Outcomes After Surgical Treatment of Infective Endocarditis with Destruction of the Cardiac Skeleton

<i>Background and Objectives</i>: Infective endocarditis (IE) continues to represent a life-threatening clinical entity, particularly in patients with advanced involvement of the cardiac fibrous skeleton. This study was designed to determine the incidence and to evaluate both short- and long-term outcomes in patients undergoing complex surgical intervention necessitating patch reconstruction for extensive and destructive IE. <i>Materials and Methods</i>: Between January 2008 and December 2024, 678 patients underwent cardiac surgery for IE at University Hospital Frankfurt/Main. The primary endpoint was long-term survival; the secondary endpoint was freedom from reoperation. <i>Results</i>: Ninety-six patients (14%) required complex patch reconstruction, owing to the severe involvement of the cardiac fibrous skeleton. The median age was 68 years (interquartile range [IQR], 16.5 years). Forty-three patients underwent redo surgery following previous cardiac procedures. Abscess formation was identified in 88% of cases (n = 85). Infective endocarditis was predominantly left-sided in 97% of patients (n = 94). In 40 patients (41%), the aortomitral continuity or the left ventricular outflow tract (LVOT) was involved. Combined surgical procedures were performed in 85 patients (87.6%), including 19 commando or hemi-commando operations. Thirty-day mortality was 20% (n = 19). The estimated 5- and 10-year survival rates were 46.5 ± 5.5% and 26.1 ± 6.8%, respectively. Survival did not differ significantly between native and prosthetic valve endocarditis, nor between commando/hemi-commando procedures and cases with abscess formation but preserved aorto-mitral continuity. <i>Conclusions</i>: In industrialized countries, extensive IE with abscess formation or destruction of the cardiac skeleton is predominantly associated with <i>Staphylococcus aureus</i>. Patients undergoing commando or hemi-commando procedures do not experience inferior survival compared with other patients with extensive IE. No survival advantage was observed for native versus prosthetic valve IE in the presence of extensive abscess formation.