Aortomitral endocarditis: is there a perfect biological solution?

I read with great interest the paper by the Leipzig group about the 5-year outcomes following complex reconstructive surgery (aortic and mitral valve replacement) for infective endocarditis involving the intervalvular fibrous body. The 3- and 5-year survival rates for all patients were 45.3 ± 5.1% and 41.8 ± 5.8%, and for those who survived the first 90 postoperative days were 75.8 ± 6.1% and 70.0 ± 8.0%, respectively. The overall 5-year freedom from reoperation was 85.1 ± 5.7%. Double valve replacement (aortic and mitral valve) and patch reconstruction of the intervalvular fibrous body are the standard techniques [1]. Aortic valve neocuspidization (Ozaki procedure) with transaortic mitral valve patch repair (hemi-Commando) using exclusively autologous pericardium especially in young patients with infective endocarditis is an innovative approach [2, 3]. Ozaki et al. showed that the midterm outcomes of aortic valve neocuspidization using autologous pericardium were satisfactory in 850 patients with various aortic valve diseases. There was no conversion to a prosthetic valve replacement. Actuarial freedom from death, cumulative incidence of reoperation and of recurrent moderate aortic regurgitation or greater was 85.9%, 4.2% and 7.3%, respectively, with the longest follow-up of 118 months [2]. Benedetto et al. combined the use of autologous pericardium for aortic valve repair and mitral valve repair. They did not use any prosthetic material so they avoided the risk of reinfection. It is also noteworthy to mention that they used the transaortic approach for the treatment of the perforation of the anterior mitral valve leaflet so a left atriotomy was not necessary [4]. It is really an interesting approach that might be a promising tool for young patients particularly those patients with infective endocarditis whose final treatment is double valve replacement with mechanical prostheses. Before we reach final conclusions we need more patients to be treated with this approach with longer follow-up because we have to confirm whether the rates of degeneration of glutaraldehyde-treated pericardial tissue, especially for patients with infective endocarditis, are low [5].