Pseudoaneurysm in the mitral-aortic intervalvular fibrosa. A cause of mitral regurgitation

Left ventricular outflow tract pseudoaneurysm is an uncommon but potentially catastrophic complication of aortic valve surgery, aortic valve endocarditis or chest trauma. We describe a case of a left ventricular outflow tract pseudoaneurysm 1 month after an aortic valve replacement that caused a systolic compression of mitral valve and a severe regurgitation. The diagnosis was confirmed using transoesophageal echocardiography, magnetic resonance image and intraoperative endoscopy. Surgical repair of the pseudoaneurysm corrected the mitral regurgitation.     

Treatment of aortic valve endocarditis with the Ross operation

Objective: Standard treatment of patients with infective endocarditis is radical debridement and valve replacement, in cases with advanced pathology the treatment is usually root replacement with either a composite graft or a homograft. Enthusiasm for the use of the Ross operation in non-infective aortic valve disease is increasing, but use of the pulmonary autograft in the treatment of aortic valve endocarditis has been limited. The objective of this prospective study is to present the technique and results of our experience with aortic valve endocarditis treated with the Ross operation. Materials and methods: Since 1992 we have treated 35 patients (median age 41 years, range 6–71 years) having aortic valve endocarditis with a Ross operation. Twenty-four patients had advanced disease defined as pathology due to endocarditis extending beyond the valve cusps (13 patients) or prosthetic valve endocarditis (11 patients). Twenty-two patients had active disease at the time of surgery, and 12 had undergone one to four previous heart operations. Results: There were two operative deaths (5.8%), both related to severe disease with very advanced pathology and heart failure. Intraoperative echocardiography demonstrated no or trivial autograft insufficiency in all patients. There have been no late deaths. There has been one (probable) recurrent right-sided endocarditis in a drug addict during a follow-up period of 3–56 months. One patient has been reoperated on for homograft stenosis. Conclusions: We are enthusiastic about the use of the Ross operation in aortic valve endocarditis and in younger patients with advanced pathology, it is our preferred treatment modality. Following removal of the autograft, unparalleled exposure of the left ventricular outflow tract is obtained. Even in patients with very advanced pathology the left ventricular outflow tract is usually intact, allowing autograft implantation in the standard fashion. For selected patients with simple endocarditis, the Ross operation is an attractive option on its usual merits.     

Homograft aortic root replacement to correct infective endocarditis requiring seven open cardiac procedures

Infective endocarditis, presumably from a septic dental focus, affecting the aortic valve was seen as acute aortic regurgitation in a 20-year-old woman. Seven open cardiac procedures for replacement of the aortic valve and left ventricular outflow tract were performed over the subsequent 6 years. Aortic root replacement using a fresh antibiotic-sterilized homograft was performed as the last definitive operative procedure. This article is presented to highlight (1) the use of homograft aortic root replacement for extensive involvement of aortic valve and left ventricular outflow tract in cases of infective endocarditis and (2) the feasibility of multiple sternal reentries when indicated.     

Left ventricular outflow tract pseudoaneurysm complicated with prosthetic valve endocarditis after aortic valve replacement

A rare case of left ventricular outflow tract (LVOT) pseudoaneurysm complicated with prosthetic valve endocarditis was reported herein. A 78-year-old male previously underwent aortic valve replacement (AVR) with a bioprosthesis. Four years after the initial operation, he presented with prolonged high fever and bloody sputum. Multi-detector row computed tomography (MDCT) clearly showed LVOT pseudoaneurysm originating from a subvalvular fibrous region. The patient underwent re-AVR and repair of pseudoaneurysm. The postoperative course was uneventful, and the patient recovered good condition.     

Cardiac reoperation in a patient with osteogenesis imperfecta: a case report.

A case of a 40-year-old man with dehiscence of the prosthetic aortic valve and recurrence of mycotic aneurysm of the left ventricular outflow tract with osteogenesis imperfecta is presented. He had an operation of aortic valve replacement and direct closure of the mycotic aneurysm for infective endocarditis twenty-one months ago. We performed reoperation of prosthetic aortic valve, patch closure of the mycotic aneurysm and graft replacement of the ascending aorta. He was complicated with multiple fractures of bilateral scapla and dislocation of left shoulder one postoperative day. Fortunately, cardiac reoperation was performed successfully in this patient despite anticipated difficulties with tissue friability with osteogenesis imperfecta.     

Transapical approach in transcatheter cardiovascular interventions

The left ventricular apex has excellent accessibility to the aortic valve, mitral valve, left ventricular outflow tract and thoracic aorta. Although the number of transapical approach in transcatheter aortic valve replacement has been decreasing in recent years, it is still a useful option for patients with very poor peripheral vascular access. The apex has been chosen as a primary access site for many devices of transcatheter mitral valve repair/replacement and mitral valve-in-valve procedures. Additionally, the transapical approach has been used for other transcatheter cardiovascular interventions such as paravalvular leak repair after mitral or aortic valve replacement, pseudoaneurysm repair of the left ventricular outflow tract, and thoracic endovascular aortic repair. Herein, I review our own experience and articles of the transapical transcatheter cardiovascular interventions and discuss about clinical usability, technical tips and complications of the transapical approach in various transcatheter cardiovascular interventions.     

Ross operation and mitral valve repair for active infective endocarditis

A 17-year-old woman was admitted to our hospital for the treatment of infective endocarditis. Echocardiography showed vegetation on the aortic valve and the anterior leaflet of the mitral valve. Because of the evidence of multiple embolisms including coronary, splenic, and right brachial arteries, emergency Ross operation was performed using Prima PLUS stentless valve for reconstruction of the right ventricular outflow tract and so was mitral valve repair with autologous pericardial patch. Although cerebral hemorrhage occurred postoperatively, she recovered well without any neurological deficit. She was in good condition without any anticoagulation therapy 12 months after surgery. The Ross operation and mitral valve repair are useful for the treatment of aortic and mitral infective endocarditis, especially in young women with the potential of future pregnancy and labor.     

Repair of Left Ventricular-Aortic Discontinuity Complicating Endocarditis from an Aortic Valve Prosthesis

A case of bacterial endocarditis from an aortic valve prosthesis is described in which subannular pseudoaneurysm caused discontinuity of the aorta and left ventricle. Successful repair was accomplished using compound sponge-felt to bolster the left ventricular outflow tract and to obliterate the aneurysm.     

Reoperation for double-outlet right ventricle (SDL type) following the Rastelli procedure: report of a case

The relationship of the conduit to the sternum is crucial in the Rastelli operation. Right-sided conduits are more greatly affected by sternal compression than left, since the position of the right ventricular infundibulum is more anterior. A 37-year-old woman developed right ventricular outflow tract obstruction, left ventricular outflow tract obstruction, and aortic valve regurgitation secondary to infective endocarditis 15 years after Rastelli repair for double-outlet right ventricle (SDL). We enlarged the ventricular septal defect, performed intraventricular rerouting and aortic valve replacement, and reconstructed the valved conduit using a Carpentier-Edwards conduit. The old conduit was densely adherent to the sternum. Subaortic stenosis was caused by a narrow fibromuscular ridge associated with a bulge of the underlying septal muscle. The patient's recovery was uneventful. She is alive and well without any complaints 1 year after surgery.     

Spontaneous closure of a large left ventricular pseudoaneurysm after mitral valve replacement

Left ventricular pseudoaneurysm is a rare, but potentially fatal, condition that generally occurs as a complication of myocardial infarction, infective endocarditis, or cardiac surgery. Surgical repair is the treatment of first choice because of the marked risk of rupture, but deteriorated hemodynamics and complicated procedures to treat the pseudoaneurysm may lead to a high mortality rate. We report a 62-year-old woman with a large left ventricular pseudoaneurysm after mitral valve replacement for rheumatic mitral valve stenosis. Surgical repair was not performed due to the patient’s refusal, but her pseudoaneurysm resolved spontaneously by 2 years after mitral valve replacement. Spontaneous obliteration of a large left ventricular pseudoaneurysm is very rare in a patient on warfarin therapy. This case suggests that a left ventricular pseudoaneurysm with a narrow neck may resolve spontaneously in rare settings.     

Pseudoaneurysm from the mitral-aortic intervalvular fibrosa following endocarditis

A rare case of a pseudoaneurysm from the mitral-aortic intervalvular fibrosa following bacterial endocarditis in a 17-year-old male is presented. Destructive infection secondarily involved the mitral-aortic intervalvular fibrosa. Perforation of this portion resulted in the formation of the pseudoaneurysm situated at the base of the left ventricle between the aorta and the left atrium. With echocardiography, computed topography, angiography, and magnetic resonance imaging (MRI), a pseudoaneurysm was diagnosed. MRI especially revealed detailed information and the extension of pseudoaneurysm. Our patient underwent resection of the pseudoaneurysm, reconstruction of left ventricular outflow with glutaraldehyde-preserved bovine pericardium, and replacement of the aortic valve. His postoperative course was uneventful. No recurrence of endocarditis was detected in the following year.     

Mitral valve repair of valve insuffficiency with broad and complex lesions due to infective endocarditis; report of a case

Surgical intervention is necessary for the treatment of infective endocarditis, although antibiotic therapy has been shown to be effective for treatment of this disorder. Mitral valve infective endocarditis frequently presents with broad and complex lesions, and thus a variety of valve repair is needed. A 40-year-old woman with mitral valve insufficiency due to infective endocarditis underwent mitral valve repair. During the operation, torn chordae, aneurysm with perforation of the anterior leaflet, and torn chordae of the posterior leaflet were found. The chordae of the anterior leaflet were reconstructed and the aneurysm was excised, and autopericardial patch repair was performed. Then, resection and suturing of the prolapsing lesion of posterior leaflet were performed. Mitral valve repair preserves the left ventricular apparatus and function. Therefore, mitral repair results in better prognosis than valve replacement. The repair of the mitral valve should be attempted for the treatment of valve insufficiency due to infective endocarditis.     

Untreated tetralogy of Fallot in an adult patient complicated by acute aortic valve endocarditis

Acute endocarditis complicated by aortic valve regurgitation is an uncommon finding in adults with surgical untreated tetralogy of Fallot (TOF). The hemodynamic consequences for both, the right and left ventricles, are significant. However, the right ventricle may be in a disastrous situation, since a compromised right ventricle from longstanding pressure overload may not tolerate acute volume overload. Here we report a 28-year-old African adult patient with TOF and acute severe aortic valve regurgitation due to bacterial endocarditis with preoperative low cardiac output syndrome. After aortotomy a large abscess cavity underneath the left and non-coronary sinus and a TOF typical perimembranous ventricular septal defect (VSD) were visible. Autologous glutaraldehyde-treated pericardium was used to reconstruct the aortic-mitral curtain. For repair of the TOF a vertical incision in the right ventricular outflow tract was performed and the infundibular septum was resected. The perimembranous VSD was closed with glutaraldehyde-fixed autologous pericardium, whereas the cranial part of the patch formed the aortic annulus. An aortic homograft was implanted as a full aortic root. The patient recovered early and uneventful. Adult TOF may be complicated by acute aortic valve endocarditis with emergent surgical intervention. Homograft aortic valve replacement is feasible in this setting.     

Successful management of early aortic root abscess with aortic homograft implantation in children after Ross operation

The Ross operation is the best surgical procedure for aortic valve replacement in children of all age groups. A 3.5 years old boy developed early autograft endocarditis (9 days) following a straightforward Ross operation. Due to progressive neo-aortic valve destruction and aortic root abscess extending to the mitral annulus and valve, the pulmonary autograft had to be removed. A cryopreserved aortic homograft with its attached mitral valve leaflet was used to reconstruct the left ventricular outflow tract and repair the native mitral valve defect.     

Use of the Alfieri edge-to-edge technique to eliminate left ventricular outflow tract obstruction caused by mitral systolic anterior motion

A 68-year-old woman with concentric left ventricular hypertrophy, prosthetic valve endocarditis with aortic root abscess, and sepsis had aortic root replacement with an aortic allograft. On weaning from cardiopulmonary bypass, she had hemodynamic instability caused by systolic anterior motion of the mitral valve, which resulted in a left ventricular outflow tract obstruction; the peak pressure gradient across the left ventricular outflow tract was 130 mm Hg, and there was moderately severe (3+) mitral regurgitation. After reinstitution of cardiopulmonary bypass, a central Alfieri edge-to-edge stitch was placed between the anterior and posterior leaflets of the mitral valve. This reduced the gradient across the left ventricular outflow tract to 10 mm Hg and eliminated the mitral regurgitation, which enabled successful separation from cardiopulmonary bypass.     

Active mitral valve endocarditis with widespread interventricular septal abscesses in a paediatric patient

We present the case of a previously healthy 2-year-old boy with extensive infective mitral valve endocarditis, with 2 huge, mobile vegetations attached to the anterior leaflet of the mitral valve and to the left ventricular outflow tract, and interventricular septal abscesses extending into the left ventricular outflow tract without any septal defects. He underwent mitral valve repair and simultaneous drainage of the interventricular septal abscesses excluding the inlet portion to avoid postoperative complications.     

Left ventricular outflow tract false aneurysm late after aortic valve replacement

We describe an unusual case of left ventricular outflow tract (LVOT) pseudoaneurysm late after aortic valve replacement. A 77-year-old man, who had undergone aortic valve replacement with mechanical prosthesis 7 years ago, presented, asymptomatic, with a transesophageal echocardiography (TTE) diagnosis of a large cavitary mass arising behind the aortic wall. The orifice of the pseudoaneurysm was successfully surgically closed and the aortic root reconstructed with cryopreserved homograft.     

Left ventricular outflow enlargement by the Konno procedure

The optimal management of patients with small aortic anulus or left ventricular outflow tract obstruction remains unclear. Between 1976 and March, 1982; 18 patients have undergone enlargement of their left ventricular outflow tract by means of the Konno or a modification of the Konno procedure. Fourteen of these 18 patients had previous operations for aortic stenosis or tunnel left ventricular outflow tract, and two patients had undergone three previous operations. All 18 patients had symptoms of either heart failure of chest pain, or had electrocardiographic evidence of strain. They ranged in age from 4 years to 58 years, with 13 of the 18 patients being less than 20 years of age. A Dacron patch was used to enlarge the left ventricular outflow tract after incising down the ventricular septum. In all patients, at least a 21 mm valve could be placed, with between 50% and 65% of the valve anulus being made up of natural tissue. The remaining portion of the valve anulus was constructed from the Dacron patch. The patch was extended up to enlarge the ascending aorta, and a pericardial patch was used to close the defect in the right ventricular outflow tract. In all 18 patients the gradient was obliterated at the time of operation. There was one early death in a patient who had previous insertion of a left ventricular apical-aortic conduit in which the heterograft valve had degenerated. There has been one late death because of bacterial endocarditis in a child who also had a parachute mitral valve and evidence of pulmonary hypertension. The remaining 16 patients are functioning well after the Konno procedure. Three are receiving warfarin sodium, and 13 are receiving aspirin. These results suggest that this is an acceptable method of treating patients with small aortic anulus or left ventricular outflow tract obstructions and would appear to have advantages over a left ventricular apical-aortic conduit.     

Discrete membranous subaortic stenosis complicated by infective endocarditis: a case report

Discrete membraneous subaortic stenosis is an uncommon cause of left ventricular outflow tract obstruction. Although its relationship to infective endocarditis is well defined, the expected site of vegetation is over the aortic valve. We report on a 46-year-old man who had a discrete membranous subaortic stenosis, complicated with infective endocarditis, in which the vegetation was over the subaortic membrane and the aortic valve was spared. To our knowledge, this is the first reported case of that entity.     

A successful repair of infective endocarditis accompanied by a pseudoaneurysm of the left ventricle

The present paper reports a successful surgical treatment of a 47-year-old male with a pseudoaneurysm of the left ventricle. The patient has also been administered Penicilin G for 5 months to treat endocarditis. Cardiac catheterization showed severe aortic stenosis and a pseudoaneurysm of the left ventricle which was dilating in systole. The patient underwent patch closure of the pseudoaneurysm whose ostium was situated at the miral-aortic inter valvular fibrosa followed by aortic valve replacement and direct closure of a right Valsalva sinus aneurysm. His postoperative course was uneventful. The patient had no recurrence of endocarditis nor malfunction of the prosthetic valve for one year postsurgery. This is the first report in Japan of successful surgical treatment of a pseudoaneurysm of the left ventricle due to perforation of the miral-aortic intervalvular fibrosa after endocarditis.