Complex aortic valve infective endocarditis (IE) is a serious condition requiring surgical intervention. The optimal surgical approach remains a topic of debate. We sought to evaluate and compare the immediate and long-term results of aortic root replacement (ARR) versus patch repair (PR) in patients with aortic valve IE and root abscess.

A comprehensive search of multiple electronic databases was completed to identify relevant studies published from inception to April 2023. We included studies reporting outcomes of ARR and PR in patients with aortic valve IE complicated by root abscess. Primary endpoints were short and long-term mortality and re-operation rates. Secondary endpoints included permanent pacemaker implantation, single-arm pooled incidence of mortality, recurrence, and re-operation.

A total of 32 studies met the inclusion criteria (n=2,554). We found no difference in short-term mortality (odds ratio [OR] 1.12; 95% confidence interval [CI] 0.70–1.80; I²=34%). The PR group had superior long-term survival (hazard ratio [HR] 0.69; 95% CI 0.52–0.90; I²=25%), however, they also had a significantly increased need for re-operation (HR 1.79; 95% CI 1.11–2.88; I²=0%). There were no differences in postoperative permanent pacemaker insertion (OR 0.62; 95% CI 0.34–1.12; I²=0%). Using a meta-analysis of proportions, the pooled rate of documented IE recurrence following was 5% after ARR and 8% after PR.

Our review shows a long-term survival benefit associated with PR for aortic root abscesses. This benefit is offset by a higher incidence of re-operations and IE recurrence. ARR appears to confer better protection against recurrence. However, based on the available weak evidence, individualised approaches should still be considered until further robust data is available to guide treatment decisions.