Ann Thorac Surg 1998;66:2108-2110
© 1998 The Society of Thoracic Surgeons
Case Reports
A brimmed valved conduit in repair of fibrous skeleton abscess
Takayuki Kameyama, MDa,
Fumitaka Ando, MDa,
Fumio Okamoto, MDa,
Masaharu Hanada, MDa,
Nozomu Sasahashi, MDa
a Department of Cardiovascular Surgery, Hyogo Kenritsu Amagasaki Hospital, Amagasaki, Japan
Accepted for publication June 2, 1998.
Address reprint requests to Dr Kameyama, Department of Cardiovascular Surgery, Hyogo Kenritsu Amagasaki Hospital, Higashi-Daimotsu 1-1-1, Amagasaki 660, Japan
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Abstract
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Aortomitral common annular involvement, which is not uncommon in infective endocarditis, necessitates deliberate surgical procedures. To repair fibrous skeleton abscess accompanied with annuloaortic ectasia, we used a brimmed valved conduit. Tension-free reconstruction of the aortic root and aortomitral common annulus was easily performed with this method.
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Introduction
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More than one third of cases of infectious endocarditis are complicated with annular abscess [1]. It must be fully excised in surgical operation. We present a case of combination of annuloaortic ectasia and infectious endocarditis that required reconstruction of the aortic root and aortomitral common annulus, and mitral valve replacement.
A 48-year-old man suddenly experienced high fever and fatigue July 8, 1997. He visited a nearby hospital on July 14. There he underwent detailed examination, and diagnosis of annuloaortic ectasia and infectious endocarditis was made. Immediately after the urgent admission, a blood culture was performed, which grew methicillin-resistant Staphylococcus aureus. His fever and signs of systemic inflammation gradually subsided with medical therapy, however, serial echocardiogram revealed residual annular abscess and worsening mitral regurgitation. On July 28, the patient was transferred to our hospital for surgical therapy, and transesophageal echocardiography was performed, which revealed existence of the abscess at the junction of the aortic annulus and mitral annulus, and blood flow passing from the left ventricular outflow tract to the left atrium through the abscess. His aortic root showed the typical appearance of annuloaortic ectasia, and aortic regurgitant flow was against the anterior leaflet of mitral valve. The anterior mitral leaflet showed slightly abnormal echogenicity, and mitral regurgitation was also detected. We took into consideration emergent operation, because of the existence of the abscess and valve regurgitation, however, at that time the patient’s general condition was very stable. We decided to delay the operation until the local inflammation had abated. Medical therapy was continued for 4 more weeks. Surgical operation was performed electively August 21. Under general anesthesia, a normal median sternotomy incision was made. After encircling the aorta and venae cavae with tape, arterial and venous cannulas were inserted into the ascending aorta and venae cavae, respectively. Extracorporeal circulation with moderate hypothermia was commenced; then the ascending aorta was clamped and retrograde cold blood cardioplegic solution was administered. A transverse aortotomy was made when we found that an abscess cavity existed under the left noncoronary commissure as preoperatively diagnosed. Its floor was perforated into the left atrial cavity. Next, a so-called combined transseptal–superior left atriotomy was made. The aortotomy incision was extended to the left noncoronary commissure, then this line was extended again until being connected with the left atrial incision line. These combined incisions enabled us to resect the whole abscess with its surrounding fragile tissue (three aortic cusps, the major part of the common annulus, and the anterior mitral leaflet). Now the aortic orifice and mitral orifice became one large opening, and an excellent operative view was obtained (Fig 1, lower left). A prosthetic valve (St. Jude, 29 mm, St. Jude, MN) was implanted with pledgeted U-stay sutures placed in the residual mitral annulus. In the portion facing the resected common annulus, U-stay sutures were placed only in the prosthetic skirt. A previously made brimmed valved conduit (St. Jude, 25 mm with a 28-mm Dacron [Boston, MA] tube graft, Fig 1, upper) was seated with pledgeted U-stay sutures placed in the residual aortic annulus. The brim was made with a part of a Dacron (C. R. Bard, Haverhill, PA) tube graft internally lined with equine pericardium. After the brim was trimmed properly for the spatial relation with the surrounding tissues, it was sutured onto the residual common annulus. Then the U-stay sutures that had been placed only in the mitral prosthetic skirt were passed through the brim, again properly for geometric relation, and secured. With these procedures, aortic root reconstruction and mitral valve replacement were eventually completed. Then the rest of the brim was trimmed, and the left atrial superior wall was repaired (Fig 1, lower right). Reimplantation of the coronary orifice cuffs and a distal anastomosis of valved conduit with ascending aorta were done. Warm terminal cardioplegic solution was infused through the aortic root cannula, and the aortic cross-clamp was removed. The patient was easily weaned from the extracorporeal circulation when rewarming and removal of air were completed. Hemodynamics were good and there was no difficulty with hemostasis. The resected abscess showed suppurative endocarditis on pathologic examination, but no bacteria were grown from it. The postoperative course was uneventful. Intravenous antibiotics administration was continued for approximately 5 weeks postoperatively. At 6 weeks after the operation he was discharged from our hospital with no significant problem. At present his clinical status is New York Heart Association class I without signs of recurrence of infectious endocarditis and valve malfunction.
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Comment
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Fibrous skeleton abscess is a not uncommon pathologic occurrence in the course of infectious endocarditis. As many investigators have mentioned, these inflamed tissues must be fully excised. It is also very important to avoid local tension. Various ideas [2–5] have been advocated about the method of annular reconstruction. Practically, after resection of the majority of the aortomitral curtain, it is difficult to determine the correct suture line for the prostheses. In our method, both aortic and mitral prostheses were seated before annular reconstruction. This means that the planes of the aortic and mitral rings are determined first. Then, the common ring can be reconstructed to minimize the tension in the prosthetic suture lines. Our method is useful for ease of reconstruction of aortomitral common annulus and reduction of time. From the viewpoint of an accessible operative field, connection of the incision line of the superior left atriotomy with that of the Manouguian incision produced excellent views of both valves and the fibrous skeleton. This method makes suturing on the mitral and aortic annular remnant easier. Some authors have recommended the autologous pericardium, rather than prosthetic material, for reconstruction of the fibrous skeleton [1]; however, we are afraid that the autologous pericardium might be too weak for that. Therefore, we made the brim of the conduit with a Dacron prosthesis internally lined with equine pericardium, such that it had both appropriate strength and resistance to infection. A recently published report [6] showed a relatively high rate of recurrence in patients undergoing operations for paravalvular abscess. For this reason we think this patient must be closely watched for recurrence.
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References
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David T.E., Komeda M., Brofman P.R. Surgical treatment of aortic root abscess. Circulation 1989;80(Suppl 1):269-274.
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Watanabe G., Haverich A., Speier R., Dresler C., Borst H.G. Surgical treatment of active infective endocarditis with paravalvular involvement. J Thorac Cardiovasc Surg 1994;107:171-177.[Abstract/Free Full Text]
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Ergin M.A., Raissi S., Follis F., Lansman S.L., Griepp R.B. Annular destruction in acute bacterial endocarditis. J Thorac Cardiovasc Surg 1989;97:755-763.[Abstract]
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VanHooser D.W., Johnson R.G., Hein R.A., Elkins R.C. Successful management of aortic valve endocarditis with associated periannular abscess and aneurysm. Ann Thorac Surg 1986;42:148-151.[Abstract/Free Full Text]
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Black M.D., Walley V.M., Keon W.J. Fibrous skeleton endocarditis: repair using Konno procedure. Ann Thorac Surg 1994;57:255-258.[Abstract/Free Full Text]
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D’Udekem Y., David T.E., Feindel C.M., Armstrong S., Sun Z. Long-term results of operation for paravalvular abscess. Ann Thorac Surg 1996;62:48-53.[Abstract/Free Full Text]
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Abstract
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