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Ann Thorac Surg 1998;65:1450-1452
© 1998 The Society of Thoracic Surgeons

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Case Reports

Ross Operation and Mitral Homograft for Aortic and Tricuspid Valve Endocarditis

^a Service de Chirurgie Cardiaque, Hôpital Cardiologique, Centre Hospitalier Régional et Universitaire de Lille, Lille, France

Accepted for publication December 3, 1997.

Address reprint requests to Dr Prat, Service de Chirurgie Cardiaque, Hôpital Cardiologique, Centre Hospitalier Regional Universitaire, 59037 Lille Cedex, France
e-mail: (aprat{at}chru-lille.fr)

	Abstract

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We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta–right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful.

	Introduction

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Several surgical techniques have been reported for the treatment of infective endocarditis. These include the use of mechanical valves, bioprotheses, homografts, or pulmonary autografts. Although the choice of surgical technique remains debatable, it has been established that the radical excision of all infected tissue is a prerequisite for the successful treatment of the condition. We report here a case of aortic and tricuspid valve endocarditis associated with a congenital aorta–right atrium fistula treated with a Ross procedure and a cryopreserved mitral homograft.

A 26-year-old woman was referred to the emergency department in April 1997 for acute dyspnea, weakness, and persistent fever. Her medical history revealed only an unexplored grade 2/6 systolodiastolic murmur and a cesarean delivery 15 days earlier. A physical examination of the patient disclosed a grade 4/6 systolic and diastolic murmur. A chest radiograph showed mild cardiomegaly, and the electrocardiogram showed a sinusal tachycardia. Transthoracic Doppler echocardiography revealed a massive aortic and tricuspid regurgitation, and several vegetations were observed on the posterior leaflet of the tricuspid valve. A fistula was noted with a continuous flow (> 4 m/s) between the noncoronary sinus and the right atrium. These data confirmed the diagnosis of acute aortic and tricuspid valve endocarditis. Blood cultures were positive for Staphylococcus epidermidis. Intravenous antibiotics including penicillin (semisynthetic ß-lactamase–resistant) and gentamicin rapidly controlled the septic syndrome. Abdominal echography and a dental examination revealed no focal infection. Based on these findings, we concluded that the endocarditis was probably related to the recent obstetric procedure.

Operation was indicated for the correction of the massive aortic and tricuspid incompetence. There was a direct fistulous communication 6 mm in diameter between the aortic noncoronary sinus and the right atrium. This fistula was a congenital form of aneurysm of the sinus of Valsalva, readily distinguishable from an acquired mycotic aneurysm (Fig 1).

View larger version (122K): [in this window] [in a new window]   Fig 1. Left (*) and right (**) coronary buttons detached from the aortic wall. The fistula originates from the noncoronary sinus (arrow).

View larger version (122K): [in this window] [in a new window]   Fig 2. Replacement of the tricuspid valve with a mitral homograft. The annular anastomosis was made with continuous running sutures.

	Comment

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The aortic valve is a more common site of infective endocarditis than the tricuspid valve. Valve replacement is indicated in cases of uncontrolled sepsis, congestive heart failure, or recurrent systemic emboli. In young patients, advantages of the autograft include long-term durability of autologous tissue, excellent hemodynamics, an absence of thromboembolism, and no need for anticoagulation treatment [1].

Although a more complex procedure than a simple aortic valve replacement, aortic root replacement with a pulmonary autograft is safe [2]. Oswalt [3] reported no deaths and no recurrent infections for up to 3.5 years postoperatively in a group of 20 patients operated on for active endocarditis.

Tricuspid valve endocarditis is rare and usually occurs in intravenous drug users. Cases have also been reported in patients with a right heart congenital defect [4]. The surgical management of patients with this condition remains disputable, with treatments ranging from tricuspid valve excision to valve repair or valve replacement. In the first procedure, tricuspid incompetence may lead to valve replacement as a second-stage procedure if infection is eradicated [5]. Tricuspid valve repair after partial resection is certainly the most attractive treatment, but it is not feasible in the case of massive valvular damage. Pomar and associates [6] have achieved good results using a cryopreserved mitral valve homograft as an alternative to other methods of tricuspid valve replacement in septic tricuspid endocarditis.

The case of the patient described here is quite remarkable. This uncommon simultaneous left and right-sided endocarditis was the consequence of a fistula between the aortic noncoronary sinus and right atrium.

In conclusion, autograft and homograft implantation is a good alternative to prosthetic valve replacement for the treatment of multivalvular endocarditis in carefully selected young patients.

	References

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1. Ross D., Jackson M., Davies J. The pulmonary autograft. A permanent aortic valve. Eur J Cardiothorac Surg 1992;6:113-117.[Abstract]
2. Prat A.G., Doisy V., Savoye C., Moreau D.C., Monier E.J., Stankowiak C. Total aortic root replacement with pulmonary autografts: short-term results in 45 consecutive patients. J Heart Valve Dis 1995;4:368-373.[Medline]
3. Oswalt J. Management of infective endocarditis by autograft valve replacement. J Heart Valve Dis 1994;3:377-379.[Medline]
4. Hvass U., Lansac E., Chatel D., Henri I. Mitral homograft for tricuspid valve endocarditis complicating a congenital fistula between the right coronary artery and right ventricle. J Heart Valve Dis 1996;5:564-566.[Medline]
5. Arbulu A., Holmes R.J., Asfaw I. Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years’ experience. J Heart Valve Dis 1992;2:129-137.
6. Pomar J.L., Mestres C.A., Pare J.C., Miro J.M. Management of persistent tricuspid endocarditis with transplantation of cryopreserved mitral homografts. J Thorac Cardiovasc Surg 1994;107:1460-1463.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alain Prat Vincent Doisy Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Prat, A. Articles by Shaaban, G. Search for Related Content PubMed PubMed Citation Articles by Prat, A. Articles by Shaaban, G.