CONGRESS ABSTRACT

Reoperative aortic root surgery for infective endocarditis (IE) on a bioprosthesis represents one of the most formidable challenges in modern cardiac surgery. This condition is frequently associated with extensive anatomical destruction, including annular involvement, perivalvular abscesses, pseudoaneurysms, or intracardiac fistulae. Consequently, aggressive surgical management is mandatory to eradicate the infection and restore structural integrity. After radical debridement, aortic root reconstruction typically follows two primary pathways: cryopreserved homografts (allograft) or prosthetic conduits. Homografts are considered the biological gold standard for destructive endocarditis. As human tissue, allografts exhibit superior resistance to recurrent infection and provide excellent hemodynamics. Their inherent flexibility allows for the tailoring of the conduit to cover extensive abscessual defects (e.g., patching of the sinuses of Valsalva). However, limited availability and a long-term tendency toward calcification restrict their universal application. On the other hand, "on-the-shelf" prosthetic grafts for sub-annular Bentall procedure, anchoring the prosthesis deeper than the native annular plane, has immediate availability and a standardized surgical technique. In the current literature, perioperative mortality remains high (15–25%), reflecting the severity of the pathology and the inherent fragility of the reoperative patient population. In our center, from January 2020 to December 2025, 38 sub-annular Bentall procedures for aortic bioprosthetic endocarditis have been performed, paired with various associated planned procedures. Risk profile of those patients is high (median EuroSCORE 35) with a common clinical presentation of septic shock (25%). Procedure remains long and challenging (median cross clamp time 180 min) but no in-theater mortality has been observed. In-hospital mortality has been observed in 5 patients (14.7%), mainly those presenting with septic shock or undergoing more than 2 nd procedure. Transfusional support and inotropic support were high as expected (median VIS score 30). Most frequent complications included revision for bleeding (but without identifiable source) in 65%, and need for renal replacement therapy (48%). Despite technically challenging, this sub-annular Bentall might produce an “on-the-shelf” and readily available graft for complex redo procedures, and limitations of homograft might be overcome.