| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2001;121:584-586
© 2001 The American Association for Thoracic Surgery
Brief Communications |
From the Cardiothoracic Unit,a the Cardiothoracic Unit,b and the Intensive Care Unit,c Hôpital Cardiologique, Lyon, France.
Received for publication April 28, 2000. Accepted for publication Sept 3, 2000. Address for reprints: J. F. Obadia, MD, PhD, Hôpital Cardiologique, Avenue du Doyen Lépine, 69003 Lyon, France (E-mail: jean-francois obadia{at}chu-lyon.fr).
The treatment of complex valvular endocarditis remains a surgical challenge (ie, when facing a redo operation,
1 double valvular disease, or large abscess caused by aggressive bacteria). In such a situation, we propose a technique that allows a large resection of all the septic tissue and a repair by means of a cryopreserved monobloc aorto-mitral homograft.
Clinical summary
A 16-year-old boy was operated on for resection of a subvalvular aortic stenosis. Two months later, postoperative endocarditis caused by Staphylococus aureus necessitated a reoperation. A mechanical bivalvular replacement was performed, and the follow-up was uneventful.
This patient was 42 years old when he had a mandible fracture treated with an intermaxillary blockage. The patient presented with endocarditis caused by Kingella denitrificans. There was a large disinsertion of both prostheses, a paravalvular abscess, and a fistula between the aorta and the right atrium. A double valvular replacement redux associated with a closure of the communication was performed.
One month later, the abscess had increased, and the 2 prostheses were disinserted again (Fig 1). The hemodynamic results were unstable, and the patient was operated on for the fourth time. This reintervention (Fig 2) was done through a superior transseptal approach. 2 The 2 prostheses and all the fibrous mitro-aortic tissue, including both trigones, were removed. This huge resection, enlarged to the roof of the left atrium and to the first 3 cm of the aortic root, allowed a complete resection of the paravalvular abscess. It left a large opening on the right and left atria, the left ventricle, and the aortic root. The 2 coronary ostia were preserved in the button, and their first 2 cm were mobilized. A cryopreserved monobloc aorto-mitral homograft was prepared with a Carpentier Physio ring (Baxter Healthcare Corporation, Irvine, Calif) inserted extracorporeally. The papillary muscles of the left ventricle were dissected to receive the sutures of the papillary tips of the homograft. The posterior leaflet of the homograft was secured with a running suture. The aorto-mitral junction, including the 2 trigones of the monobloc homograft, was left intact. The remaining part of the aortic anulus was sutured with separated stitches. As a matter of fact, the mitro-aortic continuity and the mitral subvalvular apparatus were reconstituted. 3 The left atrium roof was repaired with a pericardial patch. According to the Bentall technique, the 2 ostial buttons were reimplanted on the aortic root of the homograft, and the distal aorta was sutured terminally.
|
|
Results
The follow-up was favorable, with the patient extubated at 12 hours. A permanent pacemaker was implanted on day 6. Echocardiographic and angiographic follow-up performed on days 8 and 10 show perfect function of both homograft valves (Figs 3 and 4). There was no mitral leak or stenosis. There was no aortic leak, with a transvalvular gradient of 12 mm Hg. The echocardiographic data were stable after an 8-month follow-up period.
|
|
4,5 The technique proposed herein is different and cannot be improvised because we need a disposable cryopreserved monobloc aorto-mitral homograft. Such a homograft was prepared for several months in our tissue bank. Actually, this concept seemed interesting to us, and the case herein reported represented a good indication for such a solution. This original approach comprises 2 steps. The first step is a large and complete resection of all the septic tissue, without any limitation. The valves themselves and also the anulus; the paravalvular and fibrous structures, including both trigones; the aortic root; and the left atrial roof can be largely resected. The second step is a bivalvular repair with a monobloc homograft.
Conclusion
This new approach is not a simple bivalvular replacement but a replacement extended to all the lesions as a result of the infective process (valves, anulus, trigones, left atrial roof, and aorta). This approach is particularly adapted to complex and destructive valve endocarditis.
References
This article has been cited by other articles:
|
|
 |
|
  T. E. David Surgical Treatment of Aortic Valve Endocarditis Card. Surg. Adult, January 1, 2008; 3(2008): 949 - 956. [Full Text]
|
|
|
|
 |
|
 S. Chocron, D. Buklas, C. Taberlet, D. Kaili, P. E. Falcoz, and J.-P. Etievent Monobloc Aorto-Mitral Homograft: Report of Two Cases Ann. Thorac. Surg., October 1, 2007; 84(4): e14 - e16. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J.F. Obadia, R. Henaine, C. Bergerot, I. Ginon, P. Nataf, N. Chavanis, J. Robin, X. Andre-Fouet, J. Ninet, and O. Raisky Monobloc aorto-mitral homograft or mechanical valve replacement: A new surgical option for extensive bivalvular endocarditis J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 243 - 245. [Full Text] [PDF]
|
|
|
|
|
|
T. E. David Surgical Treatment of Aortic Valve Endocarditis Card. Surg. Adult, January 1, 2003; 2(2003): 857 - 866. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
