (n = 4)
Ascending aorta replacement	23.2% (n = 26)
Coronary artery bypass surgery	12.5% (n = 14)
ECC mean time (min) ± SD	148 ± 50.3
Cross-clamping mean time (min) ± SD	115 ± 32.9

.	N = 112 .
Annular/perivalvular abscess	52.7% (n = 59)
Technique of homograft implantation
Cylinder inclusion	13.4% (n = 15)
Subcoronary implant	19.6% (n = 22)
Free-standing root	64.3% (n = 72)
Adjunctive technique after abscess resection
Homograft alone	25.4% (n = 15)
Homograft + anterior mitral leaflet of the homograft	42.4% (n = 25)
Homograft ± anterior mitral leaflet of the homograft + pericardial patch	32.2% (n = 19)
Associated procedures
Mitral valve surgery	26.7% (n = 30)
Tricuspid valve surgery	3.6% (n = 4)
Ascending aorta replacement	23.2% (n = 26)
Coronary artery bypass surgery	12.5% (n = 14)
ECC mean time (min) ± SD	148 ± 50.3
Cross-clamping mean time (min) ± SD	115 ± 32.9

ECC: extracorporeal circulation.

Figure 1:

Operative image of an abscess resection involving the right atrium and the interventricular septum (A), reconstruction with a pericardial patch (B) and aortic valve replacement with the aortic homograft (C). RA: right atrium; LVOT: left ventricular outflow tract; TV: tricuspid valve; RCA: right coronary artery; LCA: left coronary artery; HG: aortic homograft.

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Homografts were all cryopreserved and provided by the European Homograft Bank (EHB, Brussels, Belgium).

Follow-up

The clinical follow-up data were collected by a questionnaire sent to all patients. When the questionnaire was not returned or incomplete, phone contact was made with the patient or the referring physician. Subsequent hospitalization and routine visit data were collected from hospital records and cardiologists' reports. The follow-up time was calculated either to death or to the last verified contact with patient. The follow-up time for valve-related events was calculated until the last valid assessment of these complications and patients were censored at the time of death. Completeness of follow-up was calculated according to Clark et al. [7] and was 93.5%. The median duration of follow-up in this series is 7.8 years (IQR 4.7–17.6) and the cumulative follow-up is 782.5 patient-years. Morbidity and mortality were reported according to the 2008 Society of Thoracic Surgeons/American Association for Thoracic Surgery/European Association for Cardio-Thoracic Surgery guidelines [8]. Early mortality was defined as any death occurring during hospital stay or during the first 30 days after the operation, while any other death was considered a late death. Clinical outcomes of interest were early and late death, valve reoperation, recurrent infective endocarditis and valve-related thromboembolic and bleeding events.

Statistical analysis

All continuous variables were normally distributed after verifying with the Shapiro–Wilk test and were reported as the mean ± SD. Categorical variables were reported as proportions. Survival was estimated with a Kaplan–Meier estimator. A proportional hazard model (Cox regression) was built to identify significant predictors of early and late death. Variables that were significant in the univariable analysis were included in a multivariable model together with clinical meaningful ones (such as age and gender although they were significant or not at univariable test). The Student's t-test was used to detect significant differences between groups for continuous variables and χ² or Fishers' exact tests (when one or more of the cells had an expected count of 5 or less) for the analysis of proportions.

Results were considered statistically significant at a two-tailed P-value of ≤0.05. All analyses were conducted with STATA 11.2 (StataCorp LP, College Station, TX, USA).

RESULTS

Early morbidity and mortality

Eleven patients (9.8%) required chest re-exploration for bleeding in the immediate postoperative period, whereas 1 patient (0.9%) required urgent bypass grafting for coronary ischaemic complications. In addition to the 2 patients who had preoperative complete atrioventricular (A-V) block, 11 patients (9.8%) had a postoperative diagnosis of complete A-V block and underwent a permanent pacemaker implantation within 30 days.

The 30-day mortality for the whole cohort was 13.4% (95% CI 7.7–21.1%; n = 15). Eight patients out of 59 with an abscess died early after surgery accounting for a 30-day risk of death of 13.6% (95% CI 6.0–24.9%) in the presence of an abscess. On the other hand, 7 of 53 patients without an abscess died early for a risk of death of 13.2% (95% CI 5.4–25.3%). The difference in 30-day mortality between these two groups was not statistically significant (P = 0.9). Similarly, 9 of 46 patients with PVE died early after surgery accounting for a 30-day risk of death of 17.4% in the presence of PVE. In the group of NVE, 6 of 66 patients died early for a 30-day risk of death of 9.1%. Similarly, the difference in early mortality between these two groups was not statistically significant (P = 0.15). At univariable Cox regression analysis, none of age, gender, PVE, the presence of an abscess, technique of homograft implantation, associated procedures and the causative pathogen were significant predictors of early death.

Late mortality

Two patients were lost to follow-up; therefore, 95 patients (84.8%) were available for long-term analysis.

The late mortality for the whole cohort was 28.4% (n = 27); a ‘cardiac’ death was diagnosed in 11 patients (40.7%). The overall long-term survival was therefore 80.1% (95% CI 71.3–86.4%), 73.9% (95% CI 64.5–81.3%), 63.6% (95% CI 52.4–72.8%) and 53.8% (95% CI 40.6–65.3%) at 1, 5, 10 and 15 years, respectively.

Eighteen of 50 patients with an abscess died late after surgery accounting for a long-term risk of death of 36% (95% CI 22.9–50.8%) in the presence of an abscess. On the other hand, 9 of 45 patients without an abscess died late for a long-term risk of death of 20% (95% CI 9.6–34.6%) without an abscess. Similarly, 8 of 35 patients with PVE died late after surgery accounting for a long-term risk of death of 22.8% (95% CI 10.4–40.1%) in the presence of PVE. In the group of NVE, 19 of 60 patients died late for a long-term risk of death of 31.7% (95% CI 20.2–44.9%). Long-term survival of all patients and of patients with PVE or NVE is depicted in Figs 2 and 3, respectively.

Figure 2:

Cumulative long-term survival considering the entire cohort: 80.1% (95% CI 71.3–86.4%), 73.9% (95% CI 64.5–81.3%), 63.6% (95% CI 52.4–72.8%) and 53.8% (95% CI 40.6–65.3%), respectively, at 1, 5, 10 and 15 years.

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Figure 3:

Long-term survival according to the type of valve present at the time of surgery. Survival in the PVE group was 91.2 + 4.9%, 77.6 + 7.6% and 64.7 + 13.4%, respectively, at 1, 5 and 10 years. In the NVE group, survival was 93.2 + 3.3, 89.7 + 4.0 and 72.9 + 6.7%, respectively, at 1, 5 and 10 years. PVE: prosthetic valve endocarditis; NVE: native aortic valve endocarditis.

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At univariable Cox regression analysis of the whole cohort, only age was a significant predictor of late death (HR 1.04, 95% CI 1.02–1.07, P = 0.01), whereas abscess, female gender, causative pathogen and prosthetic valve endocarditis were not.

However, when considering only patients who survived the perioperative period, abscess was a significant risk factor for late mortality. Nevertheless, a higher proportion of women and prosthetic valve were found in the abscess group compared with that of the no abscess group (29.4 vs 7%, P = 0.004 and 47.1 vs 28.2%, P = 0.05, respectively). Therefore, after adjusting for age, gender and prosthetic valve, abscess was associated with an HR of 3.2 of late death (95% CI 1.3–8.1, P = 0.01).

Aortic homograft reoperations

Late reoperation occurred in 16 patients (16.8%) at a median time of 11.6 years (IQR 8.3–14.5) after the first operation. Reoperation was needed in 14 cases (87.5%) for structural valve degeneration (SVD; 3 stenosis and 11 regurgitations), and in 2 cases (12.5%) for a new episode of endocarditis. None patient died at reoperation.

Freedom from reoperation was 100, 96.9 ± 2.1, 86.3 ± 5.5 and 47.3 ± 11.0%, respectively, at 1, 5, 10 and 15 years postoperatively (Fig. 4).

Figure 4:

Freedom from homograft reoperation for any cause. At 10 and 15 years, freedom from reoperation was 86.3 ± 5.5 and 47.3 ± 11.0%, respectively.

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At Cox regression analysis, young age was a significant risk factor for reintervention (HR 0.96, 95% CI 0.92–0.99, P = 0.02), whereas the presence of abscess, PVE, the technique of implantation of the homograft, associated procedures, gender and recurrence of endocarditis were not.

Figure 5 shows the freedom from homograft reoperation stratified by age (≤40 and >40 years).

Figure 5:

Freedom from homograft reoperation for any cause stratified by age (≤40 vs >40).

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Recurrence of endocarditis

A new endocarditis episode occurred in 5 patients (5.3%): 1 on the mitral valve, 3 on the aortic valve and 1 on both. Four cases were reinfection and 1 was a relapse (MRSA infection). Three of the 5 patients needed reoperation, 1 was medically treated and 1 died from septic shock without surgery.

Freedom from new endocarditis episodes was 97.8 ± 1.6, 96.3 ± 2.1 and 85.2 ± 7.7% at 1, 10 and 20 years, respectively (Fig. 6).

Figure 6:

Freedom from recurrent endocarditis on the aortic valve with the use of a homograft. At 10 and 15 years, freedom from recurrent infection was 96.3 ± 2.1 and 91.2 ± 5.3%, respectively.

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Thromboembolic and haemorrhagic events

During follow-up, 7 patients (7.3%) experienced an ischaemic stroke, whereas 2 (2.1%) had transient ischaemic attack. Furthermore, 2 patients (2.1%) had a haemorrhagic stroke and 2 (2.1%) patients had a peripheral bleeding. The rate of arterial embolism and major bleeding combined was 1.7% per patient-year.

DISCUSSION

Despite the progress in medical treatment, AIE of the aortic valve often requires a surgical approach, especially in case of extravalvular involvement by the infective process [9]. Surgical treatment in this context is still affected by a high mortality and morbidity, particularly in patients with a prosthetic valve infection [10]. Moreover, the risk of recurrence remains a worrisome complication [11, 12], varying between 2 and 6% [5]. Because of their natural resistance to infection [2], homografts are considered, by various authors [1, 13, 14], the optimal valve substitute, while others believe that prosthetic valves, whether xenografts or mechanical valves, provide comparable or better results than allografts [15]. However, till now, the literature failed to show any significant difference between homograft, biological and mechanical prosthesis [16], and even the ESC 2015 Guidelines do not suggest any universal approach [5].

Our study shows that, despite the high complexity of the intervention and the high incidence of periannular abscess, early mortality after AVR with homograft in acute infective aortic endocarditis (AIAE) is similar to that with biological or mechanical prosthesis as reported in other series [17]. Klieverik et al. [15] found a lower 30-day mortality, but their cohort was younger, with a lower incidence of perivalvular abscess and did not include prosthetic valve endocarditis. Interestingly, we did not find any significant difference in 30-day mortality between NVE and PVE. Therefore, although PVE is usually considered at higher risk of early death [18, 19], the use of homograft in our experience was associated with a similar perioperative risk in both groups.

Furthermore, main postoperative complications in our series were chest re-exploration for bleeding and permanent pacemaker implantation for complete A-V block, similarly with the results of Perrotta et al. [14] without any differences between PVE and NVE.

It is also interesting to see that in our series, no patient suffered infective recurrence during the first 30 postoperative days and only 5 patients presented infection recurrence during the follow-up, of which only 1 was a relapse. With a freedom from recurrence of over 95% at 10 years, we have observed a significantly lower rate of recurrence than series with prevalent use of mechanical prostheses and stented xenografts [19]. These results confirm our current strategy in the management of acute aortic endocarditis. Although we did not change the general admitted indications for surgery, we believe that timing is essential. Indeed, once the indication for surgery is confirmed, the operation should not be further delayed. The reason for an early surgery is primarily to reduce the complications due to the infection (haemodynamic destabilization, septic shock due to the high incidence of abscess and sudden death caused by completed A-V block). Obviously, surgery is very challenging in this acute phase considering tissues fragility (still infected) and the extravalvular and extracardiac localization. In these circumstances, the risk of perioperative contamination and postoperative dissemination is significant. It is admitted by some authors that, in this setting, the most important step is the radical debridement and the complete excision of the infected tissue, while the choice of prosthesis plays a smaller role [10]. If we consider in fact that AIE is often associated with peripheral septic embolization, a condition that may cause a persistent bacteraemia and an early infective relapse after the surgical intervention, we could logically find in the homograft a good ally to fight persistent infection.

A major concern to the use of the homograft is the risk of valve degeneration over time. Indeed, in our cohort, the primary cause of reintervention was structural degeneration, requiring surgery at a median time of over 10 years. Furthermore, freedom from reoperation on the homograft for all causes is similar to that reported by Takkenberg et al. [20], although only 32% of the patients in their series had endocarditis at the time of surgery. Younger age at operation was the only predictive factor for reintervention in our series, obviously due to the longer life expectancy of young patients who expose themselves to a higher risk of homograft degeneration and reintervention. Nevertheless, considering the safety of the reoperation in our experience and the long-term risk of mechanical prostheses, we still consider the homograft a good option in younger patients, particularly in the presence of an abscess. The Ross procedure is another interesting option in such patients with endocarditis limited to the aortic valve as it offers probably more resistance to recurrence than the homograft and better durability. However, this option is not recommended in case of annular destruction since the absence of this anatomical support could result in an early dilatation of the ventricular–aortic junction, leading to the failure of the autograft over time.

Regarding the long-term results, our 10- and 15-year survival, including patients who required reintervention on the homograft, is similar to the survival reported in the literature [1, 17, 21] and, if we consider the patients who survived after the first 30 postoperative days, is adversely affected by the presence of a perivalvular abscess (68.5 ± 7.1% vs 79.2 ± 8.0% at 10 years, P-value = 0.04), as shown also in previous reports [22]. Nevertheless, the presence of an abscess at the time of the intervention was not a significant predictor of early death. This might encourage us, once more, to not hesitate to proceed to surgery even in patients with extreme and disheartening endocarditis. Furthermore, no significant difference was found in survival between patients with previous AVR and those with native valve at the time of surgery (at 5 years 77.6 ± 7.6 vs 89.7 ± 4.0% and at 10 years 64.7 ± 13.4 vs 72.9 ± 6.7%, P = 0.8).

Finally, we cannot forget that as described in the literature, the sensitivity of preoperative echo assessment in detecting abscess during AIAE is as low as 80.5% [23]. Echo may fail in conditions such as in patients with prosthetic valves where the image quality can be limited by the shadow of the prosthesis itself, in very acute infection when the abscess is still made of inflammatory tissue with no echographical evidence of cavity, and in patients with anterior septo-muscular abscess. In such cases with the presence of an undiagnosed abscess, the surgeon may face an unexpected and difficult operative condition where a homograft could be more helpful than a simple prosthetic valve. Indeed, the homograft can more easily fit into a highly inflamed and fragile tissue compared with stented prostheses, and the anterior leaflet of the mitral valve that usually comes with the homograft may also allow an easier reconstruction of the mitro-aortic continuity eventually injured by the abscess [19].

Limitations

This is a retrospective study covering a long period where some selection bias is unavoidable. Moreover, next to the unavailability of certain preoperative data, medical treatment and approaches have evolved during those two and half decades. In the same line, long-term medical treatment was managed mainly by their referring physicians; therefore, differences in individual treatment and lack of standardization may have an impact on long-term outcomes.

CONCLUSION

In this study, we showed that the use of aortic homograft in acute aortic valve endocarditis is associated with a remarkably low risk of relapsing infection and very acceptable long-term survival. The risk of reoperation due to the SVD is significant after one decade especially in young patients. We believe that aortic homograft is ideally suited for reconstruction of the aortic valve and cardiac structures damaged by the infective process and should be available in the operative room particularly in this condition where preoperative assessment could fail in detecting perivalvular abscess.

ACKNOWLEDGEMENTS

The authors thank Corinne Coulon for her outstanding work of data manager.

Conflict of interest: none declared.

REFERENCES

APPENDIX. CONFERENCE DISCUSSION

Dr M. Musci(Berlin, Germany): Low early reinfection rate and the excellent long-term freedom from reinfection reported in this study documents the outstanding role of the homograft in the surgical treatment of infective endocarditis especially in the presence of annular abscess formation and confirms the findings of previous studies, but several aspects have to be highlighted in this analysis, and I would like to focus the discussion on two points: First, what is really the best choice of prosthesis in endocarditis patients; and second, the high incidence of structural valve deterioration of homografts especially in young patients.

The first point. The most important step in surgical treatment of infection is the radical and aggressive debridement of all infective tissue and exclusion of the myocardial abscess from the bloodstream. While in the literature, the role of a prosthesis seems to play a smaller role. Many studies have shown that survival and reinfection rate are independent whether you use a homograft or you use a prosthetic root replacement using mechanical or biological prosthesis. So my question to you is: In your study from 290 replacement patients, 62% didn't have homografts made either biological or mechanical prosthesis. So what is your philosophy in your hospital? You have 30% of homograft and 70% of other.

Dr Solari: Now, at the time, our strategy in surgery is if it's possible if the endocarditis is limited to the aortic leaflets and we can repair the valve, we repair the valve. If it's not possible and you have to change the valve, surely we choose a homograft.

Dr Musci: So do you think that homograft is much better than a mechanical prosthesis, like the first author reported?

Dr Solari: No, because we believe in early surgery. When we pose the indication, surgical indication, we do not attend, we go to the OR. So in this case we have a high risk of peripheral contamination of the peripheral embolization, and in this case we think that the homograft is more resistant to reinfection. That's the first point. The second point is that in the case of very acute endocarditis, very acute surgery in endocarditis, the tissues are more fragile and then we think that homograft can suit better the cardiac structure.

Dr Musci: The second point is structural valve deterioration. Tachenberg could demonstrate in a mathematical analysis the median time to reoperation, for example, it is 23 years for a 65-year-old patient and approximately 12 years in a 25-year-old patient. So my question to you is: What would you recommend to a 40-year-old female patient with abscess formation?

Dr Solari: Well, in this case we have another option maybe, that is the Ross procedure.

Dr Musci: Well, you didn't report about Ross in your study. I saw that you did a lot of repairs.

Dr G. El Khoury(Brussels, Belgium): Yes – sorry, Silvia. I mean, the indication for Ross procedure, at the beginning, even if you have abscess, we went for Ross procedure but the problem is if you have destructed annulus, there is no more support for the Ross. So we abandoned in the presence of abscess to do Ross procedure. We do Ross procedure only in case of limited destruction of the leaflet in young patients. So a patient with abscess, I think in my experience is not that ideal for Ross procedure because the fibrous skeleton is destructed and no more support.

Dr Musci: So I agree with you. But what are you doing with a 40-year-old female patient now?

Dr El Khoury: Homograft, if necessary, yes. I mean, if no way to do the Ross, we go for homograft, yes.

Author notes