Abstract
INTRODUCTION: Prosthetic valve endocarditis following aortic root replacement (ARR) typically necessitates redo-ARR, which involves complete graft removal, extensive aortic root dissection, and coronary reimplantation. This highly invasive procedure carries substantial surgical risk, including high operative mortality. In select high-risk patients without evidence of prosthetic graft infection, alternative surgical strategies may reduce procedural complexity and improve outcomes. CASE PRESENTATION: Here, we report 3 cases of prosthetic valve endocarditis following the Bentall procedure, a common ARR technique, in older patients (mean age: 73.7 ± 3.5 years). All preoperative blood cultures were negative, and no signs of prosthetic graft infection were noted on CT. Due to advanced frailty (Clinical Frailty Scale scores of 7 or 8), conventional redo-ARR was deemed prohibitively high-risk. Risk assessment using the JapanSCORE showed a mean predicted mortality of 32.5% ± 21.0%, with combined mortality and morbidity of 63.7% ± 22.9%. Instead of redo-ARR, annular reconstruction using a bovine pericardial patch was performed, followed by redo aortic valve replacement. All patients underwent successful surgery with no postoperative reinfection. One patient required prolonged intensive care and was transferred to another facility for rehabilitation, while the other 2 recovered uneventfully and were discharged. During a mean follow-up of 26.3 ± 17.6 months, 2 patients died due to non-cardiac causes: one from pneumonia and the other from gastric cancer. CONCLUSIONS: In high-risk patients without clear evidence of prosthetic graft infection, aortic valve replacement with annular patch reconstruction may represent a viable alternative to redo-ARR, particularly in settings where homografts are not readily available. This approach reduces operative complexity while maintaining structural integrity. Further studies are warranted to validate infection control criteria and assess long-term outcomes.