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J Thorac Cardiovasc Surg 1994;108:990-991
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Cryopreserved homografts in the treatment of relapsing fungal cardiovascular infections

Department of Cardiovascular Surgery^a

To the Editor:

Anatomic reconstruction of infected vascular or prosthetic segments is controversial and surgical treatment is a matter of intense debate ¹ We have used homologous tissue for cardiac valve replacement and especially for infective endocarditis of the aortic root. Successful sequential aortoiliac and aortic root replacement with cryopreserved vascular and aortic homografts has been performed for the treatment of relapsing multisegmental Candidainfection.

A 39-year-old man who occasionally abused intravenous heroin had aortic valve replacement with a 23 mm Hancock porcine bioprosthesis (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) at another hospital because of Candida lusitaniaeendocarditis of the native aortic valve. Serial transthoracic echocardiography showed a normally functioning aortic bioprosthesis. A follow-up blood culture on September 9, 1992, was also positive for C. lusitaniae. Because of the suspicion of early prosthetic valve endocarditis, he was transferred to our institution for further treatment.

The man had dyspnea on minimal exertion and peripheral edema. He was afebrile. Transesophageal echocardiography showed a trivial perivalvular leak but no vegetations, abscesses, or fistulas at the aortic root level. Signs of congestive heart failure rapidly progressed. Cardiac catheterization showed a normally functioning aortic bioprosthesis and a high cardiac output of 15 L/min. A continuous murmur on the right abdominal flank was heard. Venous digital subtraction angiography confirmed an aorta–inferior vena cava fistula.

A second operation was performed on October 29, 1992. Subrenal aortoiliac resection was done and vascular reconstruction was performed with a cryopreserved bifurcated aortoiliac graft. Histologic examination showed Candida. Intravenous amphotericin B and oral flucytosine were restarted. The patient had an uneventful recovery. A follow-up digital subtraction angiogram showed a normal terminal aorta and bifurcation (Fig. 1). He finally received a total dose of 2 gm of amphotericin B (cumulative dose of 4.4 gm) and was prescribed a regimen of oral itraconazole.

View larger version (191K): [in this window] [in a new window]   Fig. 1. Postoperative angiogram showing the patency and appearance of the bifurcation homograft.

The use of homologous tissue in cardiovascular surgery is not new. In 1951, Dubost, D'Allary, and Oeconomos ² reported the first successful replacement of an infrarenal aorta with a homograft. Forty years later, it seems clear that valve homografts are the best substitute available for infective endocarditis and also useful in all types of disease of the aortic root. The introduction of fabric arterial prostheses and the development of textiles that are durable and otherwise resistant to infection led to the progressive increase in their use for vascular replacement. Difficulties in procurement, preservation, and storage contributed to the abandonment of vascular homografts.

Work done in cardiac surgery has prompted a continued search for the best way to increase the availability of vascular homografts that could be used in selected situations. Today, interest in the use of homografts for cardiovascular replacement and reconstruction has been renewed. At our institution, valvular and arterial vascular homografts are procured through the National Spanish Transplant Coordinators Network from brain-dead multiorgan donors. The homografts are cryopreserved with a specific software for computerized freezing and stored in liquid nitrogen at -196° C at our Criobarna Cardiovascular Bank, Hospital Clinico, Barcelona. The case presented herein was considered suitable for homograft replacement of the aortic bifurcation because Candidainfections need aggressive surgical excision of tissues. Because the patient was a young and otherwise healthy man, we thought that anatomic reconstruction with an arterial bifurcation homograft was the best option. We have recently performed a few more vascular homograft implants in complex vascular situations. Because of the work done over the past years and even though no large series have yet been published, we believe that vascular homografts can perform properly when implanted to treat vascular infection, trauma, or congenital disorders. ^3-5 Given the proper tissue bank facilities, the use of vascular homografts in selected situations can be strongly recommended in an organized program, in addition to the use of valve homografts.

References

1. Pasic M, Carrel T, Tönz M, Vogt P, von Segesser L, Turina M. Mycotic aneurysms of the abdominal aorta: extraanatomic versus in situ reconstruction. Cardiovasc Surg 1993;1:48-52.[Medline]
   
2. Dubost C, D'Allary M, Oeconomos M. A propos du traitement des anevrismes de l'aorte. Ablation de l'anevrisme, rétablissmennt de la continuité par la greffe d'aorte humaine conservée. Mem Acad Chir 1951;77:38.
   
3. Schuch D, Wolff L. Repair or mycotic aneurysm of the innominate artery with homograft tissue. Ann Thorac Surg 1991;52:863-4.[Abstract]
   
4. St Cyr JA, Campbell DN, Fullerton DA, Grosso M, Bishop DA, Clarke DR. Cryopreserved allograft repair of aortic hypoplasia and interrupted aortic arch. Ann Thorac Surg 1992;53:1110-3.[Abstract]
   
5. Kieffer E, Bahnini A, Koskas F, Ruotolo C, Le Blevec C, Plissonier D. In situ allograft replacement of infected aortic prosthetic grafts: results in forty-three patients. J Vasc Surg 1993;17:349-56.[Medline]
   

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