J Thorac Cardiovasc Surg 1994;107:1540-1541
© 1994 Mosby, Inc.
Cryopreserved pulmonary homograft for Bentall replacement of aortic root in a case of purulent bacterial endocarditis
Carmine Minale , MD,
Fred H. Splittgerber , MD,
Bernard Cramer , MD
Department of Cardiothoracic and Vascular Surgery
Wuppertal Heart Center
Wuppertal, Germany
To the Editor:
The outcome of bacterial endocarditis with perianular abscesses and extensive aortic root destruction is generally poor despite surgical intervention.
1 Recently, complete aortic root replacement by aortic homograft and reimplantation of the coronary ostia has been advocated as a method with better results. 2-4
In 1992 a 57-year-old man was operated on because of intractable prosthetic aortic valve endocarditis and acute cardiac failure. At operation a large annular leak with multiple periannular abscesses was found. The aortic root was friable. After the aortic valve prosthesis was removed, a circumferential discontinuity between the aortic anulus and aortic wall was evident. Below the left sinus of Valsalva, the aortic root communicated freely with the transverse sinus. A thorough débridement of the aortic root was carried out, including the friable portion of adjacent aorta. At that time, only pulmonary homografts were available at our institution. A 25 mm diameter pulmonary homograft was implanted as a valved conduit and sutured to the aortic root with simple interrupted 4-0 Ethibond sutures (Ethicon, Inc., Somerville, N.J.). Tension between the short pulmonary conduit and the patient's ascending aorta was avoided by interposition of a 2 cm piece of 30 mm Dacron fabric tube. The coronary ostia were implanted separately into the pulmonary graft wall with running 5-0 Prolene sutures (Ethicon). One of the most serious intraoperative problems was the tendency of the pulmonary homograft wall to tear at any stitch. For this reason the patient's systolic blood pressure was kept at 110 mm Hg or less during the first 10 postoperative days.
The patient recovered promptly, his group B streptococcal sepsis resolved, and he was discharged on the fifteenth postoperative day. Antimicrobial drugs were prescribed for 6 weeks. Six months later he proved to be cured of the sepsis. The homograft valve was functioning well, as shown echocardiographically. Neither enlargement of the pulmonary homograft wall nor dehiscence at the line of junction with the Dacron graft was seen by magnetic resonance imaging (Fig. 1).
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Fig. 1. Magnetic resonance imaging coronal slice through aortic root replaced by valved pulmonary conduit. Continuity between pulmonary conduit and ascending aorta is restored with short Dacron fabric tube. Image in diastole shows homogeneous continuity from pulmonary conduit to Dacron graft to ascending aorta.
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The use of a cryopreserved pulmonary homograft as a valved conduit in the aortic position has not been described before. Recently experimental studies 5 have shown that cryopreserved pulmonary allograft conduits dilate substantially at systemic pressure. In particular, pseudoaneurysm formation at the suture line between the pulmonary allograft conduit and the noncompliant Dacron fabric prosthesis was observed. In similar cases, an aortic homograft is definitely superior.
Because of the desperate situation in the presented case and the otherwise poor outcome, we attempted to use the only available "live" graft. We learned that an extremely atraumatic technique is required to avoid tearing the cryopreserved pulmonary conduit. Accordingly, we avoided high pressure during the early healing period. On the basis of the present available experimental data, close surveillance of the homograft diameter is mandatory.
References
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Brottier E, Gin H, Brottier L, Chaussat A, Aubertin J. Prosthetic valve endocarditis: diagnosis and prognosis. Eur Heart J 1984;5(Suppl C):123-7.
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Tuna IC, Orszulak TA, Schaff HV, Danielson GK. Results of homograft aortic valve replacement for active endocarditis. Ann Thorac Surg 1990;49:619-24. [Abstract]
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Kirklin JK, Pacifico AD, Kirklin JW. Surgical treatment of prosthetic valve endocarditis with homograft aortic valve replacement. J Card Surg 1989;4:340-7. [Medline]
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Ross D. Allograft root replacement for prosthetic endocarditis. J Card Surg 1990;5:68-72. [Medline]
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Kodoba K, Arminger LC, Sawatary K, Jonas RA. Mechanical durability of pulmonary allograft conduits at systemic pressure. J THORAC CARDIOVASC SURG 1993;105:123-41.
