Aortic valve reconstruction using pericardium for infective endocarditis

Abstract

Background:

Aortic valve endocarditis with annular abscess is a serious disorder, requiring complete debridement of infected tissue and aortic valve repair.

Methods:

68-year-old male presented with infective endocarditis of severe aortic regurgitation with mobile vegetations on the aortic valve and Valsalva sinus aneurysm.

Results:

He underwent emergency surgery that included complete patch and aortic valve reconstruction using autologous pericardium. Antibiotics was strongly administrated. Echocardiography showed trivial aortic regurgitation and computed tomography showed reconstructed aortic valve.

Conclusion:

This unique technique of aortic valve reconstruction was successfully applied to a patient with aortic valve endocarditis.

Introduction

The use of a prosthesis to treat aortic valve endocarditis with an annular abscess was associated with high mortality and poor prognosis compared with an allograft; ¹ however, an allograft could not be prepared in all the cases, especially in emergency cases. Recently, aortic valve reconstruction was successfully performed with autologous glutaraldehyde-treated pericardium. ² We describe a case of successful aortic valve reconstruction using autologous pericardium for aortic valve endocarditis with annular abscess.

Case report

A 68-year-old man who suffered from continuous high fever and back pain was transferred to our hospital. Because his stool and blood cultures showed the presence of methicillin-resistant Staphylococcus aureus (MRSA), antibiotic therapy including linezolid was continued for 2 months and terminated when cultures were negative for MRSA. However, 2 weeks later, he suddenly developed orthopnea and shock. Echocardiography showed severe aortic valve regurgitation with mobile vegetations on the aortic valve and the noncoronary sinus of Valsalva aneurysm (Figure 1). An emergency operation was performed because of his hemodynamics instability.

Figure 1.

Preoperative echocardiography showing severe aortic valve regurgitation with annular abscess (white arrow).

Under general anesthesia, the pericardium was exposed through a median sternotomy. Autologous pericardium (8 cm × 12 cm) was soaked in 0.6% glutaraldehyde solution with a buffer for 10 min followed by irrigation three times in physiological saline solution.

Cardiopulmonary bypass was instituted and the aortic valve procedure was performed under intermittent cardioplegic arrest. The aortic valve and sinus of Valsalva were exposed through a transverse aortotomy. There was calcification of the aortic valve cusp, noncoronary leaflet perforation of the aortic valve and bulging of the noncoronary sinus of Valsalva with degenerative tissue (Figure 2(a) and (b)). There was also vegetation on the right coronary cusp, and it was removed using a Cavitron Ultrasonic Surgical Aspirator (CUSA) (SonoSurg, Olympus, Tokyo, Japan). A defect of the annular tissue of the noncoronary cusp was closed using a glutaraldehyde-treated autologous pericardial patch and 6-0 polyprolene suture to exclude the bulging area of the Valsalva (Figure 2(c)). The distance between each commissure was measured to determine the size of the new cusp using a sizing instrument (The OZAKI APS; Yasuhisa KOKI Co., Ltd, Tokyo, Japan), and the glutaraldehyde-treated autologous pericardium was trimmed to the appropriate size. These three created cusps were sutured to the right and left annulus and on the pericardial annular patch at the noncoronary annulus with 4-0 polypropylene suture (Figure 2(d)). Intravenous linezolid was continued for 2 weeks followed by intravenous teicoplanin for 6 weeks until inflammatory responses turned negative. Postoperative echocardiography showed trivial aortic regurgitation and closure of the noncoronary annular defect (Figure 3(a)). Postoperative computed tomography showed closed noncoronary annular defect by the pericardial patch (Figure 3(b) and (c)). He was transferred to another hospital on the 72nd postoperative day and was doing well without any events 6 months after the operation.

Figure 2.

Operative pictures showing (a) a noncoronary leaflet perforation (white arrow), (b) annular abscess (white arrow), (c) closed annular cavity with pericardium and (d) reconstructed pericardial cusps on the annular patch.

Figure 3.

(a) Postoperative echocardiography and schema showing repaired noncoronary annulus (arrow) with pericardial patch. (b, c) Postoperative computed tomography showing pericardial patch on the noncoronary cusp (black arrow).

Discussion

For the treatment of aortic valve endocarditis, the aortic homograft is thought to be the gold standard; however, good results have also been achieved with the use of a stentless valve. ³ In some situations, these homografts and xenografts are not available, and other alternative procedures using mechanical and biological prosthesis and the Ross procedure should be considered. Moreover, recent reports have failed to confirm the superiority of allografts over other conduits in terms of long-term survival and freedom from reoperation. As an alternative technique, aortic valve repair using autologous pericardium for active endocarditis was reported to result in better survival compared with valve replacement. ⁴ The best treatment for aortic valve endocarditis is controversial.

Durán et al. ⁵ described aortic valve repair using autologous pericardial cusp extension. The technique included commissurotomy, annuloplasty, cusp free-edge unfolding and supra-aortic crest enhancement, and the actual freedom from reoperation at 13 years was 75%. Recently, Schäfers et al. ⁶ achieved successful results in aortic valve reconstruction with aortic valve assessment, including measuring the effective height and evaluating cusp configuration. Furthermore, freedom from reoperation in reconstructed tricuspid valves for active aortic valve endocarditis was 87% at 5 years, which was identical to that in patients who underwent aortic valve replacement. ⁴

Concerning the use of pericardial aortic valve leaflet grafts, Hammer et al. ⁷ reported guidelines for sizing an unstrained leaflet estimated from the diameter of sino-tubular junction in a single-leaflet replacement. Ozaki et al. ² reported original total aortic valve reconstruction. Although long-term results were not reported, this technique was reproducible and provided an alternative strategy for aortic valve reconstruction.

Radical debridement of the annular abscess requires annular reconstruction. Several materials including autologous pericardium, equine pericardium, and Dacron patch have been used to close the abscess. ¹ In our case, a noncoronary annulus was created with an autologous glutaraldehyde-treated pericardial patch, which had stiffness and flexibility facilitating to cut out the pericardium in accordance with the annular defect.