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.     

Surgical treatment of infectious endocarditis complicated by discrete subaortic stenosis: report of a case

A 39-year-old male with a history of cardiac murmur from early childhood was diagnosed as having infectious endocarditis (IE) complicated by discrete subaortic stenosis (DSS). Echocardiography revealed severe aortic regurgitation, subaortic membranous structure and mild mitral regurgitation. The pressure gradient across the subaortic stenosis was 105 mmHg according to continuous Doppler wave ultrasonography. Aortic valve replacement and resection of subaortic membranous tissue and mitral annuloplasty were performed. Postoperative cardiac catheterization demonstrated that the hemodynamic data were remarkably improved, and the patient was free of symptoms. He is currently well at 6 months after the operation.     

Medium-term results of aortic valve replacement with cryopreserved homograft valves: importance of a domestic homograft valve bank

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.     

A case of subaortic stenosis due to parashute accessory mitral valve tissue]

An 11-year-old boy with subaortic stenosis due to parashute accessory mitral valve tissue was treated successfully with surgery. He had a mild left ventricular-aortic pressure gradient associated with mild aortic regurgitation. The abnormal subaortic tissue was attached to the anterior leaflet of the mitral valve and was complicated with discrete subaortic stenosis. This tissue had five chordae connecting to the anterior papillary muscle and the anterior leaflet of the mitral valve. By resection of this accessory tissue and the part of the septal discrete stenotic tissue, stenosis of the left ventricular outflow tract was relieved completely.     

Prosthetic valve endocarditis after aortic valve replacement with freestyle stentless xenograft

A 52-year-old man underwent aortic valve replacement with freestyle stentless xenograft, using subcoronary technique for active infective endocarditis in June, 2001. Eighteen month later he had late prosthetic valve endocarditis associated with aortic annular abscess due to Staphylococcus epidermidis infection. The abscess was debrided and gelatin-resorcin-formalin glue (GRF glue) was injected into the abscess cavity. Abscess cavity was closed with continuous running suture of 3-0 polypropylene stitches. Finally the aortic valve was replaced with ATS mechanical valve (20 mmAP). After administration of vancomycin and gentamicin for 4 weeks, he discharged on 57th postoperative day in good condition. We strongly suggest that GRF glue is essential to close the aortic annular abscess of combined with aortic regurgitation due to active infective endocarditis.     

Emergency valve-in-valve transcatheter aortic valve implantation for endocarditis degeneration

The use of transcatheter aortic valve implantation (TAVI) in the emergency setting has not been widely reported, and TAVI is generally contraindicated in the context of endocarditis. Here we describe a patient developing acute cardiogenic shock due to prosthetic aortic valve degeneration with free-flow aortic regurgitation 8 months after receiving treatment for confirmed infective endocarditis. Due to his clinical status, he was deemed unfit for redo surgery, and he underwent salvage valve-in-valve (ViV)-TAVI. The patient made an excellent recovery. Postprocedure he was treated with a 6-week course of antibiotics, and at 18-months follow-up remains very well with no evidence of reinfection. This case may demonstrate that for selected patients with degenerative prosthetic aortic valve disease, despite a history of infective endocarditis, ViV-TAVI may be considered an alternative to redo surgery in the emergency setting.     

Surgical pathology of aortic valve disease. A study based on 602 specimens

A consecutive series of 602 surgically excised aortic valves was evaluated by means of macroscopic and histological study. Pure aortic stenosis was diagnosed in 140 patients, pure incompetence in 254 and combined dysfunction in 208. Of the cases with pure aortic stenosis, 38% were rheumatic, 34% were calcified bicuspid valves and 23% showed dystrophic calcification. Half the patients with pure aortic regurgitation showed aortic root dilatation. Most cases of combined aortic stenosis and regurgitation were the sequelae of rheumatic fever. A male prevalence was detectable in each group (mean male: female ratio = 2.6), and was highest in infective endocarditis and aortic root dilatation. Infective endocarditis was a frequent complication of congenitally bicuspid valves. In conclusion, rheumatic disease is still a frequent cause for surgical replacement of the aortic valve. At least half the explanted aortic valves have degenerative or congenital diseases which are often the site of a superimposed infective endocarditis.     

Aortic root replacement with a mechanical valve and prosthetic conduit for the complicated degeneration of the ascending aorta resulting from infective endocarditis.

A 28-year-old man with infective endocarditis of the aortic valve underwent a course of antibiotic therapy, but developed severe aortic root deformity requiring aortic root replacement with a mechanical composite valve conduit. Of note, this patient had undergone a previous aortic valve operation for bicuspid valve stenosis, and indurations and fragility of the aortic root caused by the preceding operation may have contributed to subsequent aortic root deformity during the course of infective endocarditis of the aortic valve. Over the 7-year follow-up period, the patient showed no signs of recurrent infection or new cardiac events. For younger patients with endocarditis, the use of a mechanical valve and prosthetic conduit with sufficient surgical debridement and appropriate antibiotic therapy appears to be a safe and effective treatment strategy.     

Ascending aortic infected pseudoaneurysm with aortic insufficiency following cardiac operation for infective endocarditis.

An infected pseudoaneurysm of the ascending aorta after heart surgery is a fatal disease due to its rapid progress, worsening of the systemic condition and a tendency of recurrence. We report a 53-year-old man with this condition who presented with fever and an aortic regurgitation due to compression of the ascending aortic root 2 months after mitral valve replacement for infective endocarditis. We performed an aneurysmectomy with a cardiopulmonary bypass using groin cannulation and moderate systemic hypothermia. A pseudoaneurysm developed 5 mm proximally of the previous aortotomy. There was no dehiscence of the former aortic suture line. After debridement of the ascending aorta involving the previous aortotomy and pseudoaneurysm, we elected to directly close the aortic defect using Teflon felt strips to avoid a prosthetic graft. The aortic valve had no infective endocarditis and other abnormality. Postoperatively, there was no aortic regurgitation, and the cause of the previous aortic regurgitation was believed to be due to a compression of the aortic root from outside. The postoperative course has been good.     

Bicuspid aortic valve.

The bicuspid aortic valve is a common congenital cardiac anomaly, having an incidence in the general population of 0.9% to 2.0% and a frequency of 54% in all patients aged >15 years with valvular aortic stenosis. In most cases it remains undetected until infective endocarditis or calcification supervenes. The bicuspid aortic valve may function normally throughout life, may develop progressive calcification and stenosis or may develop regurgitation with or without infection. The association of the bicuspid aortic valve with dissection of the aorta is also common. The recognition of the bicuspid valve in patients with aortic valve disease remains an important challenge to the clinician, whereas preoperative knowledge of valve morphology would be helpful in planning the surgery. Antibiotic prophylaxis is also recommended in such patients, since these valves are likely to become the most important intrinsic cardiac predisposition for infective endocarditis with the virtual disappearance of rheumatic fever in developed countries.     

Discrete subaortic stenosis: incidence,morphology and surgical impact of associated subaortic anomalies

BACKGROUND: The association between discrete subaortic stenosis and other subaortic anomalies is a well known but rarely reported occurrence. The aim of this study is to define the incidence, morphology, and surgical impact of associated anomalies of the left ventricular outflow tract in children operated on for discrete subaortic stenosis. METHODS: Between 1994 and 2000, 45 consecutive children were operated on for discrete subaortic stenosis. Patients were divided in two groups according to the obstructive lesion detected by echocardiography. RESULTS: A localized shelf was found as an isolated lesion in 31 patients (group A), whereas additional subaortic anomalies were found in 14 cases (31%) and were multiple in 5 cases (group B). The anomalies included anomalous septal insertion of mitral valve (7 cases); accessory mitral valve tissue (2 cases); anomalous papillary muscle (2 cases); anomalous muscular band (8 cases); and muscularization of the anterior mitral valve leaflet (1 case). Cardiopulmonary bypass and aortic cross-clamping times were significantly shorter in group A. There were no operative deaths nor major complications or deaths during follow-up. A gradient of 15 mm Hg or more was found at follow-up in 5 cases whereas aortic regurgitation was estimated to be not clinically significant in all but 1 patient. Six cases of recurrent subaortic stenosis were found in our series, 3 of them with other subaortic anomalies. CONCLUSIONS: This study shows that discrete subaortic stenosis can often be associated with other subaortic abnormalities. Surgical treatment of these anomalies produces excellent early and mid-term relief of obstruction without any increase in mortality and morbidity.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm]

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

A case of quadricuspid aortic valve with aortic regurgitation

A 67-year-old man with grade 3 aortic valve regurgitation was found to have a quadricuspid aortic valve. The aortic valve consisted of 1 large, 2 intermediate and 1 small sized cusp. An accessory cusp located between the right and noncoronary cusps, and shaped like a hammock which sling by the fibrous strings originating from the both commissures to the aortic wall. Aortic valve replacement was successfully performed with a 23 mm St. Jude Medical prosthetic valve, and the patient is asymptomatic five months post-operatively. Histological examination of the resected cusps showed fibrous thickening and no rheumatic valvulitis or infective endocarditis.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

Aortic valve reconstruction using autologous pericardium (Ozaki procedure) for active infective endocarditis: a case report

Approximately one-third of patients with infective endocarditis require surgical treatment, but the ideal procedure that prevents infection ensures long durability and maintains quality of life remains unclear. A 21-year-old man who was diagnosed with aortic active infective endocarditis was referred to our hospital for surgical treatment. Echocardiography showed bicuspid aortic valve, severe aortic regurgitation, a large vegetation, and a paravalvular abscess. We planned to perform elective surgical treatment after antibiotic therapy; however, progression to heart failure required urgent operation. Aortic valve reconstruction (AVr) using autologous pericardium was performed. Perioperative and postoperative courses were uneventful. No recurrence of infection or adverse events were observed 4 years postoperatively. Considering prosthetic valve infection and redo operation, AVr may be considered among young patients.     

Saccular aneurysm of the aortic cusp associated with discrete subaortic stenosis

A 54-year-old male who experienced a syncopal episode underwent aortic valve replacement for aortic stenosis and regurgitation. The aortic valve was incompetent as a result of thickening of the left coronary cusp and noncoronary cusp. In addition a saccular aneurysm was indicated on the left coronary cusp. A shelf of tissue protruding at right angles from the ventricular septum was particularly prominent below the right coronary cusp, resulting in subvalvular stenosis. The cause of the saccular aneurysm was most likely caused by the long-term effects of the jet stream instigated by discrete subaortic stenosis.     

Re-operation of an aortic pericardial bioprosthesis 23-years after implantation; report of a case

A 49-year-old female suffered from dyspnea on exertion and jaundice from June, 2009. She had undergone aortic valve replacement with Carpentier-Edwards pericardial bioprosthesis due to active infectious endocarditis 23-years previously. The echocardiography showed severe aortic stenosis with moderate regurgitation. She was diagnosed as having prosthetic valve malfunction. Re-replacement of the aortic valve with mechanical valve was successfully performed. As far as we can see, this is one of the longest-term cases of implantation of pericardial bioprosthesis.     

Surgical aspect of active infective endocarditis

Twenty patients with active infective endocarditis, 11 with native valve endocarditis (NVE) and 9 with prosthetic valve endocarditis (PVE), were treated surgically from 1975 through April 1987 at Kyushu University Hospital. The operative indications were congestive heart failure mainly due to massive aortic regurgitation in 18, periannular abscess in 6, major embolism in 5 and severe hemolysis in 3 patients. In the group of NVE, single aortic valve replacement was performed in 4 patients and multiple valve replacement in the remainder. One patient died early postoperatively from LOS. Two patients with recurrent infective endocarditis, which occurred within 60 days after previous prosthetic valve replacement, were operated subsequently as early PVE. All other patients became NYHA class I postoperatively except for one patient who died from thrombosed valve. In the group PVE, re-AVR was done in 3, re-MVR in five, double valve replacement in two and re-fixation of the prosthesis to the aortic annulus in one patient. Two patients with early PVE died from recurrent endocarditis late postoperatively. One of 7 patients with late PVE, who had suffered from myocardial and cerebral infarction before reoperation, died from multiple organ failure. There were 3 patients with perivalvular leakage due to late active PVE, whose preoperative signs of inflammation were negative or minimum. As recurrent perivalvular leakage due to persistent infective endocarditis might frequently occur in such cases, complete resection and debridement of infected foci should be emphasized.     

Early valvular obliteration of cryopreserved aortic valve allograft

This report describes a 60-year-old male patient who developed early valvular obliteration of a cryopreserved aortic valve allograft with associated severe valvular leakage. The patient had previously undergone two operations for aortic valve insufficiency resulting from infective endocarditis, and prosthetic valve endocarditis: aortic valve replacement with a mechanical prosthesis was done 4 years ago, and two years later aortic root replacement with a cryopreserved allograft was performed. Perforation through the non-coronary cusp of the aortic allograft was found, and valve replacement was achieved using a mechanical prosthesis. The intraoperative findings, histological, immunological, and bacteriological studies of the resected cusps demonstrated negative for infection and rejection, therefore, the valvular perforation might have been caused by an injury or degeneration during management of the homologous graft. The patient showed neither aortic regurgitation on echocardiography nor recurrence of endocarditis 10 months after surgery.     

Late results after resection of fixed subaortic stenosis

Resection of fixed subaortic stenosis was performed on 44 patients with median age 14 (range 2-61) years. Concomitant aortic valve pathology was present in 14 (32%) cases (congenital stenosis in 2, thick fibrotic cusps in 8 and incompetent cusps in 4) and other congenital cardiovascular malformations in eight (18%). There was no perioperative mortality. Of the six late deaths, three were due to non-cardiac causes. During follow-up (median 6, range 2-21 years), six reoperations were performed for residual or recurrent obstruction and/or aortic incompetence. Aortic valve replacement was required at two primary and four second operations. Actuarial 5-year and 10-year survival rates were 89% and 76%, respectively, and rates with freedom from cardiac death endocarditis and reoperation 83% and 64%. At follow-up evaluation two patients had significant aortic regurgitation and all survivors had a systolic ejection murmur. At Doppler echocardiography in 29 patients without reoperation, the median pressure difference in the left ventricular outflow tract was 10 (range 0-55) mmHg--in three cases greater than or equal to 30 mmHg. Careful follow-up is advisable after resection of fixed subaortic stenosis, because of the risk of residual or recurrent obstruction and of significant aortic valve incompetence.