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Ann Thorac Surg 2005;79:1486-1490
© 2005 The Society of Thoracic Surgeons
Department of Adult Cardiovascular Surgery, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
Accepted for publication October 14, 2004.
* Address reprint requests to Dr Nottin, Marie-Lannelongue Hospital, 133 Ave de la Résistance, 92350 Le Plessis-Robinson, France (E-mail: rnottin{at}ccml.com).
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Abstract |
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METHODS: Between 1980 and 1992, we included 21 patients and evaluated their long-term outcome. The surgical technique included extracting the aortic valve prosthesis, resecting all infected tissue, restoring the left ventricular outflow tract, and translocating the aortic valve into the ascending aorta, associated with myocardial revascularization of the left main trunk and the proximal right coronary artery.
RESULTS: All patients required emergency surgery: 15 patients were in severe congestive heart failure, 3 patients were in cardiogenic shock, and 3 patients had multiple neurologic and peripheral signs of distal embolization. Fifteen patients had active prosthetic valve endocarditis. Intraoperative findings dictated the translocation. The overall hospital mortality was 14%. None of the 18 hospital survivors had prosthetic aortic valve endocarditis recurrence. All patients were observed from 12 to 22 years, are alive, and have resumed normal activities.
CONCLUSIONS: In severe forms of prosthetic valve endocarditis, this technique provides a safe and reliable alternative to homograft replacement. The long-term results are satisfactory.
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Introduction |
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Necrotic inflammation of the annulus and large subannular or intramyocardial abscesses are the result of the devastating effects subsequent to the iterative procedure added to the infectious process on the fibrous structure of the aortic annulus [5–7]. Aortic valve reinsertion, whenever feasible, often results in recurrent endocarditis or valve dehiscence. For these patients complex surgical techniques are required to cure the infection and restore the anatomy of the left ventricular outflow tract (LVOT). With the goal of preventing recurrent infection in these ill patients by avoiding direct implantation of prosthetic material in the infected area, we managed 21 patients with severe aortic PVE by translocation of the aortic valve prosthesis into the ascending aorta, coronary artery bypass grafting to the right and left coronary arteries, and closure of the native coronary artery ostia as described by Danielson and colleagues [8]. We modified their technique by direct revascularization of the left coronary main trunk through a transverse sinus approach and inserted the valve prosthesis inside a short Dacron tube, thereby reducing the complexity of the surgical procedure, allowing antegrade revascularization of the coronary arteries.
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Patients and Methods |
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Determination of Prosthetic Valve Endocarditis
Prosthetic valve endocarditis was termed early when it appeared within 2 months of the previous valve replacement and late when occurring after 12 months. Three criteria were used in the definition of active PVE: positive blood culture within 2 months of operation, positive direct microscopic examination of the surgical specimen, and positive cultures of the surgical material removed at reoperation. All patients received intravenous antibiotics for varying periods ranging from 1 to 8 weeks (mean, 26 days). The choice of antibiotics was determined by microbial sensitivity, and the suitability of the association was confirmed in every case by determination of serum bactericidal titers. Antibiotics were continued postoperatively for 4 weeks if cultures were negative and for 6 weeks if positive or longer when infection persisted. In all patients the diagnosis was based on clinical and bacteriologic findings supported by echocardiography and cardiac catheterization in 13 patients.
There were 7 early and 14 late PVE. Fifteen patients had active PVE at the time of surgery (Table 1). Indication for reoperation was congestive heart failure in 15 patients (New York Heart Association class IV), cardiogenic shock with anuria in 3 patients, and uncontrolled sepsis with neurologic and peripheral signs of embolization in 3 patients. The mean time lapse between valve replacement and reoperation was 23.6 months (1 to 144 months).
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Operative Technique
Median sternotomy with femorocaval bypass was used in all patients. The latter permitted distal clamping of the ascending aorta. Myocardial protection was ensured by warm retrograde blood cardioplegia through the coronary sinus. The previous aortotomy was reopened and the lesions evaluated. The aortic valve prosthesis was removed, and all infected and necrotic tissue were excised. The decision for translocation was based on the following criteria: extensive root infection with major disruption of the aortic annulus, dehiscence of greater than 50% of the valve prosthesis with perivalvular necrosis extending to greater than 50% of annular circumference, and the presence of one or more periannular abscesses. Consequently, the aorta was circumferentially transected 1 cm above the coronary ostia. A sizer was used to measure the aortic diameter and to choose the appropriate Dacron graft. While the surgeon performed bypass grafting of the coronary arteries, the surgical assistant sewed a prosthetic valve inside the Dacron tube. The coronary circulation was restored using saphenous vein grafts. The distal anastomosis of the bypass graft was performed near the origin of the left main coronary artery, which was approached after mobilizing the pulmonary artery from the aorta. The distal anastomosis was made almost in a perpendicular fashion to avoid kinking. The venous graft was then passed through the transverse sinus to emerge onto the right of the aorta. Likewise, an aorto–right coronary artery venous graft was then anastomosed proximally on the right coronary artery. The proximal anastomoses of the left and right coronary arteries were made to the right lateral wall of the native aorta and the anterior aspect of the native aorta, respectively (Fig 1). In 1 patient with no venous reserve, an expanded polytetrafluoroethylene (Gore-Tex, Newark, DE) tube was used to bypass the coronary arteries. The native coronary ostia were then closed with a Dacron patch. The LVOT was reconstructed by means of Dacron patches in 10 patients and by glutaraldehyde-fixed equine pericardial patches in 7 patients. Three patients had LVOT reconstruction with buttressed sutures. After removal of air and aortic declamping, temporary atrial and ventricular electrodes were positioned and tested.
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Results |
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Eighteen patients were discharged from the hospital and were free from active infection. There were 3 hospital deaths (14%), this being defined as death before discharge from the hospital regardless of the duration of hospitalization. One patient arrived in cardiogenic shock and died of extensive mesenteric infarction and bilateral renal cortical necrosis, the second of tamponade 18 hours after surgery, and the third patient died of left ventricular insufficiency resistant to medical treatment 48 days postoperatively. Three days before death, angiography of the last patient showed no anomalies of the valve and patent vein grafts. Patients were observed for 3 to 186 months with a mean of 74 months. No patient was lost to follow-up. All patients underwent postoperative angiography and were monitored by a cardiologist.
There were 7 late deaths: sudden death in 2 patients (1 and 8 years), rupture of a cerebral mycotic aneurysm in 1 (2 months), anticoagulation-related cerebral hemorrhage in 1 (2 months), one suicide (3 months), complete atrioventricular block awaiting pacemaker implantation in 1 (8 months), and leukemia in 1 (20 years). None of these 7 late deaths had signs of PVE recurrence or paravalvular leakage.
The 5-, 10-, and 15-year actuarial survival rates were 38%, 38%, and 35%, respectively. All 11 surviving patients are in New York Heart Association functional class I or II. Doppler echographic studies performed the last year of follow-up demonstrated good prosthesis function. None of the survivors developed further aortic root dilatation. We encountered no PVE recurrence or paravalvular leakage. Late cardiac angiography revealed asymptomatic mild coronary–ventricular flow as a result of incomplete coronary ostium closure in 2 patients.
Three patients underwent reoperation. One patient had deterioration of a mitral bioprosthesis 8 years postoperatively. A subcoronary mechanical valve was implanted 16 months postoperatively in 1 patient for intermittent locking of the aortic prosthesis with the Dacron tube. Recurrent angina 65 months postoperatively because of a severe stenosis in the anastomotic site of the Gore-Tex graft was treated by coronary artery bypass grafting in another patient. At reoperation none of these 3 patients had evidence of PVE recurrence. Conduction trouble was commonly encountered. Six patients who survived surgery required definitive cardiac pacing for complete heart block.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Aortic homografts have been considered as the first choice of substitute materials in such patients given their supposedly greater resistance to infections compared with prosthetic valves. Nevertheless, persistent infections have been reported after homograft replacement [5]. Furthermore, homografts may not be adapted to reconstruct a severely damaged aortic root. Moreover, they are fraught with high early calcification rates and the problems of availability. The favorable results of endocarditis treated with prosthetic material [5, 6] question the absolute necessity of using biologic grafts in the treatment of infectious endocarditis and advocate the use of prosthetic material with comparable results [9, 10].
We describe a technique that permits surgical repair of ventriculo-aortic disconnection and aortic root damage after PVE in 21 patients, often in an emergency context. Similar techniques of translocation of the aortic valve have been described as case reports or in small series [8, 11]. The technique described by Danielson and associates [8] implied inserting the valve in a supraannular position in the native aorta, thus leaving the debrided annular area in continuity with ventricular pressure and flow and concocting a Y anastomosis between the two venous grafts used to bypass the coronary arteries. However, the patient becomes dependent on a single common venous stem as the sole source of coronary blood flow. Reitz and colleagues [11] recommended the use of three bypass grafts on the basis of the assumption that the circumflex artery might be inadequately supplied from left anterior ascending artery collaterals, but this obliges the surgeon to dissect the entire left heart from often severe pericardial adhesions to perform the bypass. In both techniques, anastomoses of the venous grafts on the coronary arteries were performed rather distally, whereas we believe that each coronary artery should be grafted alone and the distal anastomosis of each graft be made quite proximal on the coronary artery. This simplifies the surgical procedure and obviates the need for left heart dissection.
In our study 30% of the patients required a definitive pacemaker. The destructive pathologic disease process of the aortic root is often associated with conductive tissue damage. It is therefore important to emphasize cardiac rhythm surveillance and eventually cardiac pacing in the early postoperative period as heart block is not an unusual complication.
Consequent LVOT reconstruction can be performed by several techniques. Small cavities can be obliterated by simple suture plication. Larger abscesses exceeding 2 cm in diameter associated with partial annular destruction cannot be plicated without concomitant distortion of the aortic root, adjacent coronary ostia, and mitral annulus. Thus, they should be treated with a patch technique to achieve tension-free repair. In this study, 10 patients had LVOT reconstruction with a pericardial patch.
We and others [12] have not encountered aneurysmal dilatation of the aortic root as described originally by Danielson and coworkers [8], probably because in most cases with severe destruction of the annular region, the LVOT was reinforced by mattress sutures or by patch repair. The main concern of this technique is venous graft disease. Jault and colleagues [12] reported an incidence of 10% of late coronary artery bypass graft stenosis. In this series, graft stenosis was observed in the patient with a Gore-Tex tube graft. Absence of available venous grafts obliged the use of synthetic material in this particular patient, which remains exceptional. An asymptomatic aneurysm of a venous graft to the right coronary artery detected incidentally in the patient requiring mitral valve replacement was replaced with another graft in the same setting.
The operative mortality was 14% without any PVE recurrence. Among the 7 late deaths, 2 were sudden deaths in patients with congestive heart failure. However, no autopsy was performed to confirm the exact cause of death.
In the surgical management of acute PVE complicated by destruction of the perivalvular apparatus, root replacement with a prosthetic conduit, translocation of the aortic valve, and coronary artery bypass grafting carry low operative mortality and incidence of recurrent endocarditis. This technique is reserved for patients with extensive annular destruction and subannular abscesses after failure of conventional methods and can be used as an alternative to homografts whenever these are unavailable.
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References |
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This article has been cited by other articles:
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  N. Al-Attar, R. Nottin, R. Ramadan, and A. Azmoun Translocation of the aortic valve in severe aortic root abscess. An alternative to homografts Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 509 - 510. [Full Text] [PDF]
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