Ann Thorac Surg 2004;78:2191-2192
© 2004 The Society of Thoracic Surgeons
How to do it
Minimizing Foreign Material in the Reconstruction of Infected Complex Annuloaortic Disruption
Kiick Sung, MDa,
Young Tak Lee, MDa,*,
Pyo Won Park, MDa,
Kay-Hyun Park, MDa,
Tae-Gook Jun, MDa,
Ji-Hyuk Yang, MDa
a Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
Accepted for publication October 2, 2003.
* Address reprint requests to Dr Lee, Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul, 135-280, South Korea
ytlee{at}smc.samsung.co.kr
 |
Abstract
|
|---|
For repairing disrupted ventriculoaortic continuity caused by complicated aortic root infection, my colleagues and I simply approximate it without any patch material to decrease the possible risk of recurrence of infection. After massive and aggressive debridement of the infected tissue, all discontinuities or abscess cavities were excluded by using interrupted sutures to anchor a new valve substitute in 13 patients. Only 1 patient died of uncontrolled sepsis. During the follow-up period (mean, 21.5 months) all 12 survivors have done well, without any evidence of paravalvular leakage or recurrent infections.
|
Introduction
|
|---|
The surgical management of aortic root abscess is a challenging procedure because patients frequently have complicated destruction of their heart architecture. Moreover, in patients with advanced prosthetic valve endocarditis, because the suture site is a good habitat for microorganisms, after radical resection of all infected tissue, which is essential to prevent recurrence of the infection, a large and completely disconnected gap is frequently inevitable [1, 2].
Patch exclusion of this large gap with insertion of a prosthetic composite graft [1] has been most commonly used. However, to decrease the possible risk of recurrence of infection, my colleagues and I have used a simple obliterative exclusion technique for dealing with complex root lesions by using biological or prosthetic valves in patients with repeated prosthetic or native aortic valve endocarditis.
|
Technique
|
|---|
Thirteen patients with complicated aortic root infections were surgically treated by 1 surgeon (Y.L.) between March 1996 and December 2002. Six had prosthetic valve endocarditis, and 7 had native valve endocarditis. Two patients had received 2 previous root procedures with homografts or prosthetic valves because of repeated endocarditis, and 2 patients with native valve endocarditis had received other cardiac procedures.
In 2 patients who had aortic or root pseudoaneurysms, we performed re-sternotomy under deep hypothermic circulatory arrest. Other patients received the usual bypass graft technique. Myocardial protection was obtained by using antegrade induction with warm or cold blood cardioplegia and was maintained with retrograde continuous cold blood cardioplegia followed by warm antegrade reperfusion.
Aortic valve replacement was performed with aortic homografts in 7 patients: pulmonary autografts in 2, a pulmonary homograft in 1, and mechanical prosthetic valves in 3. For implantation of a homograft or an autograft, multiple interrupted simple sutures (approximately 24 stitches) of 4-0 polypropylene were used in 9 patients, preserving enough thickness of the muscular tissue of the homograft for the large gap (Fig 1). By incorporating 3 layers together within 1 stitch, additional patch material was not needed to exclude the abscess cavity, even in the 2 patients who had ventricular septal muscle longitudinal tears beneath the ventriculoaortic discontinuity.
View larger version (49K):
[in this window]
[in a new window]
|
Fig 1. For implantation of a homograft or an autograft, multiple interrupted simple sutures (approximately 24 stitches) of 4-0 polypropylene were used, incorporating enough thickness of the myocardium of the left ventricular outflow and the aortic wall in 9 patients.
|
|
Three other simple aortic valve replacements were also performed by using simple mattress sutures to hold the prosthetic valve through the myocardium and aortic wall even in large gaps (Fig 2); in 1 of them, an additional patch was used to close the septal perforation through the right ventricle.
View larger version (50K):
[in this window]
[in a new window]
|
Fig 2. Simple aortic valve replacements were performed by using simple mattress sutures to hold the prosthetic valve in 3 patients.
|
|
Mitroaortic annular discontinuity, which was accompanied by ventriculoaortic discontinuity, was closed by using a mitral valve curtain attached to the aortic homograft (Fig 3) in 1 patient. One patient who had received a third operation with a homograft died because of an uncontrolled fungal infection 23 days after the operation. All 12 survivors were followed up recently at postoperative times ranging from 5 to 66 months (mean, 22.5 months) and had no evidence of paravalvular leakage or recurrence of infection.
View larger version (53K):
[in this window]
[in a new window]
|
Fig 3. Mitral valve perforations contiguous to the aortic annulus were closed by using the mitral valve curtain attached to the aortic homograft in 1 patient.
|
|
|
Comment
|
|---|
Patch exclusion in the large gap caused by infective endocarditis has been used most commonly in patients for whom a homograft was not available, because it is easy to exclude the infected tissue without tension [1]. However, it may lead to recurrence of the infection on the patch, and it may not be easy to stitch around the defect in some instances.
Aortic homografts or pulmonary autografts have some advantages for treating complex aortic valve endocarditis, because they are relatively resistant to infection, are small, give good hemodynamic performance, do not require anticoagulation, and offer excellent size compliance [3, 4]. By leaving a generous amount of muscular tissue around the homograft during harvesting, we were able to obtain a substantial degree of flexibility in filling the large ventriculoaortic discontinuity. The curtain of the mitral valve attached to the aortic homograft was also useful [5] in 1 patient to repair a mitral valve perforation.
Here, a simple interrupted exclusion technique for prosthetic valve replacement in patients with advanced native endocarditis should be defined, because there is a large gap after extensive resection of the infected tissue and the possibility of tension. With the idea of a simple interrupted closure for a large subarterial ventricular septal defect [6], this technique could be used in an attempt to suture the healthy myocardium while completely excluding the gap. Our experience with 3 patients with prosthetic valve replacements supports this idea.
On the basis of our limited experience, complete debridement and aortic reconstruction with an aortic homograft, pulmonary autograft, or prosthetic valve by using deep-biting approximation sutures is an effective technique for reconstruction of the root, even in patients with ventriculoaortic discontinuities resulting from advanced infection.
|
References
|
|---|
- David TE, Bos J, Christakis GT, Brofman PR, Wong D, Feindel CM. Heart valve operations in patients with active infective endocarditis. Ann Thorac Surg. 1990;49:701–705[Abstract]
- Ralph-Edwards A, David TE, Bos J. Infective endocarditis in patients who had replacement of the aortic root. Ann Thorac Surg. 1994;58:429–433[Abstract]
- Niwaya K, Knott-Craig CJ, Santangelo K, Lane MM, Chandrasekaran K, Elkins RC. Advantages of autograft and homograft valve replacement for complex aortic valve endocarditis. Ann Thorac Surg. 1999;67:1603–1608[Abstract/Free Full Text]
- Pettersson G, Tingleff J, Joyce FS. Treatment of aortic valve endocarditis with the Ross operation. Eur J Cardiothorac Surg. 1998;13:678–684
- Dearani JA, Orszulak TA, Schaff HV, Daly RC, Anderson BJ, Danielson GK. Results of allograft aortic valve replacement for complex endocarditis. J Thorac Cardiovasc Surg. 1997;113:285–291[Abstract/Free Full Text]
- Yacoub MH, Khan H, Stavri G, Shinebourne E, Radley-Smith R. Anatomic correction of the syndrome of prolapsing right coronary aortic cusp, dilatation of the sinus of Valsalva, and ventricular septal defect. J Thorac Cardiovasc Surg. 1997;113:253–261[Abstract/Free Full Text]
Top
Abstract
Introduction
