Ann Thorac Surg 2002;73:1973-1975
© 2002 The Society of Thoracic Surgeons
Case report
The Ross procedure for endocarditis in a 4-month-old infant
Abdul Aziz S. Al-Baradai, MDa,
Roger J.F. Baskett, MDa*,
Andrew E. Warren, MDb,
David B. Ross, MDa
a Divisions of Cardiovascular Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
b Pediatric Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
Accepted for publication November 1, 2001.
* Address reprint requests to Dr Baskett, Maritime Heart Centre, Room 2269, 1796 Summer St, Halifax, Nova Scotia B3H 3A7, Canada
e-mail: rogerbaskett{at}hotmail.com
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Abstract
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Streptococcal endocarditis in an infant is rare. We report a case of acute aortic valve endocarditis with abscess and aorta-to-right atrial fistula formation. This 4-month-old infant with a structurally normal heart had been previously well. The child was successfully treated with the Ross procedure and remains well 13 months postoperatively.
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Introduction
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Aortic valve endocarditis with massive destruction of the aortic valve is infrequently seen in children and is usually due to Staphylococcus aureus [1]. The management of this in infants and children is somewhat controversial. In most cases, a homograft is used to replace the valve [2, 3]. However, the more complex Ross procedurehas been used for acute infective endocarditis in a child as young as 14 months [1].
A previously well, 9.3-kg, 4-month-old boy with no known cardiac disease was admitted to the orthopedic service with a 5-day history of fever, irritability, and decreased movement of the left leg. His past medical history was unremarkable except for a recent chicken pox contact. The physical examination was remarkable only for minimal agitation with movement of the left hip. The child’s temperature was 39.4°C and the white blood cell count was elevated at 18.5. On admission, the chest and hip roentgenograms were normal. Blood cultures revealed Streptococcus pneumoniae. The child was treated for septic arthritis with cefotaxime and vancomycin and had surgical drainage of the left hip; the gram stain and culture of the fluid drained were negative.
Two days postoperatively, a new diastolic murmur was noted and the chest roentgenogram now showed an enlarged heart. An echocardiogram revealed a large vegetation on an apparently trileaflet aortic valve, which appeared to extend to the anterior leaflet of the mitral valve (Fig 1).
There was severe aortic insufficiency, and an aorta-to-right atrial fistula. The patient was started on diuretics and rifampin was added. The fever resolved, the white blood cell count returned to normal, and repeat blood cultures were negative, but the child continued to be in heart failure.
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Fig 1. Preoperative transthoracic echocardiogram (long-axis parasternal view). Large vegetation in the left ventricular outflow tract (upper arrow). Extension of the abscess to the anterior leaflet of the mitral valve (lower arrow).
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Five days after his initial presentation, the child was returned to the operating room. There was massive enlargement of the heart with distension of the right atrium and a large abscess at the root of the aorta displacing the right atrial appendage. The left and right coronary cusps appeared normal, whereas the non-coronary cusp was completely destroyed and replaced by a large vegetation. There was a large abscess cavity forming a false aneurysm from the subaortic area extending circumferentially from the left main coronary artery to the right atrium, separating the mitral from the aortic valve, and ending in a 3-mm diameter fistula into the right atrium.
A Ross procedure was undertaken using standard cardiopulmonary bypass with bicaval cannulation and mild hypothermia. Cold retrograde blood cardioplegia was given at 15-minute intervals or more often through a 9 French retrograde cannula (Chase Cardiovascular, Richardson, TX) placed under direct vision and held in place by a purse-string suture. A large amount of vegetation material was carefully removed from the aortic annulus and also from the mitral valve, which was undamaged. The abscess cavity was excluded by rotating the autograft to suture the anterior right ventricular muscle of the pulmonary autograft to the healthy tissue of the mitral valve annulus with interrupted 5-0 Prolene sutures (Ethicon, Somerville, NJ), thus resuspending it. The autograft was then implanted as a standard root replacement and the pulmonary outflow tract reconstructed with a 17-mm aortic homograft. The fistula to the right atrium was closed from the atrium with a horizontal mattress suture. After a cross-clamp time of 130 minutes and a bypass time of 160 minutes, the child was easily weaned from bypass on 4 µg/kg/minute of dopamine.
While preparing for transport to the intensive care unit, there was a sudden drop in blood pressure and a widening of the QRS complex. Cardiopulmonary bypass was rapidly reinstituted and a transesophageal echocardiography performed, revealing markedly reduced left ventricular function with no flow seen in the left main coronary artery. After antegrade cardioplegic arrest, the aorta was reopened and an embolic vegetation was found completely obstructing the ostium of the left main coronary artery. With this removed, and after repeat cardioplegia, a transesophageal echocardiography demonstrated good flow in the left coronary artery. Profound left ventricular dysfunction prevented separation from cardiopulmonary bypass, and a left ventricular assist device was required for 3 days.
The remainder of the postoperative stay was unremarkable, and the patient was discharged home 6 weeks later, after a 7-week course of intravenous antibiotics. Thirteen months postoperatively, the child is asymptomatic, although is being treated with digoxin and an ACE inhibitor. The latest echocardiogram revealed an ejection fraction of 56%, with mild mitral regurgitation, trivial aortic regurgitation, and a trivial gradient across the aortic valve.
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Comment
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It is rare for Streptococcus pneumoniae to cause active endocarditis in a structurally normal heart. However, the pathogenicity of this organism may be increased in a child who has been previously exposed to a varicella infection, and this has been reported to be associated with endocarditis [4].
The optimal surgical treatment of acute aortic valve endocarditis in children is controversial. In a report from the Great Ormond Street Hospital for Children, 5 children with aortic valve endocarditis were treated with aortic homograft root replacement; 4 survived, with 2 requiring subsequent reoperation, 1 for the homograft and 1 for the mitral valve [2]. A 3-month old infant with endocarditis was reported to have been treated successfully with an aortic homograft and remains well 2 years later [3]. The other option is the more complex Ross procedure, which has been successfully used in 3 patients aged 14 months and 10 and 11 years, respectively [1].
The Ross procedure is a well-established operation for congenital aortic stenosis, and its use has been extended to neonates, infants, and patients with complex left ventricular outflow tract abnormalities [5]. There is also reasonable experience with the Ross procedure in endocarditis [6]. The long-term viability of the pulmonary autograft has been demonstrated, and it appears to be more resistant to deterioration than a homograft. Also, the autograft, unlike the homograft, is viable and thus is more likely to resist infection and has the potential of growth, minimizing the risk of reoperation [6]. However, the Ross procedure is more complex and there is still the need for later replacement of the homograft, especially in children and infants.
There was a large amount of vegetations present in the entirely destroyed aortic root and affecting the mitral valve. Although this material was removed as completely as possible, clearly, some escaped our attention.
Despite the young age of our patient, we chose to perform the Ross procedure for its inherent advantages over the homograft. From our experience and those reported previously [1], we believe that the Ross procedure is a good surgical option for infants with extensive aortic valve endocarditis.
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References
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Di Fillipo S., Bozio A., Champsaur G., Sassolas F., Debost B., Perroux V. The Ross procedure in the acute phase of infectious endocarditis in childhood. Arch Mal Coeur Vaiss 1999;92:613-619.[Medline]
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Chaturvedi R., de Leval M., Sullivan I.D. Urgent homograft aortic root replacement for aortic root abscess in infants and children. Heart 1999;81:62-66.[Abstract/Free Full Text]
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Cabera A., Armendi J., Gastiasoro L., Romero C., Martinez P. Bacterial endocarditis in the aortic valve of three month old infant. Correction with aortic homograft. Rev Esp Cardiol 1998;51:243-244.[Medline]
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Laskey A.L., Johnson T.R., Dagartzikas M.I., Tobias J.D. Endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child. Pediatrics 2000;106:E40.[Medline]
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Reddy V.M., Rajasinghe H.A., McElhinney D.B., et al. Extending the limits of the Ross procedure. Ann Thorac Surg 1995;60:S600-S603.
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Niwaya K., Knott-Craig C.J., Santangelo K., Lane M.M., Chandrasekaran K., Elkins R.C. Advantage of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg 1999;67:1603-1608.[Abstract/Free Full Text]
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Abstract
Introduction
