Ann Thorac Surg 2000;69:1264-1266
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Konno procedure for infective endocarditis involving aortic valve in a small child
Kazutomo Goh, MDa,
Hiroshi Yamamoto, MDa,
Naoya Tsuda, MDb,
Tadahiro Sasajima, MDa
a First Department of Surgery, Asahikawa Medical College, Asahikawa, Japan
b Department of Pediatrics, Asahikawa Medical College, Asahikawa, Japan
Address reprint requests to Dr Goh, First Department of Surgery, Asahikawa Medical College, Nishikagura 4-5-3-11, Asahikawa 078-8510, Japan
e-mail: kgoh{at}asahikawa-med.ac.jp
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Abstract
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The Konno procedure was performed to replace the aortic valve and the sinus of Valsalva in a 1-year-old child with pneumococcal infective endocarditis. A Dacron (C.R. Bard, Haverhill, PA) graft and a 16 AP ATS Medical valve (ATS Medical Inc, Minneapolis, MN) were used. Adequate debridement could be easily performed. Postoperative recovery was uneventful. The procedure, originally developed for a narrow aortic annulus, could be a good option for the treatment of a small child with aortic valve endocarditis.
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Introduction
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Although infective endocarditis is uncommon in the general pediatric population, patients with congenital heart disease are at higher risk. When infective endocarditis is established in a very young individual, and when the aortic valve is involved, simple aortic valve replacement is not always feasible. We describe a successful application of the Konno procedure in a small child with pneumococcal infective endocarditis involving the aortic valve and the ascending aorta.
A 12-month-old infant weighing 6.5 kg, who had undergone closure of a ventricular septal defect at the age of 4 months, presented herself with sore throat and high fever. She developed meningitis after 4 days, and endocarditis within a week after presentation. Blood and spinal fluid cultures were positive with Streptococcus pneumoniae. Although the cultures became negative after intravenous administration of panipenam, persistent fever did not disappear, and her hemodynamics became unstable. Echocardiography demonstrated severe aortic valve insufficiency, a large mobile vegetation attached to the noncoronary cusp, and dilatation of the left ventricle. A large aneurysm involving the sinus of Valsalva above the right coronary cusp and the ascending aorta was noticed at 4 weeks after presentation (Fig 1). These findings lead us to prompt surgical management.
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Fig 1. Echocardiography revealed aortic insufficiency with a dilated left ventricle. It also showed an aneurysm on the anterior wall of the ascending aorta and mobile vegetation attached to the right coronary cusp. (A) Long axis view. The arrows indicate the aneurysm in the ascending aorta. (B) Short axis view. Vegetation on the aortic valve is shown. The small arrows indicate the aneurysm.
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A 5-mm EPTFE graft (W.L. Gore & Associates, Flagstaff, AZ) was anastomosed to the right femoral artery for arterial return from the cardiopulmonary bypass. Median sternotomy was then conducted without incidence. A large aortic aneurysm, occupying the lower half of the ascending aorta and expanding to the side wall of the main pulmonary artery, was noted. Cardiopulmonary bypass was established with two separate venous cannulas in the vena cavae. The patient was cooled down to 20°C. Cardioplegia was administered through the coronary sinus. The aneurysm over the anterior wall of the ascending aorta was opened vertically. The right coronary cusp had been totally destroyed, and there was a large vegetation attached to the noncoronary cusp. The right coronary artery originated high above the noncoronary sinus. A second cardioplegia was administered through the coronary ostia. The incision over the aneurysm was extended to the right sinus, and then to the right ventricular outflow tract. Interventricular septum was also incised over the right sinus. The aneurysm and the aortic valve leaflets were excised. Approximately half the circumference of a 16 AP ATS Medical valve (ATS Medical Inc, Minneapolis, MN) was sewn into the remaining aortic annulus. A piece of Dacron (C.R. Bard, Haverhill, PA) graft was sewn to the rest of the sewing ring. The interventricular septum and the anterior wall of the aorta were closed with the Dacron graft. The right ventricular outflow tract was reconstructed with a piece of equine pericardium. The patient’s recovery was uneventful. No significant hemolysis was noted with the 16 AP ATS Medical valve in the aortic position, and the inflammatory process was suppressed successfully after operation.
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Comment
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Pneumococcal endocarditis is infrequently seen after introduction of penicillin. A relatively small number of children with pneumococcal endocarditis have been reported lately [1]. In the present case, sepsis and meningitis were controlled with appropriate antibiotics, but the invasive nature of the disease introduced a large vegetation, and destruction of the aortic wall, as well as aortic insufficiency, in a short period of time. Standard aortic valve replacement was not possible because of the small size of the patient.
Ross procedure could have been an option for this patient [2], but we hesitated to harvest the pulmonary artery, which was in direct proximity to the inflammatory process of the ascending aorta, and dissection around the pulmonary artery was practically difficult. The use of a homograft to replace the aortic root in patients with infectious endocarditis was another option, and has been reported with sufficient results [3]. However, a homograft is currently not available in Japan.
The Konno procedure was originally developed for patients with small aortic annuli or narrow left ventricular outflow tracts. Its long-term results have been reported to be excellent. Its successful application to infective endocarditis, in the native aortic valve or aortic root graft, has been reported in adult cases [4, 5]. Mavroudis and associates have applied a modification of this technique by extending the aortic incision to the membranous septum in a 6-year-old child [6]. We used the Konno procedure successfully in a 12-month-old patient with pneumococcal infective endocarditis invading the aortic valve and the ascending aorta. Good exposure and adequate debridement was possible with this procedure. It also accepted a 16 AP ATS Medical valve with excellent postoperative hemodynamics. In the present case, we consider this procedure to be a good surgical option for a small child with endocarditis involving the aortic valve, especially when the native pulmonary valve is infected and a homograft is not available.
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References
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Citak M., Rees A., Mavroudis C. Surgical management of infectious endocarditis in children. Ann Thorac Surg 1992;54:755-760.[Abstract]
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Joyce F., Tingleff J., Pettersson G. Expanding indications for the Ross operation. J Heart Valve Dis 1995;4:352-363.[Medline]
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Riberi A., Caus T., Mesana T., et al. Aortic valve or root replacement with cryopreserved homograft for active infectious endocarditis. Cardiovasc Surg 1997;5:579-583.[Medline]
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Black M.D., Walley V.M., Keon W.J. Fibrous skeleton endocarditis. Ann Thorac Surg 1994;57:225-228.[Abstract]
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Ketosugbo A.K., Basu S., Greengart A., et al. Aortoventriculoplasty in the management of an infected Cabrol graft. Ann Thorac Surg 1992;53:898-900.[Abstract]
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Mavroudis C., Wampler J., Hodsden J.E., Rees A.H., Solinger R.E., Elbl F. Modified aortoseptoplasty for annular abscess and erosion of the membranous septum. Chest 1984;85:442-444.[Abstract/Free Full Text]
Accepted for publication September 7, 1999.
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Abstract
Introduction
