Ann Thorac Surg 1996;62:262-264
© 1996 The Society of Thoracic Surgeons
Case Report
Fringed Valve Prosthesis for Aortic Root Abscess
Jun-ichi Hayashi, MD,
Shoji Eguchi, MD,
Haruo Miyamura, MD,
Hisanaga Moro, MD
Second Department of Surgery, Niigata University School of Medicine, Niigata, Japan
Accepted for publication January 2, 1996.
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Abstract
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Two patients with aortic root abscess were successfully treated with a fringed valve prosthesis, in which a fringe material was secured to the sewing cuff of a bileaflet prosthetic valve using a 4-0 running suture. This fringed valve technique provides dual security for annular attachment of the prosthesis without coronary reimplantation. Good late outcome suggests it would be a useful alternative for aortic root abscess.
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Introduction
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Annular mycotic aneurysm associated with aortic valve endocarditis often presents various surgical problems including management of the abscess cavity, coronary artery reimplantation, and repair of the left ventricular outflow tract [1–3]. Recently a composite valved conduit and an aortic root allograft were reported as useful alternatives [1, 4] because of the high incidence of valve dehiscence in conventional aortic valve replacement with debridement of the abscess cavity. We report here a simplified surgical procedure named ``fringed valve prosthesis'' in which a fringe material is secured to the sewing cuff of a bileaflet prosthetic valve to reinforce the prosthetic valve seat and the annular attachment to the prosthesis without reimplantation of the coronary arteries.
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Case Reports
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Patient 1
A 47-year-old man was referred to the Cardiac Surgery Department for severe aortic regurgitation associated with Behçet's syndrome [5] in June 1991. Mild iritis and genital ulceration with multiple nodular erythema on both legs were noted at the time of admission. Although he had received standard glucocorticoid treatment (oral prednisolone, 40 mg/day) and inotropic support for 5 months, orthopnea occurred two times. Blood culture examination revealed no microorganisms causing endocarditis. Chest x-ray examination showed moderate cardiomegaly (cardiothoracic ratio, 0.60), and echocardiography revealed severe aortic valve regurgitation with a dilated left ventricle (end-diastolic dimension, 67 mm).
Operation was performed on July 3, 1991, because of recurrent cardiac failure and echocardiogram-documented aortic root abscess. A standard cardiopulmonary bypass was set and the patient was cooled to 28°C. For myocardial protection during aortic cross-clamping, both antegrade and retrograde infusion of blood cardioplegic solution were used. A perforation 10 mm in diameter was observed in the left coronary cusp, and there was a cavity 13 mm in length and 8 mm in width in the noncoronary aortic annulus attached to the interventricular septum.
All cusps were removed and curettage of the abscess cavity was performed. Teflon felt strips laid both superior to the interventricular septum and on the outside of the aortic wall were used for complete closure of resultant defect. As the fibrous annulus was thin and fragile, the left coronary annulus was reinforced with a felt strip. At the same time, on the operating table, a fringed valve prosthesis was made as follows: first, a hole was cut in the fringe material with the same diameter as the internal orifice of the prosthesis, and the holed fringe of about 20 mm in width was sutured to the sewing cuff of a bileaflet valve using a running 4-0 suture (Fig 1, a
). Then, the sewing cuff of the fringed valve was sutured to the native aortic valve annulus and reconstructed annulus in everting mattress fashion using 2-0 polyester sutures (Fig 1, b). Finally, the edge of the fringe was trimmed away so that the aortic root excluding both right and left coronary ostia could be covered appropriately, and it was sutured to the aortic wall using 3-0 polyester sutures (Fig 1, c). The aorta was closed with felt strips using 4-0 continuous sutures. Terminal warm blood cardioplegia was infused through the coronary sinus retrogradely, and aortic clamp was removed. The heart was soon defibrillated and easily weaned from cardiopulmonary bypass. Follow-up echocardiogram revealed no periprosthetic leakage and normalization of the left ventricular dimension at 49 months after the operation. Oral prednisolone of 20 mg/day has been given for preventing recurrence of Behçet's syndrome.
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Fig 1. . Schema of a fringed valve prosthesis with a bileaflet prosthetic valve. (a) The prosthetic valve is sutured to the holed fringe material with a running 4-0 suture on the operating table. (b) Using 2-0 polyester sutures with pledget through fibrous or reconstructed annulus or free aortic wall, the sewing cuff of the fringed valve is secured to the ordinary aortic valve position. (c) After the edge of the fringe is trimmed, it is sutured to the wall of the aortic root with 3-0 polyester sutures. (Ao = aortic wall; CA = coronary artery; Fr = fringe; IVS = interventricular septum; L = left coronary ostium; P = prosthetic valve; Pa = autologous pericardial patch; R = right coronary ostium.)
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Patient 2
A 35-year-old man suffered from infective endocarditis in June 1993. Streptococcus viridans was found as the causing microorganism, and the patient received antibiotic treatment using fosfomycin and imipenem for 4 weeks. Although the white blood cell count became normal and the level of serum C-reactive protein was reduced, aortic valve regurgitation appeared and was exacerbated despite antibiotic therapy. A subvalvular abscess cavity and moderate aortic regurgitation with moderate dilatation of left ventricular chamber were detected by echocardiography (left ventricular diastolic dimension, was 68 mm). On chest x-ray examination, pleural effusion on both sides and pulmonary congestion were observed with a cardiothoracic ratio of 0.53.
An urgent operation was performed on August 5, 1993. Findings were chordal rupture on the anterolateral portion of the anterior mitral leaflet and infected aortic valve with abscess cavity on the anterior portion of the right and left cusps of the congenital bicuspid valve. All cusps were removed, and curettage of the abscess cavity was performed up to the superior interventricular septum. The intraseptal cavity was closed with a piece of glutaraldehyde-treated autologous pericardium (size, 30 x 20 mm) using a running 3-0 polypropylene suture. Then, chordal reconstruction was performed using 5-0 polytetrafluoroethylene sutures followed by Kay's mitral annuloplasty. Finally, 2-0 polyester sutures with pledgets were placed on the aortic annulus and stitched from outside of the aortic wall in areas where the annulus had been reconstructed with the pericardial patch. A hand-made fringed valve prosthesis with a 21-mm CarboMedics (Austin, TX) valve was sutured. The rest of the procedure was similar to that described in patient 1. In this case, equine pericardium (Xenomedica) was used as the fringe, whereas filamentous Dacron (Baxter Edwards AG, Switzerland) was used in patient 1.
The patient was easily weaned from cardiopulmonary bypass. Blood culture examination revealed massive gram-negative rods in the infected tissue, and antibiotic treatment was continued for 8 weeks. No hemodynamic abnormalities were found in echocardiograms at 25 months after the operation.
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Comment
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More aggressive procedures including use of an allograft or valved conduit have been reported as alternatives in aortic root reconstruction after debridement of a periannular abscess [1, 2, 4]. However, these procedures have limited application because of the increasing risk of complications in the root reconstruction using a composite valved conduit [1] and the limited availability of aortic root allografts in Japan. In many cases, the destroyed annulus and abscess cavity in the left ventricular outflow tract could be successfully reinforced with felt strips and pericardial substitute [3]; the coronary ostium is ordinarily not involved with the abscess cavity. Our fringed valve prosthesis would sufficiently secure the prosthetic valve against both the aortic annulus and the aortic root without reimplantation of coronary arteries if there remains sufficient room between the reconstructed annulus and coronary ostia to suture the fringe. Since 1987, we have used this procedure in 4 selected cases of annuloaortic ectasia; we used filamentous Dacron as the fringe in 3 patients and equine pericardium in 1. In our limited experience, equine pericardium might be preferable as the fringe because of easier handling and better attachment to the aortic wall. No periprosthetic leakage or sequelae were observed in any of the patients in this series.
A fringed valve prosthesis would be a useful alternative for aortic root abscess without involvement of the coronary ostia and without complete disruption of the ventriculoaortic connection.
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Footnotes
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Address reprint requests to Dr Hayashi, Second Department of Surgery, Niigata University School of Medicine, 1-757 Asahimachidohri, Niigata City, 951, Japan.
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References
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- Ergin MA, Raissi S, Follis F, Lansman SL, Griepp RB. Annular destruction in acute bacterial endocarditis: surgical technique to meet the challenge. J Thorac Cardiovasc Surg 1989;97: 755–63.[Abstract]
- Fiore AC, Ivey TD, McKeown PP, Misbach GA, Allen MD, Dillard DH. Patch closure of aortic annulus mycotic aneurysms. Ann Thorac Surg 1986;42:372–9.[Abstract/Free Full Text]
- David TE, Komeda M, Brofman PR. Surgical treatment of aortic root abscess. Circulation 1989;80(Suppl 1):269–74.
- Albertucci M, Wong K, Petrous M, et al. The use of unstented homograft valves for aortic valve reoperations: review of a twenty-three-year experience. J Thorac Cardiovasc Surg 1994;107:152–61.[Abstract/Free Full Text]
- Lewis PD. Behçet's disease and carditis. Br Med J 1964;1:1026–7.[Medline]
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Abstract
Introduction
