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.     

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.     

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.     

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.     

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.     

Establishment of a bank of cryopreserved valve homografts and clinical use in ninety-two patients]

Good long-term results obtained with homologous valve grafts, specially for correction of congenital cardiac defects, prompted us to create a local cryopreserved homograft bank. A 5-year experience is described, including indications for harvesting, techniques of preparation, cryopreservation and thawing. During this period, 195 homografts entered the bank and 92 were used. Among these 92 clinical cases, 74 consisted of right ventricular outflow tract reconstruction (47 valved conduit and 27 monocusp bearing patch) and 17 were left ventricular outflow tract reconstructions (11 free hand aortic valve and 6 aortic root replacement). Only one case was a tricuspid replacement with a stented homograft. Short-term results, with these homografts, are satisfactory and are compared with long-term results reported in the literature. The authors insist on using very thorough techniques and constant quality control. New developments should include viability control and immunological studies.     

The Konno aortoventriculoplasty for repeat aortic valve replacement

Objective: To evaluate the outcome of aortic root augmentation by the Konno-aortoventriculoplasty technique as part of reoperative aortic valve replacement. Methods: Since 1983, 15 patients, 12 males and three females, had repeat aortic valve replacement (AVR) with concomitant Konno aortoventriculoplasty. Age ranged from 1.2 to 18 years (mean 12.5 years). The underlying anatomic diagnoses were valve and subvalvar aortic stenosis in 11, truncal valve insufficiency in one, endocarditis in one, Shone's complex in one and severe aortic insufficiency associated with a ventricular septal defect in one patient. All patients had had previous AVR. The causes for reoperation were prosthetic valve stenosis due to growth in ten and paravalvular leak in one, homograft failure in two, xenograft failure in one, and left ventricular outflow tract obstruction (LVOTO) after mitral valve replacement in one patient. The mean size of explanted prostheses was 19.2 mm (13–23 mm) while the mean size of the implanted prostheses was 24.3 mm (19–27 mm) (P<0.01). Previous aortic root enlargement had been performed in 11 patients in conjunction with AVR. The Manougian technique was used previously in two, Konno aortoventriculoplasty in eight, and both techniques in one patient. The newly implanted aortic valves were a homograft in one patient and mechanical prostheses in 14 patients. Results: There was one operative death (1 of 15 or 6.6%) in a 17.5 year old patient with previous AVR and posterior root enlargement, due to low cardiac output state. Follow-up ranged from 6 months to 17 years (mean 7.2 years). The only late death occurred in an 11.6-year-old patient due to prosthetic valve endocarditis. Two patients had complete heart block and had permanent pacemaker insertion (2 of 15 or 13.3%). One patient had pulmonary valve replacement because of combined stenosis and insufficiency 5 years after operation. All 13-surviving patients are asymptomatic at latest follow up. Conclusion: Konno aortoventriculoplasty with repeat AVR may be safely performed. Excellent results may be achieved despite previous aortic root enlargement. It is a good surgical option for complex LVOTO and may even reduce reoperation in children by allowing placement of a larger prosthesis.     

Replacement of the aortic valve or root with a pulmonary autograft in children

Between January 1967 and December 1988, 34 patients ranging in age from 3 to 18 years (mean, 14 +/- 3.6 years) underwent replacement of the aortic valve or root with their own pulmonary valve. The indication for operation was left ventricular outflow obstruction in 16 patients (47%), aortic regurgitation in 14 (41%), mixed aortic valve disease in 3 (9%), and failure of a previously implanted aortic homograft in 1 (3%). There were four early deaths, all before 1971, giving a hospital mortality of 11.8% (70% confidence interval, 6% to 20%). Surviving patients have been followed up a cumulative total of 214 patient-years, the longest period of observation being 16 years 8 months. Late mortality was 13.3% (70% confidence interval, 7% to 23%), and 4 other patients required removal of the pulmonary autograft for endocarditis. Actuarial rates at 16 years were 74% +/- 11% for freedom from reoperation on the left ventricular outflow tract, 80% +/- 10% for freedom from reoperation on the right ventricular outflow tract, and 77% +/- 10% for late survival. There was no instance of primary structural degeneration in the pulmonary autograft, and all surviving patients were in New York Heart Association functional class I without medication. This experience demonstrates that the pulmonary autograft can achieve good early and medium-term results in young patients. Should growth potential be realized, it might constitute the ideal biological valve for the left ventricular outflow in children.     

Early experience with the ross procedure

Five patients have undergone replacement of the aortic root and valve with a pulmonary autograft. The right ventricular outflow tract was reconstructed with a homograft pulmonary or aortic valve. Technical details and relevance of this procedure in India are highlighted.     

Surgical Treatment of Prosthetic Valve Endocarditis with Homograft Aortic Valve Replacement

This article presents the University of Alabama experience with homograft aortic valve replacement for prosthetic valve endocarditis. Of 117 patients who have undergone homograft aortic valve replacement since 1981, there has been a total of 22 patients who underwent operation for endocarditis. Sixteen were isolated valve replacements, three combined with other procedures, and three were aortic root replacements. When placed in a setting of active endocarditis, there have been no reoperations for endocarditis of the homograft valve. Surgical techniques are presented for the freehand sewn homograft as well as aortic root replacement. Prosthetic valve endocarditis is a highly lethal event and when aortic valve replacement is advised in this setting, we believe a homograft aortic valve should be implanted whenever possible.     

Active infective endocarditis of a bicuspid aortic valve causing left ventricular outflow tract pseudoaneurysm and right atrium shunt: A case report

Introduction and importanceLeft ventricular outflow tract pseudoaneurysm associated with infective endocarditis is a rare but life-threatening condition.Case presentationA 68-year-old man developed infective endocarditis of a bicuspid aortic valve with suspected annulus abscess and was transferred to our department for further treatment. Cardiac workup revealed the formation of a left ventricular outflow tract pseudoaneurysm penetrating the right atrium. We successfully treated the patient with pseudoaneurysm repair using a bovine pericardium patch in combination with aortic valve replacement. The patient was uneventfully discharged after 6-week antibiotic therapy and remained well for the following 2 years.Clinical discussionSurgery is the recommended treatment for left ventricular outflow tract pseudoaneurysms. Accurate diagnosis and identification of the anatomical conditions are crucial for determining the appropriate treatment.ConclusionWhen considering the appropriate surgical treatment for left ventricular outflow tract pseudoaneurysm associated with infective endocarditis, pseudoaneurysm repair using a bovine pericardial patch and concomitant aortic valve replacement can be an effective and feasible therapeutic option.     

Extended aortic root replacement with aortic allografts

Complex left ventricular outflow tract obstruction after operation for subaortic stenosis or with hypoplastic aortic anulus remains a challenge for pediatric cardiac surgeons. We have recently applied a new technique of extended aortic root replacement using a cryopreserved aortic allograft to treat two patients who had previously been operated on for subaortic stenosis and a third who had aortic stenosis with a hypoplastic aortic anulus. This new procedure combines the concept of aortoventriculoplasty with aortic root replacement and coronary artery reimplantation. The valved aortic homograft is used in place of an aortic valve prosthesis and the attached anterior mitral leaflet augments the interventricular septum to relieve the subvalvular left ventricular outflow tract obstruction. The coronary ostia are then reimplanted into the allograft and an anastomosis between the distal graft and the ascending aorta is completed. Allograft aortic tissue is then used to patch the right ventricular outflow tract. One patient had aortic stenosis with annular hypoplasia and did well after extended root replacement. Two patients had previous operations for subaortic stenosis before undergoing extended aortic root replacement. One required mediastinal exploration and drainage at 2 weeks for Serratia marcescens mediastinitis and bacteremia, but uncomplicated recovery followed. The other patient had complete heart block for 2 days, but normal sinus rhythm resumed and convalescence was benign. This modified technique with the aortic allograft was very helpful in treating these difficult problems, and the lack of mortality, limited morbidity, and good functional results are encouraging.     

Freestyle valve for right ventricular reconstruction in Ross operation; report of a case

A 28-year-old man with active aortic valve endocarditis underwent emergency surgery. Because he had progressive congestive heart failure and uncontrolled infection. Aortic root replacement for Ross procedure was required because of complete debridment of infective tissue. His operation were performed under extracorporeal circulation and moderate hypothermia, the operation procedure was following, (1) taking off auto-pulmonary artery valve, (2) removing dysfunctional aortic valve and auto-transplantation of pulmonary valve on aortic root, (3) putting a pulmonary Freestyle Aortic Valve to rebuild right ventricular outflow tract. Follow-up showed heart function was in class I (New York Heart Association) , aortic and pulmonary valve function was very well. Streptococcus milleri group was isolated from his blood and infectious aortic valve postoperatively. We believed that a Ross operation with Freestyle Aortic Valve is more resistant to infection, therefore, it might be an option for infective endocarditis with aortic valve endocarditis.     

Arterial switch operation using aortic homograft for transposition of the great arteries with pulmonary regurgitation

We report a case of a 15 month-old boy who underwent the arterial switch operation using cryopreserved aortic homograft for transposition of the great artries with pulmonary regurgitation, with coexisting right ventricular outflow tract obstruction precluding atrial switch operation. Follow-up echocardiography at 6 months showed trivial neoaortic valve regurgitation, no significant systemic outflow obstruction, with good cardiac function. In small children, the choice of material for left ventricular outflow tract reconstruction is one of the most crucial issues. Cryopreserved homograft has been one of the primary options for the aortic valve replacement in small children because of the ease of suturing and excellent hemostasis.     

Comparison of the aortic homograft and the pulmonary autograft for aortic valve or root replacement in children

To assess late results of aortic homograft and pulmonary autograft valves implanted into the left ventricular outflow tract of children, we reviewed the case histories of 146 patients 18 years of age or younger who underwent aortic valve or root replacement between November 1964 and April 1990. One hundred three patients (mean, 12 +/- 3.9 years) received an aortic homograft and 43 (mean, 14 +/- 4.1 years) had their own pulmonary valve transferred to the aortic position. There were 54 valve and 49 root replacements with homografts and 36 valve and seven root replacements with autografts. Hospital mortality rate was 15.5% (16 patients) in the homograft group and 11.6% (five patients) in the autograft group. Survivors were followed up for a total of 867 (homograft) and 297 (autograft) patient-years. The late mortality rate was 16.7% (1.9% per patient-year) for patients with homografts and 13.2% (4.4% per patient-year) for patients with autografts, whereas the incidence for reoperation per patient-year was 2.9% and 2.0%, respectively. At 15 years actuarial rates for homografts and autografts for freedom from reoperation were 54% +/- 8.1% and 68% +/- 11.1%; freedom from endocarditis, 97% +/- 2.4% and 75% +/- 10.2%; and freedom from any complication, 41% +/- 6.5% and 50% +/- 10.3%. Valve degeneration occurred in 19 homografts (2.2% per patient-year), whereas there was no definite instance of primary tissue failure among the pulmonary autografts. This experience would indicate that either the homograft or the autograft valve can be used with acceptable results in children. However, the pulmonary autograft gives better long-term performance and, if growth potential is realized, may be the ideal valve substitute in children.     

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.     

Indications for and results of cryopreserved homograft valve replacement

The cryopreserved aortic homograft valve is one of the most reliable of the stentless biological prosthesis if implanted properly. Due to the limited availability of homograft valves in Japan, the indications for their use are different from those in other countries. The first indication is active infective endocarditis in the aortic valve position, especially infection surrounding artificial implants. Another indication is for reconstruction of the right ventricular outflow tract during pulmonary autografting. Finally, aortic valve replacement in young women of childbearing age who wish become pregnant is an accepted indication. Since 1992, cryopreserved homograft valves have been used in Japan, and the number of surgeries performed with them has gradually increased. While efforts have been made to expand the homograft bank system in some areas, the supply remains insufficient. Because the demand for homografts is high, it is extremely important to establish a nationwide tissue bank system as soon as possible.     

Redo aortic root replacement: experience with 31 patients

BACKGROUND: Aortic root re-replacement is being performed with increased frequency. Limited information is available regarding the surgical approaches and clinical outcomes of this reoperation. METHODS: Between May 1980 and May 1999, 31 patients (mean age, 45 +/- 15 years) underwent redo composite replacement of the aortic valve and ascending aorta. Indications for reoperation were prosthetic valve endocarditis in 12 patients (39%), failed biological valve in 17 (55%), and false aneurysm in 2 (6%). At reoperation, mechanical valves were implanted in 24 patients and biologic valves in 7. All patients with endocarditis had annular abscess and required reconstruction of the left ventricular outflow tract before implantation of a new valved conduit. Mechanical valves were used in 24 patients, aortic homograft in 4, and bioprosthetic valves in 3. The coronary button technique was used to reimplant the coronary arteries whenever possible. Extension of one or both coronary arteries with a short segment of saphenous vein or a synthetic graft was used in 16 patients (52%). The aortic arch was replaced in 7 patients (23%). RESULTS: There was one operative death (3%) because of rupture of an abdominal aortic aneurysm. The mean follow-up was 47 +/- 46 months and was 100% complete. There were five late deaths (16%), three of which were cardiac related. The actuarial survival was 71% +/- 12% at 5 years. Three patients experienced recurrent prosthetic valve endocarditis 4 months to 8 years after operation. The 8-year freedom from endocarditis for patients operated on for endocarditis was 82% +/- 11% compared with 100% for those operated on for other reasons (p = 0.1). At the last follow-up, 21 of 25 survivors (84%) were in New York Heart Association functional classes I or II, and 4 were in class III. CONCLUSIONS: Redo aortic root replacement can be performed with good early and late results. Patients operated on for prosthetic root endocarditis may have an increased risk of recurrent late endocarditis.     

Surgical treatment in a patient with multiple systemic complications of prosthetic aortic valve endocarditis: case report

A 31-year-old woman who had undergone aortic and mitral valve replacement 1 year previously was hospitalized with suspected prosthetic valve endocarditis. Freestyle stentless aortic xenograft was successfully replaced using freestanding total aortic root replacement techniques at the left ventricular outflow tract position, and aorta-to-right coronary artery bypass was also applied with a saphenous vein graft. The patient developed multiple systemic problems during the preoperative and postoperative periods and was successfully treated with intensive interventions. She was discharged at the postoperative fourth month, and the following 28 months were uneventful.     

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.