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Ann Thorac Surg 1999;67:533-535
© 1999 The Society of Thoracic Surgeons

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Case Reports

The freestyle stentless bioprosthesis for prosthetic valve endocarditis

^a First Department of Surgery, Osaka University Medical School, Osaka, Japan

Accepted for publication July 6, 1998.

Address reprint requests to Dr Matsuda, First Department of Surgery, Osaka University Medical School, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan

	Abstract

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We report a case of methicillin-resistant Staphylococcus aureus-induced prosthetic valve endocarditis, which was successfully treated with aortic valve replacement using the Freestyle stentless bioprosthesis. The total root and stentless design of this bioprosthesis allows for more radical removal of infected tissue and easier treatment for annular abscess, while requiring less prosthetic materials than a conventional prosthesis. This bioprosthesis thus seems to be a valuable option for active endocarditis.

	Introduction

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Prosthetic valve endocarditis (PVE) is a serious complication of cardiac valve replacement, and an aggressive combined surgical and medical approach is essential for effective treatment. Recently, stentless bioprostheses have been introduced in the field of cardiac surgery. In particular, the Freestyle aortic bioprosthesis has a design analogous to that of an aortic homograft and with a minimum of prosthetic material. These characteristics may be effective in the treatment of PVE, but so far few trials have been carried out with this option. We describe here a case of PVE successfully treated with an aortic valve replacement using the Freestyle stentless bioprosthesis.

A 70-year-old man with aortic stenosis and mitral insufficiency underwent aortic valve replacement with a St. Jude Medical prosthesis (27 mm) and mitral annuloplasty on September 11, 1996. Two weeks postoperatively he experienced a high fever, and methicillin-resistant Staphylococcus aureus was isolated from the blood and sputum. Intravenous administration of vancomycin hydrochloride and sulfamethoxazole/trimethoprim was continued until the serum level of C-reactive protein was normalized. The patient was discharged on November 12, 1996. However, 1 week later he again had fever, and the blood culture showed recurrent growth of methicillin-resistant S. aureus. The patient was admitted to our hospital again with suspected PVE on the basis of echocardiography. On admission, he was in New York Heart Association class III. His temperature was 36.7°C, pulse was 86 beats/min, and blood pressure was 102 mm Hg systolic, 55 mm Hg diastolic. Clinical examination showed a grade 2/6 diastolic murmur of aortic regurgitation.

Abnormal laboratory findings included a hemoglobin level of 6.7 g/dL and a C-reactive protein concentration of 6.2 mg/dL. The leukocyte count was 7.36 x 10⁶/µL with no shift to the left. Echocardiography revealed partial detachment of the prosthesis, resulting in moderate paravalvular aortic insufficiency. Prosthetic valve endocarditis was diagnosed and an operation was performed on day 4 of admission.

The prosthetic valve was partially detached along one third of its circumference in the region of the right coronary sinus (Fig 1). A paraannular abscess was seen in the same region, which was in communication with the right ventricle. The prosthetic valve was removed, followed by aggressive debridement. The abscess cavity was directly closed with the interrupted 4-0 polypropylene sutures. The Medtronic Freestyle aortic root bioprosthesis (27 mm in diameter; Medtronic Inc, Minneapolis, MN) was inserted in the subcoronary position.

View larger version (164K): [in this window] [in a new window]   Fig 1. A partially detached prosthetic valve with paraannular abscess.

	Comment

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Despite major advances in cardiac valve replacement and routine use of prophylactic antibiotics, PVE remains a serious complication with an incidence of approximately 2% to 4% accompanied by a high mortality that ranges between 20% and 50% [1]. Furthermore, annular abscesses are often seen in patients with PVE and increase the technical difficulties and risks accompanied with surgical treatment.

The aortic homograft has been used in this situation because of its several advantages, which include not only excellent hemodynamic performance but also resistance to reinfection [2]. Furthermore, particularly in cases with annular abscess, an aortic homograft allows for replacement of the aortic root in conjunction with exclusion of an abscess from the circulation without the need to resort to artificial materials [3].

These advantages may be offset, however, by problems of supply of homografts of a suitable size. Recently, Santini and associates [4] reported 10 cases of aortic valve endocarditis successfully treated with aortic valve replacement by means of a stentless porcine valve substitute for the aortic homograft.

The Freestyle stentless bioprosthesis resembles an aortic homograft with ligated coronary arteries. The full root and stentless design yields a superior orifice area and flow characteristics compared with the stented equivalent. Furthermore, it may be more durable because of the incorporation of the anticalcification agent and root pressure fixation, which maintains the natural leaflet morphology and function [5, 6].

For the treatment of PVE, the surgical technique for inserting a Freestyle bioprosthesis is similar to that for an aortic homograft. The bioprosthesis may be inserted in the subcoronary position for patients in whom the infection is limited to the annulus, whereas total root replacement may be needed when the root abscess is localized at and above the level of the annulus.

The full root design of the Freestyle bioprosthesis allows for application of a variety of surgical techniques depending on patient indication, including entire aortic root replacement if necessary, and permits a more radical removal of infected tissue and easy treatment for annular abscess. Although the covering cloth of the inflow muscle bar may causes problems when using this bioprosthesis for PVE because it may act as a nidus for recurrent infection, it also seems to be the major advantage over the other scalloped stentless porcine valves in this setting.

Although long-term follow-up is necessary for further evaluation of its durability, the Freestyle bioprosthesis seems to represent a valuable option for PVE as an alternative to a homograft, which has so far been considered the best option for this condition.

	References

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1. Sett S.S., Hudon M.P., Jamieson W.R., et al. Prosthetic valve endocarditis: experience with porcine bioprostheses. J Thorac Cardiovasc Surg 1993;105:428-434.[Abstract]
2. Haydock D., Barratt-Boyes B., Macedo T. Aortic valve replacement for active infectious endocarditis in 108 patients. J Thorac Cardiovasc Surg 1992;103:130-139.[Abstract]
3. Petrou M., Wong K., Albertucci M., et al. Evaluation of unstented aortic homografts for the treatment of prosthetic aortic valve endocarditis. Circulation 1994;90:198-204.
4. Santini F., Musazzi A., Bertolini P., et al. Stentless porcine bioprosthesis in the treatment of aortic valve infective endocarditis. J Card Surg 1995;10:205-209.[Medline]
5. Westaby S., Amarasena N., Ormerod O., et al. Aortic valve replacement with the Freestyle stentless xenograft. Ann Thorac Surg 1995;60:S422-S427.
6. Sintek C.F., Fletcher A.D., Khonsari S. Stentless porcine aortic root: valve of choice for elderly patient with small aortic root?. J Thorac Cardiovasc Surg 1995;109:871-876.[Abstract]

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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): Shigeaki Ohtake Hikaru Matsuda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakaguchi, T. Articles by Matsuda, H. Search for Related Content PubMed PubMed Citation Articles by Sakaguchi, T. Articles by Matsuda, H.